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Temporal Arteritis
A Cough, Toothache, and Tongue Infarction
David B. Hellmann, MD
Temporal arteritis, the most common form of systemic vasculitis in adults,
DR HELLMANN: My patient, Professor is a panarteritis that chiefly involves the extracranial branches of the carotid
R, who is a 79-year-old woman, was artery. The condition is illustrated in this article by the case of a 79-year-old
well until she developed a disorder that woman with a dry cough, toothache, tongue infarction, and vision loss. The
eventually produced blindness in her mean age of onset is 72 years and the disease rarely occurs in persons younger
right eye. Although most of the com- than 50 years. The most common presenting manifestations are headache,
mon presenting features of temporal ar- jaw claudication, polymyalgia rheumatica, and visual symptoms. Eighty-
teritis (TA) are familiar to general in- nine percent of patients have an erythrocyte sedimentation rate greater than
ternists and family physicians, the many
50 mm/h. However, about 40% of patients present with atypical manifes-
disguises of this condition may chal-
lenge the diagnostic skills of any expe- tations, including fever of unknown origin, respiratory tract symptoms (es-
rienced physician. Learning to see pecially dry cough), and large artery involvement. Familiarity with such un-
through these disguises is crucial to usual manifestations of temporal arteritis facilitates early diagnosis and
early diagnosis and the prevention of treatment, thereby reducing the risk of vision loss.
visual loss. Professor R, please tell us JAMA. 2002;287:2996-3000
how your illness began.
PROFESSOR R: All my troubles be- PROFESSOR R: No, it was dry. I saw a and tongue pain, I could not eat very well
gan the month my husband and I were physician who gave me some pills but the and lost 20 pounds during the week we
moving from our home into a retire- cough persisted. Two months later I con- were away. When we returned from Ha-
ment community. Before that, I was tinued to cough and felt exhausted. Since waii, my first visit was to the dentist. He
completely healthy, playing tennis, it was winter, we thought that if we got found nothing wrong with my teeth. It
swimming, and hiking. I am now a pro- away for a week to Hawaii I would get was actually an ophthalmologist who
fessor emeritus and still perform re- better. The afternoon before we left for first suspected the correct diagnosis be-
search on iconography of libraries in the Hawaii I awoke from a nap and could not cause of my blindness and other symp-
17th and 18th centuries. It keeps me see out of my right eye. It was all black. toms; the eye doctor tested my sedimen-
interested, traveling, and visiting li- I could not reach a physician so I told tation rate and then immediately
braries in Europe. My husband and I my husband, “Let’s just go. By the time admitted me to the hospital.
have been doing all sorts of exciting we get back I’m sure I’ll be seeing fine DR HELLMANN: That is right, the
things and I have never been in a hos- again.” And we went on our trip. erythrocyte sedimentation rate (ESR)
pital except for a broken arm. The DR HELLMANN: Did your vision get was 115 mm/h. Results of the other tests
month we sold our house I was under better? performed at that time, including a
a great deal of stress. Moving from a PROFESSOR R: No, it never did. complete blood cell count, serum chem-
house into a 2-bedroom apartment, I D R H ELLMANN : Did you experi- istries, and a chest radiograph, were
had to give up a lot, especially my own ence a headache or any other symp- normal. She was treated with intrave-
library of 2000 books. So, I was so tired toms, aside from the fatigue, cough, and
that I began to take naps for the first Author Affiliation: Johns Hopkins University School
visual loss? of Medicine, Department of Medicine, Johns Hop-
time. I thought the tiredness would go PROFESSOR R: I never had a head- kins Bayview Medical Center, Baltimore, Md.
away but after 2 to 3 weeks I also de- ache. But after I started coughing and be- Corresponding Author and Reprints: David B. Hell-
mann, MD, Johns Hopkins University School of Medi-
veloped a cough. fore I had the eye problem, I did de- cine, Department of Medicine, Johns Hopkins Bay-
DR HELLMANN: Did you bring up velop a toothache. I could not quite view Medical Center, 4940 Eastern Ave, Baltimore, MD
anything when you coughed? 21224 (e-mail:
determine which tooth or teeth hurt. My Grand Rounds at The Johns Hopkins Medical Insti-
mouth just hurt all over. Then I devel- tutions Section Editors: David B. Hellmann, MD, D.
William Schlott, MD, Stephen D. Sisson, MD, The Johns
oped a burning sensation on the left side Hopkins Hospital, Baltimore, Md; David S. Cooper, MD,
See also Patient Page.
of my tongue. Between my toothache Contributing Editor, JAMA.

2996 JAMA, June 12, 2002—Vol 287, No. 22 (Reprinted) ©2002 American Medical Association. All rights reserved.

nous methylprednisolone in high doses the eighth decade.1,3 The average age of
Table. Classic Symptoms and Findings
and underwent a right temporal artery onset of TA is 72 years. Perhaps as a re- in Temporal Arteritis*
biopsy. The biopsy showed granulo- sult of the aging population in this coun- Frequency, %
matous inflammation with multinucle- try, greater recognition of the disease on Symptoms
ated giant cells, rupture of the internal the part of physicians, or both, the inci- Headache 77
elastic lamina, and luminal narrow- dence of TA has been rising in some Jaw claudication 51
Constitutional symptoms 48
ing. These findings were diagnostic of populations.1 Temporal arteritis has been Polymyalgia rheumatica 34
temporal arteritis. One day after the bi- reported in all groups, but appears es- Visual symptoms 29
opsy, Professor R was discharged tak- pecially common in people of Scandi- Fever 26
ing prednisone, 60 mg/d. navian or Northern European heri- Abnormal temporal artery 53
Erythrocyte 94
I saw Professor R for the first time 1 tage.1,2 Certain genes (ie, HLA-DR4 sedimentation
week later. Her vital signs were normal. haplotypes 0401 and 0404/8, which are rate ⬎40 mm/h
She had minimal light perception in the contained in the HLA-DRB1 locus) have *Data derived from Machado et al.5
right eye with a relative afferent pupil- been associated with an increased risk of
lary defect. That is to say, her pupils con- developing TA.7 Although the cause of sense of discomfort in or around the jaw
stricted less when I shone a light in the TA is unknown, the disease appears to that may be unrelated to chewing. One
right eye than when I shone the light in be T-cell dependent and antigen driven.8 of my other patients had a diffuse man-
the healthy left eye. The right optic disc dibular discomfort that she attributed to
was pale. The right temporal artery was Classic Manifestations her face-lift, even though that surgery had
surgically absent while the left—barely The classic manifestations of TA are taken place months earlier and had
pulsatile—was hard and stiff. An ische- headache, jaw claudication, polymyal- healed without difficulty. A sense of den-
mic ulcer the size of a jellybean was pre- gia rheumatica (PMR), and visual symp- tal discomfort, as described by Profes-
sent along the left lateral surface of the toms (TABLE).4-6,9 Headache is the most sor R, is another common variant of jaw
tongue. The peripheral pulses were pal- common feature, occurring eventually in claudication. I have also seen patients
pable and symmetrical, and there were more than 70% of patients. Although the with TA present with pain in the sinus
no bruits in the carotid, subclavian, ax- headache often causes a deep aching pain region or in the ear. Some were treated
illary, abdominal aortic, or femoral ar- over the temporal area, the headache can with antibiotics for sinusitis or otitis de-
tery regions. be extremely variable in location, inten- spite the absence of any physical find-
sity, and quality. Quite often, the only ings to support those diagnoses. Given
DISCUSSION distinctive feature of the headache is that the variability in presentation of the head-
Professor R’s presentation is instruc- it is new. Even if the patient has experi- aches and jaw claudication associated
tive because it emphasizes some of the enced migraines or tension headaches for with TA, the diagnosis should be con-
unusual ways in which TA can pre- years, he/she will note that this head- sidered whenever anyone older than 50
sent. When it presents atypically, as it ache is different. Alternatively, the pa- years complains of persistent unex-
did in Professor R, it may not be diag- tient may say, “I am 72 and have never plained pain above the neck.
nosed before the development of blind- had headaches until now.” Some pa- Polymyalgia rheumatica is defined as
ness, the most feared complication of tients develop inflammation of the oc- pain and stiffness in the shoulders, neck,
TA. Knowing the disguises that TA can cipital artery, causing pain at the base of and hip girdle areas and is worse in the
wear affords physicians the best chance the skull. These symptoms are easily mis- morning and improves as the day goes
of diagnosing and treating TA before the taken for cervical spine disease. on. Because of the pain, a patient may
development of blindness. Jaw claudication is the occurrence of have trouble combing hair, putting on a
pain in muscles of the face caused by pro- coat, or standing up from the toilet. It has
Definition, Epidemiology, tracted chewing.9 This symptom re- been said that getting out of bed is to PMR
and Pathogenesis sults from ischemia and is essentially an- what making a fist is to rheumatoid
Temporal arteritis is the most common gina of the muscles of mastication. In arthritis. While most patients with PMR
form of systemic vasculitis in adults. The contrast to temporal mandibular joint believe the pain is associated with weak-
disease is defined as a panarteritis that disease, jaw claudication does not pro- ness, they always say that pain is the pre-
preferentially involves the extracranial duce pain with the initiation of chew- dominant feature. (This contrasts with
branches of the carotid artery.1-6 Aging ing or with the chewing of soft foods. polymyositis and other forms of inflam-
is the single greatest risk factor for the Rather, jaw claudication is induced by matory myopathy, in which weakness is
disease: TA virtually never occurs be- the chewing of tougher foods such as the major complaint). Magnetic reso-
fore the age of 50 years, and the annual meat. I emphasize, however, that only nance imaging studies have demon-
incidence rises steadily thereafter, from about half of the patients with jaw pain strated clearly that the pain of PMR results
1.54 of 100000 people in the sixth de- from TA provide a classic description of from inflammation of bursae in the shoul-
cade of life to 20.7 of 100000 people in claudication. Many report merely a vague der and hip regions, and to a lesser extent
©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, June 12, 2002—Vol 287, No. 22 2997

inflammatory responses may explain

Box. Atypical Manifestations of Temporal Arteritis why some patients have a normal ESR
Respiratory tract symptoms despite having active TA.13,14
Dry cough
Sore throat Atypical Manifestations
Tongue pain About 40% of patients with TA do not
Choking sensation present with classic symptoms but
Fever of unknown origin rather with atypical manifestations
Large artery involvement
(BOX).3,15-19 The prominence of Profes-
Upper and lower extremity claudication
Thoracic or abdominal aortic aneurysm
sor R’s dry cough is noteworthy be-
Peripheral nervous system features cause respiratory symptoms can be an
Mononeuritis multiplex (especially of the brachial plexus) important manifestation of TA. The res-
Central nervous system features piratory manifestations of TA were
Stroke highlighted by a Mayo Clinic study
Transient ischemic attacks showing that about 1 patient in 10 has
Dementia respiratory symptoms.20 In 4%, these are
Hallucinations the chief complaints. 20 Dry cough,
Syndrome of inappropriate antidiuretic hormone which our patient had, is the most com-
Tumorlike lesions mon respiratory manifestation of TA.
Breast mass
The cause of the cough is not known.
Ovarian mass
Microangiopathic hemolytic anemia Chest imaging results are normal in
these patients. Because TA is a sys-
temic disease, it is possible that cough
centers, which are distributed through-
by synovitis of the nearby joints.10 These gia. Some patients also present with ar- out the midbrain, the airways, the dia-
findings help explain why patients most thritis that can be difficult to distin- phragm, and esophagus,21 become ir-
commonly localize the discomfort to the guish from rheumatoid arthritis.12 An ritated by inflammation in nearby blood
tissues rather than to joints. abnormal temporal artery is found on vessels. The cough resolves quickly af-
Visual symptoms, including loss of vi- physical examination in only half of the ter prednisone is started.
sion and diplopia, develop in about one patients.4-6,9 Therefore, a normal tem- When should dry cough, a very com-
third of patients (Table).4-6,9 Blindness is poral artery by physical examination mon symptom with many causes, be
the most worrisome complication be- does not exclude this diagnosis. Abnor- considered a possible manifestation of
cause it is usually irreversible. Blind- malities of the temporal artery include TA? First, because TA is so rare before
ness usually results from an anterior is- thickening, enlargement, or the loss of 50 years, a younger person with cough
chemic optic neuropathy, which in turn pulsation. Professor R had a thickened, should not be suspected of having the
is caused by occlusion of the posterior ropy temporal artery. Enlarged tempo- disease. Second, dry cough is never the
ciliary artery, a branch of the ophthal- ral arteries are not specific for TA; for sole symptom of patients with TA.
mic artery. The posterior ciliary artery is example, extensive Paget disease of the Cough occurring in the absence of other
the main source of blood flow to the op- skull can be accompanied by increased symptoms is not suggestive of TA. In-
tic nerve head.11 Blindness is almost never blood flow to the skull and enlarged tem- deed, some have had classic manifesta-
the first symptom of TA. Therefore, there poral arteries. tions, including headache and PMR,
is almost always a window of opportu- The most common laboratory abnor- which happened to be less trouble-
nity to make the diagnosis and prevent malities in TA are a markedly in- some to the patient than the cough.
visual loss. When blindness occurs, it de- creased ESR (averaging nearly 100 mm/ Some patients may not have had clas-
velops an average of 5 months after the h), a normochromic normocytic sic manifestations of TA but did have
onset of TA. Unfortunately, our patient anemia, and (in approximately 30% of other symptoms. Professor R experi-
developed this complication only 2 cases) a mildly elevated alkaline phos- enced malaise, weight loss, fatigue, and
months after the beginning of her symp- phatase.4-6,9 Although an elevated ESR tooth and tongue pain before she devel-
toms. In patients with anterior ische- is usually a reliable companion of TA, oped blindness. Thus, the patient’s age
mic optic neuropathy, no disc abnor- approximately 11% of patients pre- and the results of the review of symp-
malities are detectable for the first few sent with an ESR of 50 mm/h or less and toms help identify the patients with
hours. Subsequently, the disc swells and 4% have an ESR of 30 mm/h or less.13,14 cough who warrant further evaluation.
becomes pale.11 Recent use of corticosteroids for an- Other respiratory tract symptoms of
Other common manifestations of TA other condition (eg, asthma), local- TA include a sore throat (pharyngitis-
include weight loss, fever, and arthral- ized arteritis, or inability to express fully like symptoms), tenderness of the ante-
2998 JAMA, June 12, 2002—Vol 287, No. 22 (Reprinted) ©2002 American Medical Association. All rights reserved.

rior neck, tongue pain, hoarseness, and times more likely than age-matched cal features that substantially increased
the sensation of choking.20 Tongue pain controls to develop thoracic aortic an- the likelihood of TA among these pa-
results from ischemic damage that may eurysms.23 Although the aneurysms can tients were jaw claudication (positive
manifest as glossitis, ulceration of the complicate TA at any time, the mean likelihood ratio [LR], 4.2; 95% confi-
tongue, lingual claudication (tongue pain time to recognition of the aneurysms dence interval [CI], 2.8-6.2), diplopia
with talking), or lingual infarction. is 5 to 6 years after the diagnosis of TA. (positive LR, 3.4; 95% CI, 1.3-8.6), and
Fever of unknown origin is another More recent studies using positron temporal artery beading (positive LR,
important manifestation of TA.18 Tem- emission tomographic scans suggest 4.6; 95% CI, 1.1-18.4). A normal ESR
poral arteritis accounts for only 2% of that as many as one half of all patients reduced the likelihood of TA (negative
all fevers of unknown origin, but 16% with TA develop inflammation of the LR, 0.2; 95% CI, 0.08-0.51).30
of those occurred in patients older than aorta or its major branches.25 These attempts to make the diagno-
65 years.18 The fever in TA averages Although some patients with aortic in- sis of TA evidence-based powerfully un-
39.1oC and can reach nearly 40°C; about volvement by TA are asymptomatic, oth- derscore the importance of clinical
two thirds of patients have rigors and ers develop aortic dissection resulting in judgment. While TA affects less than
drenching sweats, features that often aortic regurgitation or sudden death. One 1% of the population, 39% of the pa-
conjure diagnoses of infection or lym- of my other patients illustrates this prob- tients referred for temporal biopsy had
phoma.18 Of great help in distinguish- lem. Her disease had been quiescent for a positive result.30 It is striking to re-
ing the fever of unknown origin of TA 5 years when she suddenly developed se- port how well physicians, analyzing all
from those caused by infection or ma- vere back pain. The initial evaluation was the data, identify cases of TA, espe-
lignancy is that almost all patients with unrevealing and she was given a tenta- cially when considering the low pre-
TA and fever of unknown origin have a tive diagnosis of a nephrocalcinosis. The dictive value of individual clinical vari-
normal white blood cell count, at least next day, the identity of her problem be- ables. A broad consideration of the
before starting prednisone.18 came clear when she developed acute typical and atypical features of TA may
Large artery involvement is more com- aortic regurgitation. Pathologic studies further improve clinical judgment.
mon among patients with TA than gen- suggest that aneurysms can result from
erally appreciated.22,23 One study of 238 smoldering inflammation or from weak- Establishing the Diagnosis
patients with TA noted involvement of ening of the vessel wall from previous in- To be classified as having TA, a patient
the carotid, vertebral, and subclavian ar- flammation.23 must meet 3 of the following 5 criteria
teries in 14% of patients.22 Such involve- Other atypical manifestations of TA are established by the American College of
ment may cause upper extremity clau- mass lesions of the breast or ovaries that Rheumatology: (1) 50 years or older, (2)
dication, unequal blood pressures in the mimic tumors,26 the syndrome of inap- new-onset localized headache, (3) tem-
arms, transient ischemic attacks, or ce- propriate antidiuretic hormone secre- poral artery tenderness as decreased tem-
rebrovascular accidents. Lower extrem- tion, microangiopathic hemolytic ane- poral artery pulse, (4) ESR of 50 mm/h
ity involvement that is sufficient to cause mia, peripheral neuropathy, and central or higher, and (5) abnormal temporal ar-
claudication is rare but has been re- nervous system symptoms (Box).15,16,27,28 tery biopsy findings demonstrating
ported.24 To maximize the chance of de- Why patients with TA develop differ- mononuclear infiltration or granuloma-
tecting large artery disease, the physi- ent manifestations is not entirely clear. tous inflammation.31 However, these clas-
cal examination of patients suspected of However, evidence suggests that some sification criteria were never meant to
having TA should include the measure- clinical subsets may involve unique serve as diagnostic criteria. Others have
ment of blood pressure in both arms, pathologic pathways that are caused by demonstrated the limitations of these cri-
careful palpatation of the bracheal and differential expression of inflammatory teria, including having a positive predic-
radial pulses, and auscultation for bruits cytokines.29 For example, interferon ␥, tive value of only 29%.32
not only above the carotid but also above elaborated by T cells, is increased in pa- In clinical practice, establishing the di-
and below the clavicle for subclavian dis- tients with biopsy proven TA but not in agnosis of TA usually requires a biopsy
ease and above the flexor surface of the patients who have PMR in the absence of the temporal artery. Because skip le-
upper arm to detect axillary artery in- of vasculitis.8,29 sions are believed to occur in TA, diag-
volvement. nosis is facilitated by obtaining large bi-
Even the aorta is involved in a sub- Predicting the Presence of TA opsy specimens (⬎2 cm long) and by
stantial number of patients with TA. A A recent literature review has tried to de- examining multiple pathologic sec-
population-based study from Olmsted termine the accuracy of the history, the tions.2 The administration of cortico-
County, Minnesota, revealed that 18% physical examination, and the ESR in the steroids given for less than 2 weeks does
of patients with TA have aortic involve- diagnosis of TA.30 The analysis focused not reduce the yield of temporal artery
ment, with the most common compli- on patients referred for TA biopsy and biopsy.33 Bilateral temporal artery biop-
cation being thoracic aortic aneu- determined which features best pre- sies are not usually needed because they
rysm.23 Indeed, patients with TA are 17 dicted a positive result. The only clini- are concordant in 95% to 99% of
©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, June 12, 2002—Vol 287, No. 22 2999

cases.34-36 Patients with large artery in- trexate is a steroid-sparing agent in TA.42 20. Larson TS, Hall S, Hepper NG, Hunder GG. Res-
piratory tract symptoms as a clue to giant cell arteri-
volvement are diagnosed by arteriogra- In conclusion, TA is the most com- tis. Ann Intern Med. 1984;101:594-597.
phy or magnetic resonance angiogra- mon systemic vasculitis in adults. Its 21. Irwin RS, Rosen MJ, Braman SS. Cough: a com-
prehensive review. Arch Intern Med. 1977;137:1186-
phy, either of which may demonstrate classic manifestations are headache, jaw 1191.
long segments of smooth stenoses. Tem- claudication, PMR, and visual symp- 22. Klein RG, Hunder GG, Stanson AW, Sheps SG.
poral artery biopsy is positive in only toms. However, TA can wear many dis- Larger artery involvement in giant cell (temporal) ar-
teritis. Ann Intern Med. 1975;83:806-812.
about half of patients who manifest large guises. The case presented empha- 23. Evans JM, O’Fallon M, Hunder GG. Increased inci-
artery disease.37 Duplex ultrasonogra- sizes how dry cough, atypical tooth dence of aortic aneurysm and dissection in giant cell (tem-
poral) arteritis. Ann Intern Med. 1995;122:502-507.
phy has identified abnormalities in 93% pain, and tongue infarction can all serve 24. Le Hello C, Lévesque H, Jeanton M, et al. Lower
of patients with TA but the technique as a warning that a patient may have TA limb giant cell arteritis and temporal arteritis. J Rheu-
matol. 2001;28:1407-1412.
is operator-dependent and the sensitiv- and be at risk of losing vision. 25. Blockmans D, Stroobants S, Maes A, Mortel-
ity and specificity of temporal artery ul- mans L. Positron emission tomography in giant cell ar-
Acknowledgment: I thank my patient for sharing her
trasound outside of a few research cen- teritis and polymyalgia rheumatica. Am J Med. 2000;
story, Roy Zieglestein, MD, and John Stone, MD, for
ters are unknown.38,39 It is also too early reading and improving the manuscript, and Tambra
26. Kariv R, Sidi Y, Gur H. Systemic vasculitis pre-
Noethen for assisting in the word-processing.
to tell whether the abnormalities seen on senting as a tumorlike lesion. Medicine. 2000;79:349-
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est reduction in prednisone did not gin. Arthritis Rheum. 1981;24:1414-1418. 42. Spiera RF, Mitnick HJ, Kupersmith M, et al. A pro-
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