Mrs R, a 52-year-old union official, had been attending her local medical outpatients department for three years, under the care of Dr G, general physician. Dr G had diagnosed giant cell (temporal) arteritis when she was first referred by her GP, Dr Y. Mrs R gave a classical history of temporal headache, generalised weakness and malaise. She had a significantly elevated ESR.
Dr G treated Mrs R successfully with prednisolone. Her symptoms rapidly resolved and the ESR returned to the normal range. She was followed up in his clinic and the dose of prednisolone was gradually reduced over the years. During this time it was also noted that she was hypertensive. Her blood pressure had been controlled with bendroflumethazide and ramipril.
Over the course of her attendance at the clinic, the emphasis of letters from the medical clinic to Dr Y changed from the management of her arteritis to that of her blood pressure. When Dr G discontinued Mrs R’s prednisolone because she had been symptom free and on a very low dose of prednisolone for a year, this fact was not mentioned in the letter to Dr Y. Mrs R was eventually discharged from Dr G’s clinic.
Two years later, Mrs R started to get persistent severe headaches and saw Dr Y again. She visited on several subsequent occasions with further episodes of headache, pain in her temples and an aching jaw. On each occasion Dr Y checked her ESR, which was always in the normal range. Dr Y was reassured by this and concluded that Mrs R’s giant-cell arteritis had not relapsed and attributed Mrs R’s symptoms to tension and anxiety (she had been passed over for promotion at work and was very unhappy about this).
Mrs R later saw Dr Y because of painful eyes and blurred vision. Dr Y referred her to an ophthalmologist for advice. When he saw the eye specialist six weeks later, her vision had deteriorated and the headache and jaw pain had continued unabated. The ophthalmologist diagnosed a relapse of temporal arteritis. Unfortunately, by this time, Mrs R had suffered ischaemic optic neuropathy affecting both eyes and was left with little useful vision. Mrs R was registered as partially sighted and had to retire from her job on health grounds.
A GP expert who examined the case was of the opinion that Dr Y had not recognised a classical presentation of relapse of giant-cell arteritis and had been falsely reassured by a normal ESR. The expert felt that Dr Y should have been wary of the presentation in someone with Mrs R’s history, particularly when ocular symptoms started to surface. She pointed out that relying on the ESR is a poor indicator of relapse for giant-cell arteritis. Giant-cell arteritis is known to occur with a normal ESR, so further investigations such as a temporal artery biopsy are sometimes necessary to diagnose the condition.
The expert criticised Dr Y for not being more aware of the likelihood of relapse and for letting investigation results take primacy over the patient’s clinical condition.A GP would usually refer Mrs R urgently to a physician for advice on how to proceed, as soon as her symptoms recurred, in the face of convincing symptoms but a normal ESR. The expert was concerned at the poor communication between Dr G and
Dr Y, specifically the failure to note discontinuation of steroids and advice on the possibility of relapse.
The case was settled for a moderate sum.
- A patient’s symptoms and signs should always form the foundation for a diagnosis; investigation results can help to support or refute a diagnosis, but where the clinical scenario is typical for a condition it is risky to discount it purely on the basis of investigations. This is especially important where the diagnosis is time-sensitive.
- Before using an investigation to confirm or exclude a diagnosis it is vital to understand its usefulness, and to be aware of exceptions to the normal pattern of results.
- Giant-cell arteritis is a condition that is known to be prone to relapse; there should be a high index of suspicion of the condition in those who have a history of the illness and present with symptoms attributable to it, even if they are non-specific.
- It is rare for the ESR to be normal in a patient with giant-cell arteritis but it is a well-recognised phenomenon. If there is any doubt then refer to a specialist physician for advice.
- The lack of good communication between doctors was a major part of this case. There was also everything to gain, and nothing to lose, by copying the patient in on this communication.
Meskimen S et al., Management of Giant Cell Arteritis and Polymyalgia Rheumatica Am Fam Phys 61(7): 2061–8, 2073 (2000). Available online at www.aafp.org. Good overview of the approach to the condition(s) in primary care.
Weyand CM, Goronzy JJ, Giant-Cell Arteritis and Polymyalgia Rheumatica Ann Intern Med139:512 (2003). Available online at www.annals.org
Kavanagh S, Diagnosing Acute Headache. Avoiding Pitfalls – A Guide to Practice Casebook 2003(3), August. Available online at www.medicalprotection.org