Two months later the patient was seen in follow-up. She reported her symptoms had improved on an elimination diet. However, on review of systems, she admitted to a mild right side parietal headache, right side neck pain, right side sinus pain, a vague sensation of jaw tiredness when chewing and mildly blurry vision for two weeks. Labs revealed a CRP of 16 mg/L (normal: <10 mg/L), ESR of 56 mm/hr (normal: <30 mm/hr), a serum protein electrophoresis (SPEP) with polyclonal hypergammaglobulinemia consistent with chronic inflammation, interleukin (IL) 6 of 13 pg/mL (normal: <5 pg/mL), negative hepatitis serologies and negative QuantiFERON-TB gold. The IgG was 1,600 mg/L, which was at the top range of normal.
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Explore This IssueNovember 2018
Given the high concern for GCA, she agreed to a right temporal artery biopsy, which showed classic giant cell arteritis with transmural (predominantly medial and adventitial) inflammation comprising lymphocytes, plasma cells and multinucleated giant cells, as well as segmental destruction of the internal elastic lamina on H&E and VVG stains.
She was started on 60 mg prednisone daily and 81 mg aspirin daily.
Psychiatric complications of steroid use are seen in about 6% of patients on steroids & seem to be dose dependent; psychosis typically occurs at doses of greater than 20 mg
She was seen in follow-up one week later, and she reported that all of her symptoms—including her myalgias, headache, jaw pain and vision changes—had completely resolved. Her only new complaint was difficulty sleeping, but she declined a sleep aid. Labs showed normalized inflammatory markers. At her next office visit a month later, she was found to be emotionally labile with anxiety, pressured speech, suicidal ideation and episodes of events in which laughing and crying would trigger a loss of muscle tone but not consciousness (this was observed in the exam room). She was admitted to the hospital for management of new-onset, steroid-induced mania, depression, anxiety and cataplexy.
During her hospitalization, her prednisone was quickly weaned to 30 mg/day, but she subsequently developed recurrent symptoms of headache and blurry vision, and her CRP jumped from <3 mg/L to 31.1 mg/L. Her prednisone dose was, therefore, increased to 50 mg daily, and she was started on olanzapine for psychosis and lithium for mood stabilization. Additional steroid-
sparing agents were discussed with the patient and her family, but she adamantly refused treatment with methotrexate (because she knew someone who had side effects to methotrexate), and she wasn’t willing to start any new medication for GCA.