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A severe migraine-type headache and permanent loss of vision in the right eye occurred on December 10th while preparing for bed. I administered an injection of Imitrex and a second injection an hour later when the first didn’t help. This was the prescribed protocol for migraine headaches which we had done often before over the years. I learned later that Imitrex is a vasoconstrictor – producing the opposite effect of what Pearl needed in this crisis. GCA reduces the flow area in the arteries so a vasoconstrictor would contribute to further reduction of flow to the optic nerve if it weren’t already completely closed. Permanent blindness occurs in four hours if the optic nerve is starved of blood.
In the morning sight hadn’t returned in her right eye so the FFP advised that she go to the hospital ER. There we heard Giant Cell Arteritis mentioned for the first time – they sent us to see an Ophthalmologist immediately. He examined Pearl upon arrival at his office and confirmed the GCA diagnosis and the permanent loss of vision - he prescribed oral prednisone which was started at once.
The hospital did a blood test before Pearl was taken to the Ophthalmologist’s office. The Ophthalmologist received a copy of the results during our visit and became irate because the sed rate was 124 mm/hr – he called the FPP to question why he didn’t diagnose her condition earlier, noting the highly elevated sed rate. The FPP pointed out that the sed rate was normal at 19 when he tested it a month earlier - November 9, 1998. It should be noted that sed rate is considered "normal" if it is less than 40 – this applies to an average elderly woman. Sed rate varies for individuals and circumstances. I learned later that Pearl’s normal sed rate is 10 mm/hr or less so it was elevated in November but not recognized to be. Another fact not recognized then was that sed rate might not be elevated in all cases of GCA/PMR inflammation so symptoms are very important also.
With loss of vision in one eye we returned to the FPP for referrals to several other specialists who Pearl would need to confirm and manage this new illness. These included a Rheumatologist, Hematologist, and Gastroenterologist.
The Rheumatologist we learned would provide the prednisone management after the immediate vision crisis passed. The Ophthalmologist monitored closely the dosage and tapering prescribed by the Rheumatologist until 20 mg/day was reached. By that time he was confident she would retain vision in the good eye with the dosage needed to control the GCA inflammation.
The Hematologist was needed because the platelets were highly elevated at 751 (normal range 140-440). This could be lupus rather than GCA if platelets exceeded 1,000 in the coming days.
The Gastroenterologist was solicited by the FPP to advise him of why the Alk Phos had been elevated in the November 9th blood test.
The temporal artery biopsy on the right side was done by the Ophthalmologist on December 16, 1998, and being positive confirmed the diagnosis of GCA. Giant cells were found within the temporal artery wall.
Our immediate task at home was to search the internet and medical reference books for what we could learn about GCA. We weren’t aware yet of polymyalgia rheumatica, the companion illness.