A 68-year-old woman with a history of amyloidosis complicated by end-stage renal disease on peritoneal dialysis presented to the emergency department with 3 days of right-sided neck pain. The patient noticed severe sharp pain in her right posterior neck and proximal right shoulder on wakening, which progressed to include the right side of her head. The pain was exacerbated by chewing and associated with blurry vision, which had resolved by the time of presentation. Physical examination revealed tenderness to palpation in the right temporal region and normal visual acuity. Laboratory results were significant for an elevated erythrocyte sedimentation rate above 100 mm/h, and a computed tomographic scan of the head and neck did not show an acute abnormality. Owing to concern for giant cell arteritis (GCA), the patient was immediately started on therapy with 20 mg of oral prednisone. This dose was lower than the standard dose for empiric GCA treatment because the patient had previously developed delirium with higher doses of prednisone. The patient was then admitted to the medicine service for temporal artery biopsy.
Hamilton KT, Lee BJ. In-Hospital Delirium While Awaiting Temporal Artery BiopsyA Teachable Moment. JAMA Intern Med. 2014;174(12):1891-1892. doi:10.1001/jamainternmed.2014.5310