A Cough, Toothache, and Tongue Infarction

CASE PRESENTATION DR HELLMANN: My patient, Professor R, who is a 79-year-old woman, was well until she developed a disorder that eventually produced blindness in her right eye. Although most of the common presenting features of temporal arteritis (TA) are familiar to general internists and family physicians, the many disguises of this condition may challenge the diagnostic skills of any experienced physician. Learning to see through these disguises is crucial to early diagnosis and the prevention of visual loss. Professor R, please tell us how your illness began. PROFESSOR R: All my troubles began the month my husband and I were moving from our home into a retirement community. Before that, I was completely healthy, playing tennis, swimming, and hiking. I am now a professor emeritus and still perform research on iconography of libraries in the 17th and 18th centuries. It keeps me interested, traveling, and visiting libraries in Europe. My husband and I have been doing all sorts of exciting things and I have never been in a hospital except for a broken arm. The month we sold our house I was under a great deal of stress. Moving from a house into a 2-bedroom apartment, I had to give up a lot, especially my own library of 2000 books. So, I was so tired that I began to take naps for the first time. I thought the tiredness would go away but after 2 to 3 weeks I also developed a cough. DR HELLMANN: Did you bring up anything when you coughed? PROFESSOR R: No, it was dry. I saw a physician who gave me some pills but the cough persisted. Two months later I continued to cough and felt exhausted. Since it was winter, we thought that if we got away for a week to Hawaii I would get better. The afternoon before we left for Hawaii I awoke from a nap and could not see out of my right eye. It was all black. I could not reach a physician so I told my husband, “Let’s just go. By the time we get back I’m sure I’ll be seeing fine again.” And we went on our trip. DR HELLMANN: Did your vision get better? PROFESSOR R: No, it never did. DR HELLMANN: Did you experience a headache or any other symptoms, aside from the fatigue, cough, and visual loss? PROFESSOR R: I never had a headache. But after I started coughing and before I had the eye problem, I did develop a toothache. I could not quite determine which tooth or teeth hurt. My mouth just hurt all over. Then I developed a burning sensation on the left side of my tongue. Between my toothache and tongue pain, I could not eat very well and lost 20 pounds during the week we were away. When we returned from Hawaii, my first visit was to the dentist. He found nothing wrong with my teeth. It was actually an ophthalmologist who first suspected the correct diagnosis because of my blindness and other symptoms; the eye doctor tested my sedimentation rate and then immediately admitted me to the hospital. DR HELLMANN: That is right, the erythrocyte sedimentation rate (ESR) was 115 mm/h. Results of the other tests performed at that time, including a complete blood cell count, serum chemistries, and a chest radiograph, were normal. She was treated with intrave-