| OCR Text |
Show Letters to the Editor Jaw Claudication and Temporal Artery Abnormalities in Giant Cell Arteritis: Take Advantage of Clinical Clues I read with great interest the clinical observation published by Petersen and Francis (1). Their patient had decreased visual acuity in the right eye and right-sided jaw claudication and was suspected of having giant-cell arteritis (GCA). However, the clinical picture was due to ocular ischemic syndrome secondary to complete occlusion of the brachiocephalic artery. Although highly specific for GCA, many other conditions are causes of jaw claudication. It is important to emphasize that jaw pain due to temporomandibular joint dysfunction begins right away with chewing, whereas arteritic jaw claudication develops after a brief period of chewing (2). The chewing gum test (3) is a simple and repeatable test for the differential diagnosis of jaw claudication. In the report by Peterson and Francis, examination of the temporal arteries was not described. It would be of great interest to know whether the patient had temporal artery abnormalities on clinical examination (tenderness, reduced or absent pulsation, erythema, nodularity, or swelling). It has been demonstrated that these abnormal findings are able to increase the probability of a positive temporal biopsy and are more predictive of disease than any other variable (including headache, jaw claudication, visual manifestations, and elevated erythrocyte sedimentation rate), with a positive likelihood ratio greater than 4 (2). For this reason, a thorough Jaw Claudication and Temporal Artery Abnormalities in Giant Cell Arteritis: Take Advantage of Clinical Clues: Response W e thank Dr. Vitiello for his interest in our article (1). We agree that nonarteritic causes of jaw claudication are extremely rare, and giant cell arteritis must be considered in all older individuals with this complaint. Our patient had true claudication-pain developed with extended chewing. The chewing gum test was not performed as her symptoms were quite specific, but the distinction between temporomandibular joint pain and jaw claudication is an important one when evaluating patients with jaw pain (2). Our patient had previously undergone a right temporal artery biopsy. She had right-sided frontal and temporal scalp tenderness, but the artery was not nodular when palpated. She had known diffuse atherosclerotic disease and a smoking history. She had previously undergone surgery for her peripheral vascular disease, but unfortunately she continued 458 clinical examination in search of abnormalities of the superficial temporal artery in patients with a suspicion of GCA is highly recommended (4). Jaw claudication in the patient described by Petersen and Francis was attributed to complete occlusion of the brachiocephalic artery. However, it is not clear what caused the occlusion. Was there a thrombophilic risk factor in this patient such as neoplasia, hereditary thrombophilia, lupus anticoagulant, or antiphospholipid antibodies? What was the suggested therapy and ultimate outcome? It would be helpful to have this information because of the fact that jaw claudication is a rare symptom and its causes apart from GCA are even more rare. Gianfranco Vitiello, MD Experimental and Clinical Medicine Department, University of Florence, Florence, Italy The author reports no conflicts of interest. REFERENCES 1. Petersen CA, Francis CE. Nonarteritic jaw claudication. J Neuroophthalmol. 2017;xx:xx-xx. 2. Smetana GW, Shmerling RH. Does this patient have temporal arteritis? JAMA. 2002;287:92-101. 3. Kuo CH, McCluskey P, Fraser CL. Chewing gum test for jaw claudication in giant-cell arteritis. N Engl J Med. 2016;374:1794-1795. 4. El-Dairi MA, Chang L, Proia AD, Cummings TJ, Stinnett SS, Bhatti MT. Diagnostic algorithm for patients with suspected giant cell arteritis. J Neuroophthalmol. 2015;35:246-253. to use tobacco. Surgery for her complete brachiocephalic artery occlusion was not advised by her vascular surgeon. She underwent panretinal photocoagulation for her ocular ischemic syndrome and secondary neovascular glaucoma, but continued to have significant eye pain from her chronic ocular ischemia and has since passed away. Courtney E. Francis, MD Christine A. Petersen, MD Department of Ophthalmology, University of Washington, Seattle, Washington The authors report no conflicts of interest. REFERENCES 1. Petersen CA, Francis CE. Nonarteritic jaw claudication. J Neuroophthalmol. 2017;37:xx-xx. 2. Kuo CH, McCluskey P, Fraser CL. Chewing gum test for jaw claudication in giant-cell arteritis. N Engl J Med. 2016;374:1794-1995. Letters to the Editor: J Neuro-Ophthalmol 2017; 37: 458-465 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
