Case 1

A 74-year-old Green Bay Packers Cheerleader

Q1

A 74 yo ♀ presents to the ED, where you are the physician on call. She is concerned about sudden vision loss in her left eye.

What additional history do you want to obtain?


Q2

A 74 yo ♀ presents to the ED, where you are the physician on call. She is concerned about sudden vision loss in her left eye. She states that the episode occurred about 4 hours ago.

She has had no symptoms in the right eye. There is no eye pain, but she notes that she has been having headaches for the past 2 weeks.

What is your differential diagnosis? Pick your top four choices.

Q3

You examined this patient’s eyes using a direct ophthalmoscope. The right eye was completely normal to examination. The left eye is pictured below. What is the most likely diagnosis?

Match the fundoscopic change to the pathological condition.

 

Q4

You suspect she has giant cell arteritis based on her associated headaches which were located in the temporal region on both sides.

Which other symptoms would you expect her to have if she did?

Q5

What diagnostic tests would confirm a diagnosis of giant cell arteritis?

Q6

In the ED, her ESR and CRP come back elevated at 100 mm/hr and 12 ng/mL respectively. Temporal artery biopsy is not available for the next two days as your surgeon is on vacation.

What is the next best step in the management of this patient?

Summary

Giant cell arteritis (GCA) is a granulomatous vasculitis of medium sized blood vessels. It occurs most commonly in females than males with a ratio of about 3:1, and occurs most commonly at around age 70.

Symptoms include headache and scalp tenderness, usually in the temporal region, jaw claudication, amaurosis fugax (transient monocular loss of vision in one eye), and polymyalgia rheumatica (weakness in proximal muscle groups of upper and lower limbs).

The gold standard for diagnosis is temporal artery biopsy (need at least 3 cm sample). Histology reveals non-caseating granulomas in the vessel walls. Lesions are not continuous, so a negative biopsy does not guarantee that disease is not present. Other lab tests include markedly elevated ESR and CRP, along with mildly elevated alkaline phosphatase and platelets.

Treatment should be started immediately as the possible sequelae of untreated GCA include irreversible monocular blindness secondary to ischemic optic neuropathy. High dose prednisone (40-60 mg prednisone daily) should be started immediately, and the results of the temporal artery biopsy will not be affected for the first three days of therapy.