Bertha is a 55 year old woman with a history of Polymyalgia Rheumatica with poor compliance, who presents with sudden loss of vision in her right eye initially, followed by left eye soon after, associated with headaches in her temple, pain in her jaw, weight loss and night sweats. Inspection of the temporal region shows as below.
What is the most important diagnosis to consider in this case?
- Giant Cell Arteritis
What are the differentials for this presentation?
- Giant Cell Arteritis
- Migraine
- Tension-type headache
- Trigeminal neuralgia
- Transient ischemic attack,
- optic neuritis,
- acute angle closure glaucoma,
- retinal artery occlusion
What features of history would lead you to consider a diagnosis of Giant Cell Arteritis?
- Sudden loss of central vision in 1 eye
- Visual loss rapidly become bilateral
- Associated temporal headache
- History of PMR
- Myalgia
- Malaise
- Fever
- Elderly patient
- Scalp tenderness
- Jaw claudication
- Arthralgia
- Night sweats
- Weight loss
- Intermittent blurred vision
What are the features of examination that would allow you to find a cause for Bertha’s symptoms?
- Temporal arteries tender
- Scalp tenderness to palpation
- Temporal arteries thickened
- Temporal arteries non-pulsatile (
- VA severely impaired
- Afferent pupil defect on affected side
- Fever
- cotton-wool spots on fundoscopy
- Diplopia
What key investigations would you perform in considering a diagnosis of Giant Cell Arteritis?
- Temporal Artery USS
- Temporal artery biopsy
- MRI
- ESR > 50
- CRP > 50
What is the two most important immediate steps in management?
- Immediate corticosteroids 60-100mg prednisone daily for 2-4 weeks
- Referral to ophthalmologist
What are the complications of this disease?
- Artertic Anterior Ischaemic Optic Neuropathy
- Aortic Aneurysms
- Aortic Dissections
- Stenotic lesions of the aorta
- Seizures
- Stroke
- Steroid side effects
- Loss of vision
What are the side effects of steroid therapy?
- Osteoporosis,
- Myopathy
- Bruising
- Insomnia
- Depression
- Hypertension
- Diabetes
- Elevated cholesterol
- Fluid retention
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