Rheumatology for MRCP Part 2

A 74-year-old woman describes a 3-week history of left temporal headache, scalp tenderness on brushing her hair, and jaw pain when chewing. This morning she noticed transient blurring in the left eye. ESR is 88 mm/hr. What is the most appropriate immediate action?

1. Start a non-steroidal anti-inflammatory and review in one week Wrong. NSAIDs do not treat the vasculitis, and a week's review with visual symptoms is far too slow.
2. Start low-dose prednisolone 15 mg daily Wrong dose. Uncomplicated polymyalgia-type disease may start around 15 mg, but GCA needs 40 to 60 mg, and visual involvement warrants high-dose treatment, often intravenous methylprednisolone.
3. Start high-dose corticosteroids immediately and arrange urgent temporal artery biopsy correct Correct. Giant cell arteritis with visual symptoms is an ophthalmic emergency. Steroids start at once. Biopsy remains informative for up to about two weeks afterwards, so waiting for histology risks blindness for no diagnostic gain.
4. Arrange temporal artery biopsy and start steroids once histology confirms the diagnosis Wrong, and the most dangerous option here. Any delay in a patient with amaurosis risks permanent visual loss, which is typically sudden, painless and can become bilateral.
5. Arrange an urgent MRI brain and defer treatment pending the result Wrong. Imaging does not exclude GCA and the diagnosis is clinical. Deferring steroids for any investigation with visual symptoms is the error being tested.

The point: GCA with any visual symptom: high-dose steroids now, biopsy soon. Add bone and gastric protection at the outset and consider tocilizumab as a steroid-sparing agent.

Source: BSR guideline — diagnosis and treatment of giant cell arteritis British Society for Rheumatology · tier 2, specialty society or college