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Giant Cell Arteritis — SCE Rheumatology MCQ

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ModerateVasculitisGiant Cell ArteritisSCE Rheumatology

A 70-year-old man presents with a new temporal headache, scalp tenderness, jaw claudication and transient monocular visual loss. His ESR is 86 mm/h and CRP is 92 mg/L. He has received urgent ophthalmology assessment and glucocorticoid treatment has been started. Expert ultrasound of the temporal and axillary arteries performed within 24 hours shows no features of arteritis. No alternative diagnosis is apparent, and the clinical probability of giant cell arteritis remains high. What is the most appropriate next diagnostic step?

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Correct answer: A — Obtain temporal artery biopsy or second-line vascular imaging now

The correct answer is A. A negative temporal and axillary artery ultrasound does not exclude GCA when pre-test probability remains high. The cranial ischaemic symptoms, markedly raised inflammatory markers and absence of an alternative diagnosis are discordant with the scan, so further confirmation should be sought promptly with temporal artery biopsy or appropriate second-line imaging, such as high-resolution cranial MRI or FDG-PET directed by the suspected vascular distribution. Glucocorticoids should continue because diagnostic testing must not delay treatment in a patient at risk of irreversible visual loss. Repeating ultrasound after six months is inappropriate for resolving the acute diagnosis. PMR does not explain the cranial ischaemic manifestations. Tocilizumab is not a substitute for diagnostic confirmation and is not started solely because the initial ultrasound is negative.

Reference: European Alliance of Associations for Rheumatology, EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update, overarching principles A and C and recommendation 1. https://www.rheumatology.org.uk/guidelines/artmid/1257/articleid/207/management-of-adult-patients-with-idiopathic-inflammatory-myopathy-myositis