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GCA Normal Inflammatory Markers — SCE Rheumatology MCQ

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HardVasculitisGCA Normal Inflammatory MarkersSCE Rheumatology

A 72-year-old woman has a 10-day history of a new temporal headache, scalp tenderness and jaw claudication. She has also experienced a 20-minute episode of binocular diplopia. The ipsilateral temporal artery is tender with reduced pulsation. She has not received glucocorticoids or an interleukin-6 inhibitor. Her ESR is 12 mm/hour, CRP 4 mg/L and platelet count 260 × 10^9/L. Which statement most accurately interprets these results?

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Correct answer: B — Untreated cranial GCA remains possible; about 4% of biopsy-proven cases have normal inflammatory markers

Explanation lettering: E = shown as A · C = shown as B · D = shown as C · B = shown as D · A = shown as E

GCA remains a clinical possibility despite concordantly normal ESR and CRP. Approximately 4% of biopsy-proven cases have normal inflammatory markers at diagnosis, and contemporary biopsy-verified data give a similar estimate of 3.5%. This patient has several high-risk cranial features—new temporal headache, jaw claudication, an abnormal temporal artery and diplopia—so normal blood tests must not override the pre-test probability. She requires immediate high-dose glucocorticoid treatment, same-day assessment because of diplopia, and urgent confirmatory vascular ultrasound and/or temporal artery biopsy without delaying treatment. Neither ESR nor CRP is sufficiently sensitive to exclude GCA, so A and B are incorrect. Normal-marker disease does not require constitutional or large-vessel manifestations, excluding D. Diagnostic imaging and biopsy can confirm GCA without subsequent marker elevation, excluding E.

Reference: Mills-Baker F, Bakht T, Nugaliyadde A, Paul A. Easily Missed? Giant cell arteritis. BMJ 2026;392:e086139. Published 29 January 2026. https://pubmed.ncbi.nlm.nih.gov/37024620/