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Suspected GCA — SCE Rheumatology MCQ

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ModerateVasculitisSuspected GCASCE Rheumatology

A 73-year-old woman presents with a new unilateral temporal headache, scalp tenderness and jaw claudication. Her ESR is 88 mm/hour. She has no visual symptoms, limb claudication or pulse asymmetry. She is referred urgently to a fast-track giant cell arteritis service where validated vascular ultrasonography is available on the same day. Which investigation should be arranged first to support the diagnosis, without delaying glucocorticoid treatment?

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Correct answer: E — Ultrasound of the temporal and axillary arteries

The correct answer is temporal and axillary artery ultrasound. Her age, new temporal headache, scalp tenderness, jaw claudication and markedly elevated ESR give a high pre-test probability of cranial giant cell arteritis. In a fast-track service with appropriate expertise, vascular ultrasound is the preferred initial imaging test because it is rapid, non-invasive and can demonstrate arterial wall inflammation. Glucocorticoid treatment must not be delayed while awaiting imaging. Temporal artery biopsy remains useful if ultrasound is unavailable or inconclusive and clinical suspicion persists. FDG PET-CT, CT angiography and MRI are more relevant when extracranial large-vessel involvement is suspected or when first-line assessment is non-diagnostic; this patient has no features specifically suggesting that phenotype.

Reference: British Society for Rheumatology. Diagnosis and treatment of giant cell arteritis: summary of the NICE-accredited BSR guideline, 2020. https://www.rheumatology.org.uk/news/details/articleid/217