skip to main content

Giant cell arteritis with transient visual loss — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

Moderateall topics relevant for this examGiant cell arteritis with transient visual lossMSRA

A 76-year-old man with polymyalgia rheumatica treated with prednisolone 5 mg daily presents with a 6-day history of new right-sided temporal headache, scalp tenderness and pain in his jaw when chewing. This morning, he had a 10-minute episode of painless loss of vision in his right eye, described as a curtain descending, which has fully resolved. He has type 2 diabetes mellitus managed with metformin. He is afebrile, visual acuity is currently normal in both eyes, and there is no focal neurological deficit. CRP is 48 mg/L; ESR is 18 mm/hour. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Start prednisolone 60 mg orally now, take blood tests without delaying treatment, and arrange same-day ophthalmology assessment

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

This presentation is strongly suggestive of giant cell arteritis (GCA): new temporal headache, scalp tenderness, jaw claudication and transient monocular visual loss. The visual episode is an ischaemic feature and makes this a same-day ophthalmic emergency because permanent visual loss may follow. Prednisolone 60 mg should be started immediately; diabetes increases the need for glucose monitoring but does not justify delaying sight-saving treatment. Blood tests should be obtained, but treatment must not await their results. A relatively normal ESR does not exclude GCA, particularly where the clinical syndrome is convincing and CRP is elevated. B is appropriate only for suspected GCA without visual symptoms or other cranial ischaemia, where urgent rheumatology-led assessment is appropriate. C is unsafe because ultrasound is useful diagnostically but must not delay glucocorticoids in strongly suspected GCA. D is initially attractive because transient monocular visual loss can represent a retinal TIA; however, the accompanying jaw claudication and scalp tenderness make GCA the decisive, immediately treatable diagnosis. E fails because visual symptoms require same-day ophthalmology assessment rather than routine specialist review.

Reference: Joint rheumatology/ophthalmology giant cell arteritis (GCA) referral guidelines (Reviewed 20 April 2026) — https://www.rightdecisions.scot.nhs.uk/dgrefhelp-nhs-dumfries-galloway/rheumatology/joint-rheumatologyophthalmology-giant-cell-arteritis-gca-referral-guidelines/ Suspected neurological conditions: recognition and referral — recommendations for adults aged over 16 (2019) — https://www.nice.org.uk/guidance/ng127/chapter/recommendations-for-adults-aged-over-16 Temporal arteritis (2023) — https://www.nhs.uk/conditions/temporal-arteritis/