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Giant cell arteritis with transient visual loss — MSRA MCQ

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

A 74-year-old woman with polymyalgia rheumatica takes prednisolone 7.5 mg daily. She has type 2 diabetes mellitus managed with metformin. Over 4 days, she has developed a new left-sided temporal headache, scalp tenderness and pain in her jaw when chewing. This morning, she had two episodes of painless transient monocular visual loss in her left eye, each lasting approximately 5 minutes; vision is now normal. She is afebrile and neurologically normal. Her left temporal artery is tender. ESR is 18 mm/hour and CRP is 8 mg/L. There is no focal neurological deficit, carotid bruit or symptoms of infection. What is the most appropriate management now?

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

Reveal the answer and explanation

Correct answer: C — Give prednisolone 60 mg immediately and arrange same-day emergency ophthalmology assessment

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

This presentation is highly suggestive of cranial giant cell arteritis (GCA): she is over 50 years old, has new temporal headache, scalp tenderness and jaw claudication, and has had transient monocular visual loss. The latter is an ischaemic visual symptom and makes this a same-day ophthalmic emergency because permanent visual loss may rapidly follow. Prednisolone must be given immediately; investigation and specialist assessment must not delay treatment. UK guidance supports prednisolone up to 60 mg daily where visual symptoms or jaw claudication are present, with same-day ophthalmology assessment because intravenous methylprednisolone may be required depending on specialist assessment and local pathway. Her diabetes warrants early glucose monitoring, but it is not a reason to reduce or defer sight-saving treatment. B and E incorrectly delay glucocorticoids for diagnostic imaging or specialist review. C provides an inadequate dose for suspected GCA with visual ischaemia and routes her to the wrong immediate pathway. D is initially attractive because amaurosis fugax can indicate carotid embolism, but the accompanying cranial symptoms and temporal artery tenderness make GCA the priority; treatment for GCA must begin immediately while specialist assessment evaluates competing diagnoses. Normal or minimally raised inflammatory markers do not safely exclude GCA in a patient already taking glucocorticoids.

Reference: Giant Cell Arteritis (Temporal Arteritis) (Last reviewed 1 May 2025) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/medicine/rheumatology/giant-cell-arteritis-temporal-arteritis/?UNLID=2351630320262342948&useNavigation=true Giant Cell Arteritis (GCA) Guidelines (Interim guidance current at crawl; review planned 27 February 2026) — https://www.rightdecisions.scot.nhs.uk/tam-treatments-and-medicines-nhs-highland/therapeutic-guidelines/rheumatology/giant-cell-arteritis-gca-guidelines/