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Giant cell arteritis with amaurosis fugax — SCE Rheumatology MCQ

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ModerateRheumatology EmergenciesGiant cell arteritis with amaurosis fugaxSCE Rheumatology

A 74-year-old woman presents with a 10-day history of a new right temporal headache, scalp tenderness and jaw claudication. During the preceding 24 hours, she has had two episodes of painless, curtain-like loss of vision in the right eye, each lasting approximately 5 minutes. Visual acuity and fundoscopy are currently normal. CRP is 68 mg/L, ESR 82 mm/h and platelet count 512 × 10^9/L. Temporal artery ultrasonography is available tomorrow morning, and intravenous glucocorticoid treatment is immediately available. Which is the most appropriate immediate management plan?

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

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Correct answer: C — Start intravenous methylprednisolone 500 mg to 1 g daily for up to 3 days now, arrange ultrasonography tomorrow, and obtain same-day ophthalmic assessment

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

The episodes are amaurosis fugax in a patient with a high clinical probability of giant cell arteritis (GCA), supported by jaw claudication, a new temporal headache and inflammatory marker and platelet elevation. Intermittent visual loss represents cranial ischaemia and threatens irreversible visual loss in either eye. UK specialty guidance supports immediate high-dose glucocorticoid treatment; intravenous methylprednisolone 500 mg to 1 g daily for up to 3 days should be considered when acute or intermittent visual loss is present. Treatment must not await ultrasonography or biopsy, and visual symptoms require same-day ophthalmic assessment. A uses an inadequate oral dose for GCA and makes ophthalmic referral conditional on imaging. B is closer because 60 mg oral prednisolone is appropriate initial therapy for uncomplicated cranial GCA and should be given if intravenous treatment would be delayed, but it under-treats this immediately accessible visual emergency and delays ophthalmology. C risks preventable blindness by requiring diagnostic confirmation before treatment. D begins an appropriate glucocorticoid regimen but incorrectly makes ophthalmic assessment contingent on recurrent symptoms; a normal examination between episodes does not remove the threat of ocular ischaemia. Confirmatory testing should proceed promptly after treatment has started, because neither a forthcoming ultrasound nor currently restored vision justifies delay.

Reference: British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis (1 March 2020) — https://pubmed.ncbi.nlm.nih.gov/31970405/ Updated giant cell arteritis guideline launches (23 January 2020) — https://www.rheumatology.org.uk/news/details/Updated-giant-cell-arteritis-guideline-launches 2018 Update of the EULAR recommendations for the management of large vessel vasculitis (January 2020) — https://ard.bmj.com/content/79/1/19