‘Giant Cell’ Arteritis in the ED: Temporal Tantrum

-Case-

An elderly woman walks into the ED complaining of a new, persistent headache localized to her right temple. It’s been going on for days and she describes it as “pounding.” She’s also noticed some blurry vision in her right eye and says chewing seems to fatigue her jaw more than usual. Her vitals are normal, but on exam, her right temporal artery is tender and feels “cord-like”. Labs show an ESR of 85. 

-Evaluation-

Temporal arteritis, also known as giant cell arteritis (GCA), is a large vessel vasculitis that predominantly affects the elderly. It’s a critical diagnosis in the ED because of its risk for irreversible vision loss.

  • Classic Symptoms:
    • New-onset headache (typically temporal)
    • Jaw claudication (pain with chewing) +/- scalp tenderness
    • Visual changes, including blurriness, diplopia, or vision loss
    • Constitutional symptoms such as fever, fatigue, weight loss
  • Physical Exam:
    • Tender, thickened, or pulseless temporal artery
    • Visual field deficits
    • May be subtle early in disease course
  • Labs:
    • Elevated ESR and CRP are key supportive findings
    • Mild normocytic anemia is common
  • Imaging/Diagnosis:
    • Temporal artery ultrasound may show a hypoechoic “halo sign”
    • Temporal artery biopsy is the gold standard but not needed to initiate treatment

-Management-

  • Start high-dose corticosteroids immediately!!!
    • Prednisone 40-60 mg daily for patients without visual symptoms
    • IV methylprednisolone (e.g., 1g/day) for 3 days for patients with visual changes, followed by an oral taper
    • Do not wait for biopsy or specialist confirmation to start steroids!
  • Ophthalmology consult if there is visual involvement or diagnostic uncertainty (they may recommend more advanced imaging modalities for further evaluation)
  • Temporal artery biopsy can be arranged within 1-2 weeks of treatment initiation

-Fast Facts-

  • Think about GCA in any elderly patient with a new headache, especially if there’s vision change or jaw pain
  • Don’t delay treatment – early steroids can prevent blindness!
  • ESR >50 mm/hr is supportive but not diagnostic

In the ED, temporal arteritis is one of those diagnoses you only get one shot at; missing it means risking permanent blindness. In elderly patients with red-flag headache symptoms, especially those with visual changes or jaw claudication, always keep GCA on your radar. When in doubt, start steroids.

Want to learn more? Listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet. 2008;372(9634):234-245. doi:10.1016/S0140-6736(08)61077-6
  2. Hellmann DB. Temporal arteritis: a cough, toothache, or fever may be the clue. Cleve Clin J Med. 2002;69(2):119-125.
  3. Kermani TA, Warrington KJ, Crowson CS, et al. Predictors of visual improvement in giant cell arteritis. Arthritis Care Res (Hoboken). 2010;62(6):836-842. doi:10.1002/acr.20119
  4. Ing EB, et al. Impact of delay to initiation of corticosteroids on visual outcomes in giant cell arteritis: A population-based study. J Neuroophthalmol. 2019;39(4):416-422. doi:10.1097/WNO.0000000000000795
  5. Dejaco C, Duftner C, Buttgereit F, et al. The spectrum of giant cell arteritis and polymyalgia rheumatica: revisiting the concept of the disease. *Rheumatology
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