What is the most appropriate immediate management step for a 72-year-old man with suspected giant cell arteritis, presenting with transient blindness, headache, jaw pain, tender temporal arteries, and elevated erythrocyte sedimentation rate (ESR)?

Management of Suspected Giant Cell Arteritis with Transient Monocular Blindness

Immediate corticosteroid therapy (prednisolone/prednisone) is the most appropriate first step in management for this patient with suspected giant cell arteritis presenting with transient monocular blindness and other classic symptoms.

Clinical Presentation Analysis

This 72-year-old man presents with a constellation of symptoms highly suggestive of giant cell arteritis (GCA):

• Transient monocular blindness (amaurosis fugax) in the right eye
• Headache for the past month
• Jaw claudication (pain with chewing)
• Low-grade fever (38.1°C/100.6°F)
• Tender, nodular temporal arteries with decreased pulses
• Markedly elevated ESR (92 mm/h)

Immediate Management

First Step: Corticosteroid Therapy

• Start high-dose oral glucocorticoids immediately (prednisolone/prednisone 1 mg/kg/day, maximum 60 mg/day) 1, 2
• Do not delay treatment while awaiting temporal artery biopsy 1, 2
• For patients with visual symptoms, some experts recommend initial IV methylprednisolone (500-1000 mg/day for 3 days) before transitioning to oral therapy 1

Rationale for Immediate Corticosteroid Therapy

1. Prevention of permanent vision loss: Transient monocular blindness is a warning sign of impending permanent vision loss, which occurs in approximately 18% of GCA patients 1
2. High clinical suspicion: Patient has multiple classic features of GCA
3. Emergency situation: GCA with visual symptoms represents a true medical emergency 2
4. Evidence-based approach: Guidelines strongly recommend immediate initiation of high-dose glucocorticoids when GCA is suspected 1, 2

Subsequent Management Steps

Temporal Artery Biopsy

• Arrange for temporal artery biopsy within 2 weeks of starting glucocorticoids 1, 2
• Obtain a long-segment specimen (>1 cm) to improve diagnostic yield 1, 2
• Initially, unilateral biopsy is recommended 1
• Biopsy should not delay treatment initiation 1, 2

Additional Therapy

• Add low-dose aspirin (75-150 mg/day) to reduce risk of ischemic complications 1
• Consider adjunctive immunosuppressive therapy (methotrexate or tocilizumab) for steroid-sparing effects 1

Monitoring

• Monitor clinical symptoms and inflammatory markers (ESR, CRP)
• Gradually taper glucocorticoids over months based on clinical response and laboratory parameters
• Target dose of ≤10 mg/day by 3 months, with further slow tapering 1
• Monitor for steroid-related adverse effects and provide bone protection therapy

Addressing Other Management Options

• Temporal artery biopsy (option E): Important diagnostic test but should not delay treatment; not the first step 1, 2
• Aspirin therapy (option B): Recommended as adjunctive therapy, not as sole initial treatment 1
• Carotid ultrasonography (option A): Not indicated as first-line management; may be part of subsequent workup 1
• Cefotaxime therapy (option C): Not indicated for GCA management

Special Considerations

Normal ESR Does Not Rule Out GCA

While this patient has a markedly elevated ESR (92 mm/h), it's worth noting that:

• Up to 15% of biopsy-proven GCA cases may have normal ESR 3, 4, 5
• Normal ESR should not delay treatment if clinical suspicion is high 6

Risk of Permanent Vision Loss

• Visual loss in GCA is often irreversible
• Prompt corticosteroid therapy is the only intervention proven to reduce risk of vision loss in the affected and contralateral eye 1
• Delay in treatment significantly increases risk of bilateral vision loss 7

Conclusion

For this patient with classic symptoms of giant cell arteritis including transient monocular blindness, the most appropriate immediate step is high-dose corticosteroid therapy to prevent permanent vision loss, followed by temporal artery biopsy within 2 weeks for definitive diagnosis.