Immediate ED Referral for Suspected Giant Cell Arteritis
This patient requires immediate emergency department referral and should not leave your office without urgent assessment—do not delay treatment while awaiting confirmatory testing. 1, 2
Why This is a Medical Emergency
This 55-year-old patient presents with classic red flags for giant cell arteritis (GCA) that demand urgent action:
- New-onset headache in patient >50 years: Bilateral, continuous, throbbing headache with sensation of head being "stuck in something" 1, 3
- Jaw claudication: Pain when chewing is one of the strongest predictors of GCA (positive likelihood ratio 4.90) 1
- Visual symptoms: "Dull vision" and forcing eyes represents threatened vision loss—the most feared complication of GCA 1, 4, 3
- Palpable temporal arteries with pulsation: While temporal artery abnormalities increase diagnostic likelihood, normal pulsation does not exclude GCA 1
The combination of new headache, jaw claudication, and visual symptoms in a patient over 50 creates extremely high pretest probability for GCA and mandates immediate intervention. 1
Immediate Actions Required
At ED Presentation
Start high-dose glucocorticoids immediately—do not wait for biopsy or imaging results: 1, 2
- For threatened vision loss (which this patient has): Initiate IV pulse glucocorticoids (typically methylprednisolone 500-1000 mg daily for 3 days) 1
- Alternative if IV not immediately available: High-dose oral prednisone 40-60 mg daily (0.7-1 mg/kg) 1, 2, 3
- Treatment should begin within 24 hours of symptom recognition to prevent permanent blindness 1, 2
Urgent Diagnostic Workup (While Starting Treatment)
Laboratory testing to obtain immediately: 1, 2
- ESR (erythrocyte sedimentation rate): >40 mm/h supports diagnosis; >100 mm/h has high specificity (positive LR 3.11) 1, 2, 4
- CRP (C-reactive protein): Elevated in >95% of GCA cases; absence of CRP ≥2.5 mg/dL has negative LR 0.38 1, 2, 4
- Platelet count: >400 × 10³/μL has positive LR 3.75 1, 4
- Complete blood count (anemia common) 4, 5
Temporal artery biopsy: 1
- Remains gold standard for diagnosis but should NOT delay treatment 1, 2
- Should be performed within 2 weeks of starting glucocorticoids (biopsy remains positive for up to 2 weeks after treatment initiation) 1
- Unilateral biopsy with long segment (>1 cm) is recommended 1
If temporal artery biopsy is negative: Consider noninvasive vascular imaging (temporal artery ultrasound, MRI, or PET) to evaluate for large vessel involvement 1
Additional Management Considerations
Aspirin Therapy
Add low-dose aspirin (75-150 mg daily) for all GCA patients to protect against cardiovascular and cerebrovascular events, particularly given this patient's hypertension and pre-diabetes 1, 2
Adjunctive Immunosuppression
Consider tocilizumab in addition to glucocorticoids for newly diagnosed GCA, as it reduces glucocorticoid requirements and flare rates 1, 2, 6
Methotrexate may be used as steroid-sparing agent if tocilizumab unavailable or contraindicated 1, 7, 8
Critical Pitfalls to Avoid
Do not wait for normal inflammatory markers to exclude GCA: While ESR >40 mm/h and elevated CRP are present in >95% of cases, rare patients have normal values 1, 2
Do not delay treatment for biopsy: Vision loss can occur rapidly and is often irreversible; glucocorticoids should be started immediately on clinical suspicion 1, 2, 3
Do not dismiss the diagnosis based on normal temporal artery examination: Palpable, pulsatile temporal arteries do not exclude GCA—the disease can affect other cranial and large vessels 1, 4
Do not underestimate the urgency: Untreated GCA leads to permanent blindness in 14-18% of patients and can cause stroke, cranial nerve palsies, and aortic complications 4, 3, 5
Monitoring After Treatment Initiation
Once treatment is established, clinical monitoring with ESR and CRP should guide glucocorticoid tapering decisions 1, 2
Periodic vascular imaging may be necessary to assess for large-vessel involvement and complications, especially aortic aneurysms 1, 2