What are the indications for suspecting giant cell (temporal) arteritis?

When to Suspect Giant Cell Arteritis

Suspect giant cell arteritis (GCA) in any patient over 50 years old presenting with new-onset persistent localized headache (especially temporal), jaw claudication, visual disturbances, or unexplained constitutional symptoms with elevated inflammatory markers. 1

Key Clinical Features That Should Trigger Suspicion

Cardinal Symptoms (High Specificity)

• New-onset persistent localized headache, particularly in the temporal area, is the most common presenting symptom and should immediately raise suspicion for GCA 1
• True jaw claudication—pain with chewing that resolves with rest (not constant dental pain)—is highly specific for GCA and indicates high risk for cranial ischemic complications 1, 2
• Visual symptoms including amaurosis fugax (transient vision loss), diplopia, or sudden vision loss represent medical emergencies, as 15-35% of GCA patients develop visual loss, primarily before treatment initiation 3, 4
• Temporal artery abnormalities on examination, including tenderness, decreased pulsation, or nodularity 5

Supporting Clinical Features

• Constitutional symptoms such as unexplained weight loss, low-grade fever, fatigue, and night sweats support the diagnosis 1
• Polymyalgia rheumatica symptoms—proximal muscle pain and stiffness in shoulders and hip girdle—occur in up to 50% of GCA patients 5
• Age over 50 years is essentially required, as GCA is exceedingly rare below this age 5, 6

Laboratory Findings

• Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are typically present, though normal inflammatory markers do not exclude GCA if clinical suspicion is high 1, 5
• Obtain immediate ESR, CRP, and complete blood count when GCA is suspected 4

Critical Diagnostic Pitfalls to Avoid

• Dental pathology can mimic GCA: Tooth infections can elevate ESR while CRP remains normal, and dental pain can be confused with jaw claudication—constant dental pain differs from true jaw claudication that resolves with rest 1
• Do not wait for biopsy confirmation to initiate treatment: Start high-dose glucocorticoids immediately upon clinical suspicion, as vision loss is often irreversible and can occur rapidly 1, 3, 7
• Patients may not volunteer visual symptoms: Specifically ask about transient visual disturbances, as amaurosis fugax may precede permanent vision loss 7
• Atypical presentations occur: Maintain high clinical suspicion even when classic features are absent, as the disease demonstrates significant heterogeneity in manifestations 8

Immediate Action Algorithm When GCA is Suspected

1. Obtain laboratory studies immediately: ESR, CRP, and CBC 4
2. Start treatment without delay: Initiate high-dose oral prednisone (1 mg/kg/day, maximum 60 mg) immediately for suspected GCA without visual symptoms 1, 3
3. Escalate to IV therapy for visual symptoms: Administer IV methylprednisolone 500-1000 mg daily for 3 days if any visual symptoms are present, then transition to oral prednisone 1, 4
4. Arrange temporal artery biopsy within 2 weeks: Biopsy remains diagnostic even after starting steroids if performed within this window; obtain long-segment biopsy (>1 cm) to improve diagnostic yield 9, 1
5. Consider imaging if biopsy is negative: If temporal artery biopsy is negative but clinical suspicion remains high, obtain noninvasive vascular imaging (CT/MRI angiography, ultrasound, or FDG-PET) to evaluate for large vessel involvement 9, 1

High-Risk Features Requiring Emergency Management

• Any visual symptoms (amaurosis fugax, diplopia, vision loss) require immediate IV pulse glucocorticoids to prevent permanent vision loss 2, 4
• Without treatment, the risk of vision loss in the second eye approaches 50% if one eye is already affected 1, 3
• Jaw claudication with pain is a high-risk symptom that may precede cranial ischemic complications 2