What is the appropriate management for a patient presenting with bilateral temporal pallor, headache, and neck pain, with normal visual acuity (6/6)?

Urgent Evaluation for Giant Cell Arteritis Required

This patient requires immediate ESR, CRP, and temporal artery biopsy to rule out giant cell arteritis (GCA), as bilateral temporal pallor with headache and neck pain represents a vision-threatening emergency despite preserved visual acuity. 1

Critical Red Flags Present

This presentation contains multiple concerning features that mandate urgent workup:

• Bilateral temporal pallor suggests optic nerve ischemia, even with current 6/6 vision 1
• Temporal region pain with headache is classic for GCA, which can cause permanent visual loss if untreated 1
• Neck pain with headache in this context raises concern for vascular inflammation 1
• Normal visual acuity does NOT exclude GCA - optic nerve damage can progress rapidly 2

Immediate Diagnostic Algorithm

First-Line Laboratory Testing (Same Day)

• ESR and CRP immediately - even slightly elevated values warrant biopsy in elderly patients with these symptoms 1, 2
• Blood pressure, serum glucose, and hemoglobin A1c to assess vasculopathic risk factors 1

Critical Pitfall to Avoid

Do not be falsely reassured by only slightly elevated inflammatory markers - the case literature demonstrates GCA can present with minimally elevated ESR initially, yet still cause devastating visual loss if treatment is delayed 2. When clinical suspicion is high based on temporal tenderness and bilateral optic nerve findings, proceed to temporal artery biopsy even with borderline laboratory values 1, 2.

Temporal Artery Biopsy

• Perform if ESR/CRP suggest possible GCA - this is definitive for diagnosis 1
• Palpate temporal arteries during examination - tenderness is highly suggestive 2
• Consultation with neuro-ophthalmology can facilitate urgent biopsy and treatment initiation 1

Neuroimaging Considerations

When to Order MRI Brain and Orbits with Contrast

• If GCA is excluded but symptoms persist, obtain MRI to evaluate for other causes of bilateral optic nerve pallor 1, 3
• Look for demyelinating lesions, neoplasm, or increased intracranial pressure 1
• Bilateral sixth nerve involvement (if diplopia develops) suggests increased intracranial pressure or meningeal process 1

Lumbar Puncture Indications

• Evidence of increased intracranial pressure with papilledema 1
• Meningeal signs (stiff neck with headache) - measure opening pressure and evaluate for infectious, inflammatory, or carcinomatous meningitis 1
• Include Lyme and syphilis serology in this workup 1

Complete Ophthalmic Examination Required

Beyond visual acuity, perform:

• Fundus examination to check for papilledema or optic atrophy 1
• Visual field testing - may reveal defects despite normal acuity 1
• Pupillary examination - assess for afferent pupillary defect 3
• Cranial nerve assessment - look for associated palsies, nystagmus, or Horner's syndrome 1

Treatment Initiation

If GCA is Confirmed or Highly Suspected

High-dose corticosteroids must be initiated promptly to prevent permanent visual loss - this is a medical emergency 3, 2. Treatment should not be delayed while awaiting biopsy results if clinical suspicion is high 1.

If GCA is Excluded

• Treat underlying vasculopathic risk factors (diabetes, hypertension) 1, 4
• Monitor for spontaneous resolution over 4-6 weeks if vasculopathic etiology suspected 1
• Obtain neuroimaging if no improvement or if other neurologic signs develop 1

Specialist Referral

Immediate referral to neuro-ophthalmology or neurology is indicated for:

• Coordination of temporal artery biopsy 1
• Management of confirmed GCA 3
• Evaluation of alternative diagnoses if GCA excluded 1

The combination of bilateral temporal pallor with temporal region pain represents GCA until proven otherwise, regardless of preserved visual acuity at presentation 1, 2.