What is the appropriate management for a 71-year-old male with a 2-day history of headache over his left temple, tender to palpation, low-grade fever, and no visual changes?

Giant Cell Arteritis: Immediate Management Required

This 71-year-old male with temporal headache, temporal tenderness, and low-grade fever requires immediate high-dose corticosteroids (prednisone 40-60 mg daily) started today, urgent ESR/CRP testing, and same-day rheumatology referral—do not wait for laboratory results before initiating treatment. 1, 2

Immediate Actions (Within Hours)

Start Treatment Now

• Initiate prednisone 40-60 mg daily immediately, even before laboratory confirmation, as delaying corticosteroid therapy when GCA is suspected is the strongest risk factor for permanent blindness 1, 2
• The combination of new-onset temporal headache in a patient over 50 years, temporal tenderness on palpation, and constitutional symptoms (fever) creates high clinical suspicion for GCA that warrants empiric treatment 2
• Treatment can be started safely before diagnostic confirmation because temporal artery biopsy remains diagnostic for up to 2 weeks after corticosteroid initiation 1, 2

Order Laboratory Tests Immediately

• Draw ESR and CRP stat before starting corticosteroids, but do not delay treatment while awaiting results 1, 2
• ESR >50 mm/h has 78.9% sensitivity for GCA, and CRP elevation has 79.2% sensitivity 2
• Approximately 4-11% of GCA patients have normal inflammatory markers, so clinical suspicion overrides laboratory values 2, 3

Arrange Urgent Referrals

• Same-day or next-day rheumatology consultation for fast-track evaluation and temporal artery biopsy planning 1
• Ophthalmology referral within 24 hours to assess for subclinical visual involvement, even though this patient currently denies visual changes 2, 4

Critical Clinical Assessment

Confirm GCA Features Present

• Temporal artery tenderness (present in this patient) has 90.6% specificity with positive likelihood ratio of 4.70 2
• New-onset persistent localized headache in the temporal area is a key symptom of GCA 1
• Low-grade fever represents constitutional symptoms seen in active large vessel vasculitis 1

Assess for High-Risk Features

• Specifically ask about jaw claudication (pain with chewing)—this has 90.6% specificity and positive likelihood ratio of 4.90 for GCA 2
• Ask about any visual symptoms: transient vision loss (amaurosis fugax), diplopia, or blurred vision—these indicate urgent need for even more aggressive management 1, 2
• Assess for scalp tenderness beyond the temporal area 1
• Check for symptoms of polymyalgia rheumatica (bilateral shoulder/hip girdle pain with morning stiffness >45 minutes) 4

Diagnostic Work-Up (Do Not Delay Treatment)

Temporal Artery Biopsy

• Schedule temporal artery biopsy within 1-2 weeks, ideally coordinated through rheumatology 2, 4
• Biopsy sensitivity remains 67-97% even when performed up to 2 weeks after starting corticosteroids 2
• Negative biopsy does not exclude GCA if clinical suspicion remains high 2

Additional Evaluation

• Check complete blood count (anemia and thrombocytosis support GCA diagnosis) 3
• Assess bilateral upper extremity blood pressures and peripheral pulses to evaluate for large vessel involvement 4
• Consider vascular imaging if symptoms suggest extracranial large vessel disease 4

Critical Pitfalls to Avoid

• Never delay corticosteroids while awaiting ESR/CRP results or temporal artery biopsy in suspected GCA—this is the most common and dangerous error 1, 2
• Do not attribute new-onset headache in elderly patients to migraine or tension headache, especially after age 50 with temporal location 2
• Do not pursue neuroimaging (CT/MRI) first when GCA is suspected based on classic symptoms—this wastes precious time 2
• Do not assume absence of visual symptoms means low risk—vision loss can occur suddenly and is irreversible once established 1, 2

Monitoring and Follow-Up

• Monitor ESR and CRP every 2-4 weeks initially until normalization, then every 6 months during maintenance therapy 4
• Most patients require 2-3 years of treatment with gradual tapering guided by clinical symptoms and inflammatory markers 4
• Target dose after 2-3 months is 15-20 mg/day, and after 1 year is ≤5 mg/day 1
• Consider tocilizumab as glucocorticoid-sparing agent to reduce long-term steroid exposure 4

Why This Patient Cannot Wait

• The presence of fever with temporal headache and tenderness represents active arterial inflammation that can progress to involve the ophthalmic artery within hours to days 1, 2
• Once ischemic optic neuropathy occurs, vision loss is permanent and irreversible 2
• The contralateral eye is at high risk once one eye is affected, making bilateral blindness a real possibility without immediate treatment 2
• High-dose corticosteroids dramatically reduce the risk of permanent blindness and represent the single most important intervention to preserve quality of life 1, 2