Friday Afternoon Headache, Jaw Claudication, and Transient Monocular Vision Loss
A 74-year-old retired teacher presents urgently at 3:45 p.m. on a Friday with a 5-day history of right-sided temporal headache, scalp tenderness when combing her hair, and jaw pain after chewing a sandwich. This morning she noted a 'gray curtain' over the right eye lasting 10 minutes, and she now reports blurred vision OD. Best-corrected acuity is 20/60 OD and 20/25 OS; there is a right relative afferent pupillary defect, and the right disc is swollen with a few peripapillary splinter hemorrhages. She has polymyalgia rheumatica diagnosed 2 years earlier, for which she takes prednisone 5 mg daily. ESR is pending; the local laboratory closes at 5 p.m., and the on-call rheumatologist will not call back for at least an hour. She is reluctant to go to the emergency department because she is hosting family for the weekend and 'feels silly.'
1. What is your diagnosis and immediate management? What must not delay treatment?
Read the worked answer
This is giant cell arteritis with arteritic anterior ischemic optic neuropathy, and the clock is running. Age 74, new temporal headache, scalp tenderness, jaw claudication, transient monocular vision loss ('gray curtain'), then disc edema with an RAPD - this is GCA until proven otherwise. Jaw claudication and amaurosis fugax are the highest-yield history items, and both are present.
Action, in order:
- Start high-dose corticosteroid now - IV methylprednisolone 1 g/day for 3 days, or oral prednisone 1 mg/kg/day (60–80 mg) if IV access would delay care.
- Send her to the emergency department with a written note stating the diagnosis and the steroid dose given or required. The fellow eye can be lost within days to weeks without treatment.
- Recognize that her prednisone 5 mg is not protective and does not lower the pretest probability.
What must not delay treatment: the ESR/CRP result and the temporal artery biopsy. The ESR can be normal in roughly 5–10% of biopsy-proven cases, and a normal value would not change the decision to treat.
Do not order labs and send her home to 'wait for the rheumatologist's call.' That is the error this scenario is designed to catch.
2. How do you counsel a reluctant patient about steroids versus the risk of blindness?
Read the worked answer
Say it plainly: this disease can cause permanent blindness in the other eye within days, and treatment is high-dose steroids started today. The gray curtain was a warning; the blurred vision and swollen disc mean the optic nerve is already affected.
Address the resistance directly. She feels silly and has family visiting. Acknowledge it, then reframe: the alternative is bilateral blindness this weekend. Offer to call her family, arrange transport, or speak with the emergency physician.
Informed consent for steroids: short-term risks include hyperglycemia (check glucose; she may need temporary insulin), hypertension, insomnia, mood change, fluid retention, and infection risk. Long-term risks with prolonged therapy include osteoporosis, cataract, glaucoma, and adrenal suppression. These are manageable; bilateral blindness is not. Add a proton pump inhibitor, calcium and vitamin D, and a DEXA if therapy continues beyond a few months. Low-dose aspirin 81 mg is reasonable if not contraindicated.
Document the conversation, the recommendation, her initial refusal, and the plan if she declines - and have her sign an against-medical-advice form if she leaves without care. If she truly refuses, arrange the fastest possible alternative pathway rather than ending the encounter.
3. Outline the diagnostic confirmation, referral, and follow-up plan.
Read the worked answer
Confirm, but after treating: ESR, CRP, and CBC with platelets (thrombocytosis is common), plus a temporal artery biopsy within 1–2 weeks - steroids do not erase the histology for at least two weeks, so the biopsy must never delay treatment. A negative biopsy with high clinical suspicion does not exclude the diagnosis (skip lesions; roughly 10–20% false negatives).
Coordinate care: same-day rheumatology for steroid taper planning, bone protection, and TB/hepatitis screening before long-term therapy; primary care for glucose and blood pressure; ophthalmology follow-up in 1–2 weeks to monitor the fellow eye, disc edema, and acuity. Consider neurology or neuro-ophthalmology if the diagnosis is uncertain.
Prognosis counseling: visual loss present at diagnosis usually does not recover; the purpose of treatment is to protect the fellow eye and prevent other vascular events such as stroke and aortic involvement.
Every contact: ask about fellow-eye symptoms and give written instructions to return immediately for any vision change. Document this education.