Endgames Case Review

Sequential vision loss in a patient with headache

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3055 (Published 08 June 2016) Cite this as: BMJ 2016;353:i3055
  1. Siegfried Wagner, specialist trainee in ophthalmology1,
  2. Saurabh Jain, consultant ophthalmologist1
  1. 1Department of Ophthalmology, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, UK
  1. Correspondence to: S Wagner siegfried.wagner{at}ndcn.ox.ac.uk

A 74 year old woman with a history of bowel cancer and hypertension was admitted under the general medical team from the emergency department because of a constant frontal headache for several weeks and poor oral intake secondary to jaw pain, which was exacerbated by chewing. She described intermittent blurring of vision in her left eye, which had culminated in complete loss of vision three days before presentation. She felt generally unwell with increasing lethargy and generalised myalgia.

On clinical examination she had bilateral tender and pulseless temporal arteries. Fundoscopy of the left eye showed features consistent with central retinal artery occlusion.

Initial blood tests showed raised inflammatory markers (C reactive protein (CRP) 2438 nmol/L, erythrocyte sedimentation rate (ESR) 116 mm in the first hour), and thrombocytosis (platelets 588×109/L). Despite symptomatic and biochemical improvement after prompt institution of appropriate treatment, her right eye deteriorated three days later exhibiting the features seen in the retinal photograph (fig 1). The optic nerve had a swollen pale “chalky white” appearance suggestive of an anterior ischaemic optic neuropathy.

Fig 1 Retinal photograph

Questions

  1. What is the diagnosis?

  2. How would you confirm or investigate this diagnosis?

  3. What red flag symptoms should general practitioners be aware of?

  4. How would you treat this condition?

Answers

1. What is the diagnosis?

Short answer

Giant cell arteritis.

Discussion

The combination of the patient’s symptoms; the presence of thrombocytosis, raised CRP, and raised ESR; and the fundoscopic appearances is highly suggestive of giant cell arteritis (GCA). Patients with GCA are on average 70 years of age, with a female sex bias, and many have pre-existing polymyalgia rheumatica.1 Symptoms include headache, which can be generalised or localised to the temple, frontal, or occipital region; jaw claudication; and scalp tenderness. Vague constitutional symptoms of malaise, fever, and weight loss may …

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