Abstract
Case study
Mrs Hewitt, an 80-year-old lady, attends the GP with a 6-week history of bilateral earache. She has seen the GP twice in this time about her symptoms. She was initially using an over-the-counter ear spray and had also been prescribed a course of oral antibiotics for suspected otitis media. Despite this, her earache has been worsening to the point that she is struggling to sleep at night. She feels the pain in her ears is spreading, as she has had a persistent ache across the top of her head and has been finding it painful to chew food for the last week.
No abnormalities are detected on examination of her tympanic membranes. She has generalised scalp tenderness but no temporal artery abnormality on palpation. Her vision is tested and found to be normal.
A diagnosis of giant cell arteritis is suspected, and she is referred to a fast-track pathway. Urgent bloods are requested and her erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are elevated. An ultrasound Doppler temporal artery is positive for bilateral temporal arteritis and she is started on a course of high-dose steroids under supervision of the local rheumatology team.
Discussion
While giant cell arteritis can classically present with new-onset headache, jaw claudication and visual changes, these symptoms may not always be present or immediately obvious. Early symptoms of giant cell arteritis can be non-specific and include scalp tenderness, systemic features, such as fever, mono/polyneuropathy of the limbs, upper cranial nerve palsies, and can also occasionally present with ear, nose and throat symptoms.
This case is a reminder that seemingly innocuous symptoms that fail to respond to typical treatment, are worsening in severity and/or occur for longer than typically expected, should raise the suspicion of another, potentially more serious underlying diagnosis, especially in patient groups who are more at risk, such as the elderly. Mrs Hewitt’s earache did not respond to both topical and oral treatment, her symptoms had significantly worsened in severity and lasted for longer than expected if they were due to otitis media. The later development of scalp tenderness and intermittent jaw claudication raises the suspicion of a significant underlying pathological process.
Timely recognition, referral and initiation of treatment are essential as giant cell arteritis is a medical emergency, and a missed or late diagnosis can cause serious complications, such as permanent visual loss.
