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An 80-year-old woman presented with low-grade fever, weight loss and shoulder ache persistent over 6 months. She had developed headache with scalp allodynia, though these had improved spontaneously within 2 months. Physical examination revealed an absent temporal artery pulse and decreased range of active shoulder motion. Laboratory findings showed a high erythrocyte sedimentation rate (73 mm/h). Temporal artery ultrasonography revealed no halo sign, stenosis or occlusion. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed increased uptake in the thoracic aorta and carotid and subclavian branches, and bilateral shoulder, hip, and interspinal regions in the lower thoracic and lumbar spine (figures 1 and and2).2). Giant cell arteritis (GCA) with polymyalgia rheumatica was diagnosed. Symptoms improved with prednisolone (30 mg/day).
GCA is associated with chronic vasculitis of large vessels, primarily the aorta and its main branches. It occurs in individuals aged >50 years. Polymyalgia rheumatica is closely linked to GCA, occurring in about 40–50% of patients. Headache is present in 90% of cases, frequently accompanied by scalp allodynia. In some cases, the inflammatory process may spontaneously become clinically silent,1 requiring clinicians to evaluate symptoms by direct questioning.
Temporal artery ultrasonography, one of the non-invasive tests, is helpful in diagnosing giant-cell arteritis (sensitivity 88% and specificity 78%).2 FDG-PET can be used to detect subclinical inflammation of large vessels in GCA.3 Although there is no perfect method for the diagnosis of GCA at present, FDG-PET may play a role in the management of GCA when the ultrasonography is negative.
Twitter: Follow Kiyoshi Shikino at @K
Contributors: All authors were involved in managing the patient. KS wrote the first draft. MI edited the manuscript.
Competing interests: None.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.