1. Introduction

Giant cell arteritis is one the sight threatening emergency that needs urgent treatment [1]. Headache is the most common symptoms [1]. It usually affects older woman aged above 50 years, but can also affect man [2]. Upon a slight suspicion of these conditions, urgent treatment with systemic prednisolone is needed to prevent the irreversible progression of the optic nerve ischaemia [1-2]. This is absolutely critical in order to irreversible blindness.

2. Case Report

A 60 years old man presented to a primary care clinic with the complaint of headache for 2 days not amenable to analgesics. He has also noted vision deterioration in both eyes and some bodyache. There was no scalp tenderness or jaw claudication. On examination, his vital signs are stable. Physical examination was unremarkable except for decreased visual acuity in both eyes, 6/36. A diagnosis of giant cell arteritis was suspected and the patient was given a referral letter to the emergency unit of a nearby hospital. However, patient refused this offer and instead wanted to see the ophthalmologist coming morning. Patient also refused any medications.

A few days later, the patient came back to the clinic, now totally blind in two eyes since the last two days. He did not go to the hospital at all, despite having the referral letter. The physician could only comfort the patient and wished that the patient had followed his advice that day. But the physician was powerless as patient autonomy and right to treatment choices need to be respected at all times.

3. Discussion

Despite being a common rheumatological condition, especially in the elderly population, giant cell arteritis can easily be missed as the commonest symptom is temporal headache which has a multitude of causes including tension headache and ophthalmological causes [3]. Other notable symptoms of temporal arteritis include jaw claudication, scalp tenderness, blurring of vision, fever, anorexia and polymyalgia [4]. Doppler ultrasound if available should be used as it has a good sensitivity and specificity (up to 80%) [5]. This is in addition to a raised erythrocyte sedimentation rate (ESR) above 100 mm/hour. Glucocorticoids remains the treatment of choice [3]. Newer 2^nd choice treatment options available now include methotrexate and anti-IL-6 therapy, under specialist care [3].

Nevertheless, rheumatological conditions and autoimmune diseases are important to diagnose as early as possible as delay in diagnosis can bring about severe irreversible organ damage and in some cases, psychological distress for the patient and their family [6-8].

4. Conclusion

In conclusion, it is of utmost importance to diagnose rheumatological condition, especially giant cell arteritis early as a slight delay in diagnosis can cause permanent harm to the patient. Having a high index of suspicion will go a long way in order to diagnose this condition.

Acknowledgement

The author would like to thank the patient for sharing this story as a case report.

References

1. Karina Lazarewicz, Pippa Watson. Giant Cell Arteritis. BMJ 365 (2019): l1964.
2. Kenneth J Warrington. Giant Cell Arteritis. Bmj Best practice (2019).
3. Dejaco C, Brouwer E, Mason JC, et al. Giant cell arteritis and polymyalgia rheumatica: current challenges and opportunities. Nature Reviews Rheumatology 13 (2017): 578.
4. Ness T, Bley TA, Schmidt WA, et al. The diagnosis and treatment of giant cell arteritis. Dtsch Arztebl Int 110 (2013): 376-386.
5. Cockey G, Shah SR, Hampton T. Giant Cell Arteritis Presenting with a Tongue Lesion-Diagnostic Dilemma. The American journal of medicine 132 (2019): 576-578.
6. Navin Kumar Devaraj. Temporomandibular Joint Dysfunction as a Cause of Facial Pain-A Case Report. Fortune Journal of Rheumatology 1 (2019): 009-011.
7. Devaraj NK. The difficult rheumatology diagnosis. Ethiopian journal of health sciences 28 (2018): 101
8. Devaraj NK. The Atypical Presentation of Rheumatoid Arthritis in an Elderly Woman: A Case Report. Ethiop J Health Sci 29 (2019): 957-958