Temporal arteritis in the absence of headache

Abstract

A 75-year-old woman was admitted to hospital with diplopia on leftward gaze. She underwent thyroidectomy several years ago for thyrotoxicosis with subsequent hypothyroidism for which she was on thyroxine replacement. A microcytic, hypochromic anaemia had been diagnosed a few weeks before admission. She gave no history of headache, eye pain or visual loss. On examination, she was pale and had a left sixth nerve palsy. Tenderness over the temporal arteries was notably absent. A diagnosis of mononeuritis was made with a differential diagnosis of isolated ophthalmic Graves’ disease. Biochemical parameters were as shown in Table 1. Abdominal ultrasound and computed tomography scan of the head were unremarkable; in particular, no swelling of the extraocular muscles was noted. An upper gastrointestinal endoscopy and colonoscopy were performed to investigate the anaemia. A mild Campylobacter-like organism test (for Helicobacter pylori infection) proved positive for gastritis, and areas of patchy erythematous mucosa of uncertain significance were seen. Temporal artery biopsy was performed 11 days after admission and while awaiting biopsy results, she was commenced on prednisolone 60 mg daily. Histopathology confirmed giant cell arteritis, showing fragmentation of the internal elastic lamina and an inflammatory cell infiltrate including lymphocytes and multinucleate giant cells (Figure 1). Within a week of commencing steroids, her diplopia improved and resolved completely in 10 days. She was discharged on prednisolone 20 mg daily and followed up in the outpatient clinic. She remains on reducing doses of steroids along with etidronate and calcium supplementation.