Scalp Tenderness Research Articles

New-onset of giant cell arteritis with ischemic optic neuropathy following the seventh-dose of COVID-19 mRNA vaccination: A case report and literature review.

Coronavirus disease (COVID-19) vaccines have demonstrated excellent efficacy in reducing the morbidity and severity of the disease. However, some patients have been reported to develop systemic rheumatic diseases, such as rheumatoid arthritis, myocarditis, Guillain-Barre syndrome, and giant cell arteritis (GCA) following COVID-19 vaccination. We present a case of GCA with ischemic optic neuropathy following COVID-19 mRNA vaccination. A 73-year-old woman developed headache, myalgia, scalp tenderness, and jaw claudication 4 days after her seventh dose of the vaccination; she also developed severe visual disturbances 1 month after the vaccination. The blood examination tests showed an increased serum C-reactive protein level and erythrocyte sedimentation rate. The echogram for the temporal artery showed a halo sign. Ophthalmic examination revealed ischemic optic neuropathy in both eyes. The patient was treated with a high-dose glucocorticoid and tocilizumab under the diagnosis of GCA with ischemic optic neuropathy, obtaining mild improvement of the symptoms. This report underscores the need for clinical vigilance and further data collection regarding GCA cases after COVID-19 vaccination.

Fulminant Giant Cell Arteritis with Tongue Autoamputation

Abstract Giant cell arteritis (GCA) is a systemic vasculitis predominantly affecting large and medium-sized arteries. While headache, scalp tenderness, jaw claudication, and visual disturbances are common presentations in patients over 50 years old, rare manifestations such as tongue necrosis can pose diagnostic challenges. We present an 86-year-old female who initially presented with visual disturbances, jaw claudication, and constitutional symptoms. She was diagnosed with GCA based on clinical features, elevated inflammatory markers, and ultrasound findings of thickened temporal arteries. Despite treatment with high-dose corticosteroids, she subsequently developed spontaneous amputation of the anterior one-third of her tongue due to bilateral lingual artery occlusion, a rare complication occurring in approximately 1% of GCA cases. Despite treatment, the patient’s condition rapidly deteriorated, and she succumbed to the illness within 3 weeks of the initial presentation. This case highlights an atypical and fulminant presentation of GCA with tongue autoamputation, emphasizing the need for early recognition and aggressive management to prevent devastating ischemic complications.

Nodular Hidradenoma of the Scalp: A Rare Case Report

Nodular hidradenoma is a rare benign tumour originating from eccrine or apocrine sweat glands. While documented cases exist in the medical literature, nodular hidradenoma of the scalp is relatively uncommon. We present a rare case of nodular hidradenoma located on the scalp to contribute to the limited knowledge regarding its clinical presentation, diagnosis, management and outcomes in this specific anatomical site. We present a case of a 45-year-old female with a nodular hidradenoma of the scalp. The patient complained of a slow growing swelling, itchy, slightly tender scalp lump over 9 years period. Clinical examination revealed a well-defined, firm nodule measuring 3.5 x 3 cms in diameter with 2 cms wide stalk. The patient underwent complete surgical excision, resulting in a favourable outcome for regular follow up to one year

Giant cell arteritis associated with scalp, tongue or lip necrosis: A French multicenter case control study

BackgroundScalp, tongue and/or lip necrosis are rare complications of GCA. ObjectivesTo describe characteristics and outcome of patients with giant cell arteritis (GCA) -related scalp, tongue and/or lip necrosis. MethodsA retrospective nationwide multicenter study included 20 GCA patients with scalp, tongue, and/or lip necrosis diagnosed between 1998 and 2021 and 80 GCA control patients matched for age, sex and management period. Logistic regression analyses were conducted to identify baseline characteristics associated with scalp, tongue and/or lip necrosis. ResultsCompared to controls, patients with scalp, tongue and/or lip necrosis showed significantly more cranial manifestations (headache, p=0.045; scalp tenderness, p=0.006; jaw claudication, p=0.02). No differences were observed between both groups regarding the occurrence of visual symptoms or large vessel involvement. At diagnosis, GCA patients with necrosis more likely received IV methylprednisolone infusions and higher doses of oral prednisone. There were no differences regarding vascular complications during follow up. Compared to controls, survival was decreased in GCA patients with necrosis (p=0.003). In a multivariable logistic regression model, scalp tenderness [odds ratio (OR) 4.81(95 % CI: 1.57, 14.79), p = 0.006] and cognitive disorder [OR 6.42 (95 % CI: 1.01, 40.60), p=0.048] were identified as factors associated to scalp, tongue, and/or lip necrosis. ConclusionOur results suggest that scalp, tongue, and/or lip necrosis is associated to higher mortality in GCA patients. Scalp tenderness and cognitive disorder were significant factors associated to this very rare complication of GCA.

Giant cell temporal arteritis: a clinicopathological study with emphasis on unnecessary biopsy.

Temporal artery (TA) biopsy is commonly used for the diagnosis of giant cell arteritis (GCA). However, a positive biopsy is no longer mandatory for diagnosis. This study aims to correlate the histopathological findings of TA biopsies in suspected cases of GCA to the clinical presentation in an ophthalmic tertiary eye care center to draw useful conclusions and advocate the possible implementation of guidelines for TA biopsy. Data was collected from patients' medical records including, demographics, clinical data, and histopathological findings and diagnosis. The 2022 American College of Rheumatology/ European Alliance of Associations for Rheumatology (ACR/EULAR) criteria have been used and partially adopted as a guide to compare the variables between TA biopsy-positive and negative groups as well as the TA biopsy-positive group and the group of patients with TA biopsy showing atherosclerosis. Out of the total 35 patients who underwent a TA biopsy during the period of 23 years, 22.9% of patients had histopathological findings consistent with GCA and 42.9% had TA atherosclerotic changes, while the remaining 34.3% had histologically unremarkable TA. The mean age of all patients was 66 ± 10.9 years. Slightly more than half were females (54.3%) and the remaining were males (45.7%). In the group with positive TA biopsies, the mean age was 71 ± 8.4 years with a higher female predominance (female-to-male ratio of 5:3). The mean diagnostic clinical score used in our study was higher (7.5 ± 2.33) in the GCA-positive group when compared to the other groups with statistical significance (mean of 4.85 ± 2.01 in patients with overall GCA-negative biopsies and 5.13 ± 2.10 in the group with atherosclerosis). Other three clinical variables that were found to be statistically significant in the GCA biopsy-positive group were scalp tenderness, jaw claudication, and optic nerve pallor. The mean age (71 ± 8.4 years) and the female predominance of GCA in our group of patients with positive TA biopsy (62.5%) was like other reports. In our study 22.9% of performed TA biopsies over the period of the study were positive confirming the diagnosis of GCA on histological exam, which was similar to another report and is considered to be relatively low. The incorporation of increased clinically focused assessments and algorithms, with the aid of the ACR/EULAR criteria, may decrease the frequency of TA biopsies that carries unnecessary cost and risk of procedure-related morbidity. We highly recommend applying the age of ≥ 50 years as an initial criterion for diagnosis, followed by the consideration of the statistically significant clinical features: scalp tenderness, jaw claudication, and optic nerve pallor.

A Case of Bing-Neel Syndrome Presenting Like Giant Cell Arteritis.

A 55-year-old woman presented with new-onset headache, scalp tenderness, shoulder arthralgias, night sweats, and loss of appetite. She was diagnosed with giant cell arteritis by her primary care physician and commenced on oral corticosteroids. However, her headache, scalp tenderness, and night sweats persisted. She then developed right Horner syndrome and trigeminal hypoesthesia. Extensive blood work-up revealed mildly elevated inflammatory markers and a paraproteinemia. Subsequent bone marrow biopsy showed lymphoplasmacytic lymphoma, with 10% of hemopoiesis, and staging led to the diagnosis of Waldenstrom macroglobulinemia without nodal or central nervous system (CNS) lesions. Immunohistochemical staining of a temporal artery biopsy showed perivascular lymphoplasmacytic cells and paraprotein deposits. She was diagnosed with CNS involvement of her macroglobulinemia-Bing-Neel syndrome (BNS). Identification of rare CNS involvement of lymphoma is challenging when a patient is already on steroid immunosuppression. In the absence of clear diagnostic criteria, the rare and heterogenous BNS remains a clinical diagnosis.

1033 The link between vision loss and sleep

Abstract Introduction Non-arteritic ischemic optic neuropathy (NAION) is the most common optic nerve disorder among patients over the age of 50. Several risk factors have been associated with NAION including systemic hypertension, diabetes mellitus, advanced age, and certain optic disc morphologies. A significant association between obstructive sleep apnea (OSA) and NAION has also been reported. Here, we present a case of a middle-aged man with a recent diagnosis of NAION who was subsequently found to have OSA. Report of case(s) A 53-year-old man with a remote history of head injury with concussion and tobacco use was referred to the Sleep Medicine Clinic from Ophthalmology for evaluation of obstructive sleep apnea (OSA). The patient initially presented to Ophthalmology due to acute onset, painless, left-sided, inferior vision loss. The patient was otherwise healthy and denied a history of diabetes mellitus or hypertension. He did report alcohol and cigar use on the night prior to the acute onset vision loss. He denied fevers, chills, joint or jaw pain, scalp tenderness, or jaw claudication. On initial evaluation he was found to have significant left eye optic disc edema. Blood test revealed normal complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-Reactive protein (CRP). His orbit and brain magnetic resonance imaging with and without contrast revealed no significant findings. He was subsequently diagnosed with left NAION. Further review of symptoms was positive for snoring, dry mouth, nighttime awakenings, and unrefreshing sleep, concerning for OSA and leading to referral to our Sleep Medicine Clinic. During initial consultation in Sleep Medicine, he denied symptoms concerning for any other sleep disorders. He subsequently underwent a home sleep test (WatchPAT) which confirmed the diagnosis of OSA. The apnea-hypopnea index (AHI) was 7.9 and the lowest oxygen saturation was 88%. Conclusion Given the reported association between NAION and OSA, a careful history should be obtained to screen for OSA when NAION is diagnosed. Support (if any)

Tongue necrosis secondary to giant cell arteritis, successfully treated with tocilizumab: a case report

sBackgroundGiant Cell Arteritis (GCA) is a large vessel vasculitis that most commonly presents with headache, scalp tenderness, jaw claudication, and vision changes. Various other, less common, manifestations have been reported in the literature such as scalp and tongue necrosis. Though most patients respond to corticosteroids, some cases of GCA are refractory to the high doses of corticosteroids.Case presentationWe present a 73-year-old female with GCA refractory to corticosteroids presenting with tongue necrosis. This patient significantly improved with a dose of tocilizumab, an IL-6 inhibitor.ConclusionTo the best of our knowledge, this is the first case report of a patient with refractory GCA presenting with tongue necrosis that had rapid improvement with tocilizumab. Prompt diagnosis and treatment can prevent severe outcomes such as tongue amputation in GCA patients with tongue necrosis, and tocilizumab may be effective for corticosteroid-refractory cases.

P029 Ocular syphilis: a mimicker for giant cell arteritis

Abstract Background/Aims Syphilis has seen a resurgence in the United Kingdom in recent years. It is a sexually transmitted disease caused by Treponema pallidum spirochaete infection, and typically presents as painless genital ulceration in its primary stage; left untreated it can progress rapidly to secondary and tertiary stages with multi-system involvement and wide-ranging symptoms, hence it being labelled ‘the great imitator’. We report a case of a patient presenting with classical features of giant cell arteritis (GCA), ultimately being diagnosed with neuro-ocular syphilis. Methods A 65-year-old man with a background of hypertension and migraines presented to our hospital with a 3-week history of temporal headache, scalp tenderness and jaw ache. He described lethargy, weakness and weight loss. On examination he had a prominent left temporal artery, with concurrent scalp tenderness; neurological and general medical examination were otherwise normal. Blood tests showed an erythrocyte sedimentation rate (ESR) of 66 and a C-reactive protein (CRP) of 115, leading to a strong clinical suspicion of GCA. He was commenced on 60mg of oral prednisolone with immediate improvement of his symptoms at this dose. Subsequent temporal artery ultrasound and temporal artery biopsy were negative for GCA. On tapering his steroids to 40mg he experienced partial relapse of his symptoms. Following Neurology review his steroid taper was adjusted to decrease more slowly. On 20mg of prednisolone the patient began experiencing stabbing retro-orbital pain and visual blurring, and was assessed by Ophthalmology with no local cause for his symptoms identified - he was therefore pulsed with intravenous methylprednisolone for a flare of GCA. Despite an initial response, the patient continued to experience intermittent symptoms on steroids; imaging with PET-CT did not show evidence of inflammation or malignancy and an MRI of his brain and orbits was normal. Results The patient eventually re-presented to Ophthalmology with floaters, pain and decreased vision and a spot diagnosis of posterior placoid chorioretinitis was made after retinal examination. Characteristic yellowish ovoid lesions confluent in the macular area were noted, as well as ellipsoid zone loss with nodular retinal pigment epithelium on optical coherence tomography (OCT) imaging. This condition is pathognomonic of neuro-ocular syphilis and serological testing confirmed the diagnosis, with a high rapid plasma reagin (RPR) titre of 1:512. He was treated with a course of intramuscular Ceftriaxone with a rapid resolution of his symptoms, and was successfully weaned off all steroid therapy. Conclusion Diagnosing GCA remains a clinical challenge for rheumatologists, especially in cases with typical symptoms and signs but negative confirmatory testing on imaging and histology. There are a wide range of conditions that resemble GCA, and neuro-ocular syphilis is one such diagnosis that has been reported in the literature as a mimic, as demonstrated by this important case. Disclosure S. Ali: None. S. Lekh: None. C. Tench: None.

P009 Navigating giant cell arteritis (GCA) service during and post COVID-19 pandemic: an audit of GCA care at North Bristol NHS Trust against the BSR quality standards

Abstract Background/Aims GCA is a systemic vasculitis predominantly affecting the large vessels that requires prompt diagnosis and management. This clinical audit aims to study the impacts of COVID-19 pandemic on our GCA service and to identify areas for improvement to ensure good and safe practice amid healthcare crisis. Methods We audited referrals for suspected GCA from February 2021 until September 2022 and measured our patient care against the BSR quality standards. We performed retrospective data collection from digital care record systems and analysed our data using the IBM SPSS Statistics version 29. Results 106 patients with suspected GCA were included, 73% were female and the mean age was 70 years. 75% of the referrals were from primary care. Main presenting symptoms were headaches (95.7%), scalp tenderness (69.6%), tongue/jaw claudication (52.2%), visual symptoms (47.8%), constitutional symptoms (43.5%) and polymyalgic symptoms (21.7%). 33% of patients were diagnosed and treated as GCA. Mean CRP was 23.9mg/L and mean plasma viscosity was 1.89mPA. The mean referral-to-specialist review time has reduced to 1.6 days, compared with 2.7 days pre-pandemic. All patients had vascular ultrasound but only 7.5% had a temporal artery biopsy (TAB), compared with 41% pre-pandemic. Table 1 compares expected and achieved BSR quality standards. Conclusion Changes in work pattern during the pandemic meant that the time from referral to specialist review was significantly reduced, by implementing twice weekly registrar-led ‘Hot’ clinics and reserving ad hoc slot(s) in on-call consultant’s clinics for GCA referrals. We have ramped up our vascular imaging capacity for vascular ultrasound during the pandemic in response to reduced surgical operating capacity for TAB. Strategies to address areas for improvement identified in this audit include: (1) clear and timely communication with referrer about steroid initiation and dosage, at the time of referral; (2) improving communication with primary care, emphasising need for urgent Ophthalmology input in patients with suspected GCA-related visual symptoms, through updating our regional GCA guideline for primary care; (3) standardising and implementing a GCA review proforma or checklist in our department to ensure that the BSR GCA care bundle is being implemented and addressed at the earliest opportunity. Disclosure K. Lim: None. I. Shahriar: None. S.J. Villar: None. F. Sin: None.

A CLINICAL STUDY OF OCULAR CAUSES OF HEADACHE

Aims :To enumerate the Ocular causes of headache. Objectives: 1. To assess the various Ocular manifestations in patients with headache. 2. To study the various causes of headache and early diagnosis of various causes of headache 3. To assess the severity of Ocular manifestations in patient who present with headache Materials and Methods: This was a Hospital based cross sectional study done on patients who attended to OPD with a cheif complaint of headache, Dr. R.S.P.R Government Regional Eye Hospital, Andhra Medical College, Visakhapatnam from August 2021 to August 2022. Relevant detailed history and Ocular examination was done. Results: Outof 100,35(53.9%)has Refractive errors,10(12.8%)has Convergence insufficiency,14(17.95%)hasAccomadativeinsufficiency,7(9%)hasHeterophorias,1(1.3%)has Heterotropias,5(5%)has Systemic diseases. Majority were in the age group between 21-30yrs(31%)in which 13% males,17%females and least are under 0-10 and 61-70 years(3%). 52(52%)had Eye strain,10(10%)had Photophobia,12(12%)had Raised IOP, 10(10%)had Nausea,5(5%)had Frequent blinking, 5(5% )had Vertigo,3(3%)had diseases of External eye and adnexia2(2%) had Scalp tenderness 1(1%) had Photopsia and 1(1%)Iatrogenic. Conclusion: Early detection and management of Refractive errors and Accomodative squint and distinguishing the other causes of headache like migraine, sinusitis, and systemic diseases like hypertension and benign tumours.

Predictors of Relapses or Recurrences in Patients With Giant Cell Arteritis: A Medical Records Review Study.

Giant cell arteritis (GCA) is the most common systemic vasculitis in individuals aged ≥50 years. Its course is marked by a high relapse rate requiring long-term glucocorticoid use with its inherent adverse effects. We aimed to identify factors associated with relapses or recurrences in GCA at diagnosis. We reviewed the medical records of consecutive patients with GCA diagnosed between 2009 and 2019 and followed for at least 12 months. We recorded their characteristics at onset and during follow-up. Factors associated with relapses or recurrences were identified using multivariable analysis. We included 153 patients, among whom 68% were female with a median age of 73 (47-98) years and a median follow-up of 32 (12-142) months. Seventy-four patients (48.4%) had at least 1 relapse or recurrence. Headache and polymyalgia rheumatica were the most frequent manifestations of relapses. The first relapse occurred at a median time of 13 months after the diagnosis, with a median dose of 5.5 (0-25) mg/d of glucocorticoids.In multivariable analysis, patients with relapses or recurrences had a higher frequency of cough and scalp tenderness at diagnosis (20.3% vs 5.1%; odds ratio [OR], 4.73; 95% confidence interval [CI], 1.25-17.94; p = 0.022; and 41.9% vs 29.1%; OR, 2.4; 95% CI, 1.07-5.39; p = 0.034, respectively). Patients with diabetes mellitus at diagnosis had fewer relapses or recurrences during follow-up (5.4% vs 19%; OR, 0.24; 95% CI, 0.07-0.83; p = 0.024). Cough and scalp tenderness at diagnosis were associated with relapses or recurrences, whereas patients with diabetes experienced fewer relapses or recurrences.

Polymyalgia rheumatica presenting as sternoclavicular arthritis: a case report

BackgroundPolymyalgia rheumatica and giant cell arteritis are systemic inflammatory conditions of the elderly. Polymyalgia rheumatica classically presents as a bilateral proximal muscle pain and stiffness syndrome. Biceps tenosynovitis is the commonest pathology in polymyalgia rheumatica. However according to literature, erosive sternoclavicular arthritis is a rare association of polymyalgia rheumatica. Giant cell arteritis is an inflammatory granulomatous arteritis predominantly involving large cerebral arteries. Thus, its classic clinical presentation includes severe headache with scalp tenderness, jaw claudication, and sudden painless loss of vision. Urological manifestations (prostatic vasculitis and epididymo-orchitis) were seldom reported in giant cell arteritis.Case presentationA 53-year-old Sinhalese man presented with progressive right-sided shoulder joint pain and neck pain associated with constitutional symptoms and episodic generalized headache. Examination revealed restricted movements of the right shoulder joint with nontender pulsatile bilateral temporal arteries. Blood testing showed elevated erythrocyte sedimentation rate and C-reactive protein. Color Doppler ultrasound of the superficial temporal artery revealed “halo sign.” The temporal artery showed infiltration of mononuclear cells in the arterial media and adventitia. Computed tomography revealed right sternoclavicular arthritis with incidental finding of ureteric stricture. The patient was treated with high-dose oral prednisolone, and good clinical and biochemical response was observed during follow-up.ConclusionPolymyalgia rheumatica–giant cell arteritis may rarely present as erosive sternoclavicular arthritis as the initial manifestation, mimicking many rheumatological conditions. Urological involvement such as ureteric strictures may be rare associations of primary systemic vasculitis. A high degree of suspicion combined with targeted investigations would allow early identification the polymyalgia rheumatica–giant cell arteritis syndrome in the presence of atypical manifestations, leading to improved patient outcomes.

Predictive Factors of Giant Cell Arteritis in Polymyalgia Rheumatica Patients.

Polymyalgia rheumatica (PMR) is an inflammatory rheumatism of the shoulder and pelvic girdles. In 16 to 21% of cases, PMR is associated with giant cell arteritis (GCA) that can lead to severe vascular complications. Ruling out GCA in patients with PMR is currently a critical challenge for clinicians. Two GCA phenotypes can be distinguished: cranial GCA (C-GCA) and large vessel GCA (LV-GCA). C-GCA is usually suspected when cranial manifestations (temporal headaches, jaw claudication, scalp tenderness, or visual disturbances) occur. Isolated LV-GCA is more difficult to diagnose, due to the lack of specificity of clinical features which can be limited to constitutional symptoms and/or unexplained fever. Furthermore, many studies have demonstrated the existence-in varying proportions-of subclinical GCA in patients with apparently isolated PMR features. In PMR patients, the occurrence of clinical features of C-GCA (new onset temporal headaches, jaw claudication, or abnormality of temporal arteries) are highly predictive of C-GCA. Additionally, glucocorticoids' resistance occurring during follow-up of PMR patients, the occurrence of constitutional symptoms, or acute phase reactants elevation are suggestive of associated GCA. Research into the predictive biomarkers of GCA in PMR patients is critical for selecting PMR patients for whom imaging and/or temporal artery biopsy is necessary. To date, Angiopoietin-2 and MMP-3 are powerful for predicting GCA in PMR patients, but these results need to be confirmed in further cohorts. In this review, we discuss the diagnostic challenges of subclinical GCA in PMR patients and will review the predictive factors of GCA in PMR patients.

2022 American College of Rheumatology/EULAR Classification Criteria for Giant Cell Arteritis.

To develop and validate updated classification criteria for giant cell arteritis (GCA). Patients with vasculitis or comparator diseases were recruited into an international cohort. The study proceeded in 6 phases: 1) identification of candidate items, 2) prospective collection of candidate items present at the time of diagnosis, 3) expert panel review of cases, 4) data-driven reduction of candidate items, 5) derivation of a points-based risk classification score in a development data set, and 6) validation in an independent data set. The development data set consisted of 518 cases of GCA and 536 comparators. The validation data set consisted of 238 cases of GCA and 213 comparators. Age ≥50 years at diagnosis was an absolute requirement for classification. The final criteria items and weights were as follows: positive temporal artery biopsy or temporal artery halo sign on ultrasound (+5); erythrocyte sedimentation rate ≥50 mm/hour or C-reactive protein ≥10 mg/liter (+3); sudden visual loss (+3); morning stiffness in shoulders or neck, jaw or tongue claudication, new temporal headache, scalp tenderness, temporal artery abnormality on vascular examination, bilateral axillary involvement on imaging, and fluorodeoxyglucose-positron emission tomography activity throughout the aorta (+2 each). A patient could be classified as having GCA with a cumulative score of ≥6 points. When these criteria were tested in the validation data set, the model area under the curve was 0.91 (95% confidence interval [95% CI] 0.88-0.94) with a sensitivity of 87.0% (95% CI 82.0-91.0%) and specificity of 94.8% (95% CI 91.0-97.4%). The 2022 American College of Rheumatology/EULAR GCA classification criteria are now validated for use in clinical research.

DWI scalp dot sign: superficial temporal artery restricted diffusion in giant cell arteritis.

Dear Editor, We would like to report a novel finding on standard diffusion-weighted magnetic resonance imaging (DWI-MRI) in a case series of four patients with giant cell arteritis (GCA) in the superficial temporal artery (STA). GCA is considered a clinical emergency and is the most common vasculitis in adults, which, if untreated, can rapidly cause irreversible sight loss and ischaemic stroke [1]. Unfortunately, clinical presentation is variable and classic symptoms such as headache and scalp tenderness can be absent, delaying diagnosis and therapy [1]. Temporal artery biopsy (TAB) is considered the reference standard for diagnosis, but sensitivity can be as low as 40% due to skip lesions and inadequate specimens [2]. The European Alliance of Associations for Rheumatology recommends temporal and axillary artery ultrasound (US) as a first-line investigation in patients suspected of having GCA [3]. The finding of an arterial halo on US, reflecting inflammatory oedema of the arterial wall, is thought diagnostic for GCA with a specificity of 96% [4]. However, the sensitivity of US is lower (43–77%) and is highly technique and operator dependent [4, 5]. In both TAB and US, sensitivity drops further if performed after commencing steroid therapy. Post-contrast vessel wall magnetic resonance imaging (VW-MRI) has been proposed as a potential alternative first-line imaging investigation, with experienced units reporting a sensitivity of 80% and a specificity of 100% [5]. VW-MRI is still a relatively new technique and not yet readily available.

Patient with Blurred Vision

An approximately 30-year-old woman presented to the emergency department (ED) with a 1-month history of headaches, blurred right eye vision, and loss of left eye vision. She denied any head or ocular trauma. On examination, she exhibited 20/30 right eye vision and was unable to count fingers with the left eye. Cranial nerves were intact, and there was no temporal or scalp tenderness. The patient underwent camera ophthalmoscopy and magnetic resonance imaging (MRI) of the orbits (Figures 1 to 3).

Case Report: Giant Cell Arteritis presenting with 6th Nerve Palsy without Ischemic Optic Neuropathy

Purpose: Giant cell arteritis (GCA) can be a difficult condition to identify in the early stages especially in the absence of the pathognomonic arteritic anterior ischemic optic neuropathy. Optometrists serve an important role in correctly triaging and initiating appropriate work-up and treatment for this emergent condition. This case report and review serves as a refresher of the systemic and ocular signs and symptoms of GCA. Background: GCA is a systemic autoimmune condition characterized by granulomatous inflammation of medium and large arteries in patients over 50. The most well-known constellation of signs and symptoms include new onset headache, jaw claudication, scalp tenderness, temporal artery abnormality with painless vision loss secondary to arteritic anterior ischemic optic neuropathy. However, it is important to be aware of alternate presenting signs and symptoms including pain anywhere in the distribution of the external carotid (occipital, neck, tongue, throat, ear) and signs of large vessel GCA (arm/limb claudication, chest/back pain, Raynaud’s phenomenon) and Polymyalgia Rheumatica (PMR) (bilateral hip/shoulder pain and morning stiffness). Case Report: An 86-year-old Caucasian female presents for a referred exam regarding new onset diplopia with concurrent occipital headache, neck pain and sore throat originally dismissed as symptoms of her other systemic health conditions. ESR, CRP and platelets were elevated on serology and subsequent temporal artery biopsy was positive for GCA. Oral steroids were initiated, and she was lost to follow up after her ocular symptoms resolved. Conclusion: GCA can present with a large range of manifestations, and many are nonspecific and easily attributable to other causes especially when it deviates from the classic constellation of new onset headache, jaw claudication, scalp tenderness and temporal artery abnormality with painless vision loss. Optometrists as primary eye care providers may be the first point of contact and need to be cognizant of the broader set of manifestations to minimize delays in diagnosis and treatment of this life and vision threatening condition. CE Notification: This article is available as a COPE accredited CE course. You may take this course for 1-hour credit. Read the article and take the qualifying test to earn your credit. Click here to Enroll (https://www.crojournal.com/case-report-giant-cell-arteritis-presenting-with-6th-nerve-palsy-without-ischemic-optic-neuropathy) Please check COPE course expiry date prior to enrollment. The COPE course test must be taken before the course expiry date.

Repetitive Transcranial Magnetic Stimulation in a Group of Treament-Resistant Obsessive-Compulsive Disorder Patients: A Descriptive Study

Objective: This study aims to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) treatment in a group of treatment-resistant obsessive-compulsive disorder (OCD) patients and to examine the relationship between various sociodemographic and clinical variables and treatment response. Materials and Methods: Data including The Yale–Brown Obsessive Compulsive Scale (Y-BOCS) scores and various clinical and sociodemographic characteristics of 27 treatment-resistant OCD patients who received 30 sessions of low-frequency rTMS (LF-rTMS) treatment on the left dorsolateral prefrontal cortex (DLPFC) were analyzed. Results: Mean Y-BOCS scores decreased significantly across week 0 and the 3rd week (t(26)=10.59, p<.001) and continued to decrease significantly across weeks 3 and 6 (t(26)=11.47, p<.001). 21(78%) patients were responders with at least a %25 decrease in the mean Y-BOCS scores, and 10(47.6%) of these 21 patients also met the complete response criteria with a 35% or more reduction in Y-BOCS. No significant difference was observed between responders and non-responders regarding various clinical and sociodemographic variables. The only reported side effects were headaches and local scalp tenderness, which improved in a short time. Conclusion: This descriptive study has demonstrated the efficacy of a long-duration LF-rTMS application on the DLPFC in a group of drug-resistant OCD patients. This finding might contribute to the available literature, especially in drawing out a standardized treatment protocol in these cases.

Lichen Planopilaris Responsive to a Novel Phytoactive Botanical Treatment: A Case Series.

IntroductionLichen planopilaris (LPP) is characterized by chronic scarring alopecia that is progressive and typically refractory to therapy. Current drug treatments are suboptimal and not applicable for long-term use because of the high potential for adverse effects, warranting safer and more effective treatment alternatives.MethodsBased on our previous success in treating a patient with central centrifugal cicatricial alopecia using a topical botanical formulation (Gashee), we reviewed records of four patients with biopsy-proven LPP treated with the topical formulation alone or in combination with its oral preparation. Three patients had failed previous treatment with intralesional steroid injections, topical minoxidil, tacrolimus, and clobetasol. Physical examination and photographic documentation were also used as outcome measures. Treatment duration with the botanical formulations ranged from 6 weeks to 9.5 months.ResultsAll patients showed overall improvement in surrogate indicators of LPP activity as evidenced by the disappearance of symptoms (pruritus, tenderness, scalp irritation, and hair shedding), improvement in hair growth, and reduction in redness. All reported a high satisfaction level and no adverse effects.ConclusionsPatients with treatment-refractory LPP responded to a novel botanical treatment. To the best of our knowledge, this is the first published report of LPP responding to a plant-based natural treatment. Further evaluation of this treatment in a controlled trial with a larger number of patients is warranted.