A 58-year-old Indian man presents with a 3-month history of progressive headache, jaw claudication, and visual blurring. On examination, he has a prominent, tender temporal artery with reduced pulsation. ESR is 92 mm/hr, CRP is elevated, and hemoglobin is 10.2 g/dL. Temporal artery biopsy shows granulomatous inflammation with giant cells. What is the most appropriate next step in management?

Explanation

## Diagnosis: Giant Cell Arteritis (Temporal Arteritis) **Key Point:** This patient presents with the classic triad of GCA — headache, jaw claudication, and visual symptoms — with elevated inflammatory markers (ESR 92 mm/hr, elevated CRP) and a diagnostic temporal artery biopsy showing granulomatous inflammation with giant cells. The diagnosis is confirmed. **High-Yield:** The critical management principle in GCA is that **high-dose corticosteroids must be initiated immediately upon clinical suspicion** — without waiting for biopsy confirmation — to prevent irreversible vision loss from arteritic anterior ischemic optic neuropathy (AAION). In this vignette, the biopsy has already been performed and is diagnostic, making immediate corticosteroid initiation the unambiguous next step. **Clinical Pearl:** Option B ("initiate high-dose corticosteroids AND arrange urgent biopsy within 1–2 weeks") is the correct approach when biopsy has NOT yet been performed. However, since the stem explicitly states the biopsy is already done and confirms GCA, the most appropriate next step is simply to **start high-dose corticosteroids immediately** (Option A). Delaying treatment for any reason — including awaiting imaging or further workup — risks permanent blindness. **Standard Corticosteroid Regimen (Harrison's 21e, Ch 318):** - **Induction:** Prednisolone 40–60 mg/day (or IV methylprednisolone 500–1000 mg/day for 3 days if vision is threatened) - **Taper:** Gradual reduction over 9–12 months guided by clinical response and ESR/CRP - **Maintenance:** Low-dose prednisolone (5–10 mg/day) for 1–2 years **Why NOT the other options:** - **Option B:** Arranging a biopsy is redundant — biopsy is already done and diagnostic. - **Option C:** Methotrexate is used as a steroid-sparing agent adjunct, never as monotherapy for active GCA. - **Option D:** Deferring corticosteroids pending imaging is dangerous and contraindicated when diagnosis is confirmed. **Mnemonic: GCA Red Flags** — **H**eadache, **J**aw claudication, **V**ision loss, **E**levated ESR/CRP, **B**iopsy positive = Act **immediately** [cite:Harrison 21e Ch 318]