A 62-year-old woman develops sudden-onset painless visual loss in the left eye. She has a 6-month history of scalp tenderness, jaw claudication, and morning stiffness. ESR is 95 mm/hr, CRP is markedly elevated. What is the most important immediate next step?
- A Temporal artery biopsy before initiating any treatment
- B Ophthalmology consultation and initiation of aspirin only
- C Urgent high-dose corticosteroids (prednisolone 1 mg/kg or IV methylprednisolone) without waiting for biopsy ✓
- D MRI brain to rule out ischaemic stroke
Explanation
In giant cell arteritis (GCA) with visual loss (anterior ischaemic optic neuropathy), immediate high-dose corticosteroids are paramount to prevent blindness in the contralateral eye — vision loss is irreversible once established, but further loss can be prevented. If visual loss is present, IV methylprednisolone 500–1000 mg/day for 3 days is preferred, followed by oral prednisolone 1 mg/kg/day. Temporal artery biopsy should be performed within 1–2 weeks of starting steroids (biopsy positivity remains for 2–4 weeks), but never delays treatment. Aspirin alone is insufficient for GCA.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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