Medical Case: Severe headaches and visual disturbances in winter

Mysterious complaints: What's behind them?

On a cold winter day, 51-year-old Ms. S., accompanied by her husband, visits the emergency room. She complains of severe headaches in her left temple area that have been present for four days and reports new visual disturbances that she noticed this morning. She has been diagnosed with polymyalgia rheumatica for a year and was treated with cortisone for three months. Since the symptoms quickly subsided, the medication was discontinued.

In recent weeks, she has felt increasingly fatigued and noticed unintentional weight loss. She also reports recently experiencing pain when chewing, which makes eating difficult. She works in administration and lives with her husband and dog in a small apartment in the city center.

Clinical Examination

General: Pale, exhausted patient, subfebrile (37.8°C).

Head: Tenderness and hardening of the left temporal artery, no palpable pulse.

Eyes: Reduced vision in the left eye, without papilledema.

Muscles: Slight morning stiffness and pain in the shoulder and pelvic girdle muscles, which increased again during the winter.

Lab values

Parameter	Result	Reference range
Inflammatory markers
CRP	120 mg/L	<5 mg/L
ESR	80 mm/h	<20 mm/h
Blood count
Hemoglobin	11.0 g/dL	12–16 g/dL
Leukocytes	9.5 Thsd./µL	4.0–10.0 Thsd./µL
Platelets	450 Thsd./µL	150–400 Thsd./µL
Autoantibodies
ANA	Negative	Negative

Parameter

Result

Reference range

Inflammatory markers

CRP

120 mg/L

<5 mg/L

ESR

80 mm/h

<20 mm/h

Blood count

Hemoglobin

11.0 g/dL

12–16 g/dL

Leukocytes

9.5 Thsd./µL

4.0–10.0 Thsd./µL

Platelets

450 Thsd./µL

150–400 Thsd./µL

Autoantibodies

ANA

Negative

What is your suspected diagnosis?

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What would you diagnose?:

Diagnosis

Temporal arteritis (giant cell arteritis) in a patient with known polymyalgia rheumatica.

What is giant cell arteritis?

Giant cell arteritis (GCA) is "related" to another rheumatic disease, polymyalgia rheumatica (PMR). Both can occur independently but are often diagnosed together or overlap. The two diseases practically never occur before the age of 50, with the prevalence of PMR being approximately one to two per 1,000. Polymyalgia rheumatica typically manifests as severe muscle pain in the shoulder and pelvic girdle area, accompanied by significantly elevated inflammatory markers and general symptoms such as fatigue.

Approximately 10 to 20 percent of PMR patients also develop giant cell arteritis over time. Conversely, 40 to 60 percent of patients with giant cell arteritis exhibit typical polymyalgia symptoms. The characteristic signs of temporal arteritis that are particularly clinically significant include new-onset temporal headaches, pain when chewing, and visual disturbances such as blurred vision, sudden loss of vision, or occasionally double vision. Overall, 20 to 50 percent of patients with giant cell arteritis develop visual symptoms that require prompt diagnosis.

Treatment and Course of Disease

Following initial treatment with high-dose prednisolone (60 mg/day), the patient experienced significant improvement in headaches and visual disturbances within 48 hours. Inflammatory markers also gradually began to normalize. After two weeks of stable clinical course, the patient was discharged to outpatient care. She received a reduced prednisolone regimen with regular monitoring of inflammatory parameters and clinical symptoms. To minimize the risk of recurrence, maintenance treatment with prednisolone at a dose of 10 mg/day for a period of two years was recommended.