Case description
A 51-year-old man came to our outpatient clinic for visual blurring of the left eye. Ophtalmologic examination revealed signs of papilledema with suspicion of focal retinal ischemia. Two months earlier, the patient reports polymyalgia with functional impairment, asthenia, weight loss of 3 kg and night sweats. Blood test showed increased C-reactive protein (CRP) at 62 mg/l. Viral and bacterial infectious disease were excluded, notably a SARS-CoV-2 infection. A methylprednisolone (mPDN) trial – without a definite diagnosis - with an initial dose of 32 mg/day during 5 days was tried with clinical improvement. Visual blurring occured about 15 days after the discontinuation of corticosteroids therapy and lasted for several days in a steady state. The rest of the physical examination was unremarkable. His medical history includes hypothyroidism, arterial hypertension and a chronic renal insufficiency stage 2 of unknown origin. The patient did not describe headache, jaw claudication, scalp tenderness or temporal artery tenderness. Control blood test in hospitalization showed high erythrocyte sedimentation rate (ESR) and CRP (73 mm/h and 54 mg/l respectively). Screening for auto-immune disease showed low positivity of lupus anticoagulant with negative antinuclear factors (FAN) and anti-neutrophil cytoplasmic antibodies (ANCA). Screening for tuberculosis, syphilis, HIV, borrelia, bartonella and toxoplasmosis was negative. Cerebral magnetic resonance imaging (MRI), lumbar puncture (with meningeal panel excluding cytomegalovirus, herpes simplex virus 1 and 2 and herpes zoster virus) and visual evoked potential were normal. Due to the suspicion of GCA, treatment by mPDN 64 mg/day was started with improvement of the inflammatory syndrome and disappearance of papilledema at ophtalmological control. PET-CT scan and ultrasonography of the temporal arteries – performed before starting mPDN - were normal. Microscopic examination of temporal artery biopsy revealed a discrete inflammatory infiltration of the adventitia with preservation of media and intima layers. No disruption of the internal or external elastic lamina, nor giant cell formation were observed in serial sections. According to the histologic patterns’ classification proposed by Hernandez-Rodriguez et al (5), the case was diagnosed as giant-cell arteritis adventitial pattern (Figures 1 & 2 ).