CP5 She's going blind!

A 76-year-old woman woke with painless visual loss in her left eye. It was preceded by a 6-week history of headache, jaw claudication, anorexia and weight loss. Visual acuities were hand movements on the left and 6/9 right with left optic disc swelling. ESR was 80 and CRP 40. A high clinical suspicion of giant cell arteritis led to immediate treatment with oral prednisolone (80 mg). Further investigations including neuroimaging and cerebrospinal fluid analysis were negative. Bilateral temporal artery biopsies were also negative. A week later, right visual acuity deteriorated to 6/12 with associated optic disc swelling. Five days of intravenous 1 g methylprednisolone/day was commenced, along with aspirin, dipyridamole and simvastatin. However, right visual acuity progressively worsened to 6/24. 18F-fluorodeoxyglucose positron emission tomography (PET) imaging performed showed avid aortic uptake. Consequently, she was treated with 270 mg IV infliximab. Five days later, right visual acuity started improving to 6/18. Methotrexate 10 mg/week was commenced with gradual steroid reduction. The left eye remained unchanged but the right continued to improve and stabilised at 6/6 following a catarectomy months later. This study demonstrates both how PET-imaging can be useful in temporal biopsy negative cases, and that infliximab has a potential role in corticosteroid resistance.