CASE 1

A woman in her fifties was referred urgently from the ophthalmology emergency department to the rapid access neurology outpatient clinic. She gave a 24 hour history of sudden loss of vision in her partially amblyopic left eye on a background of being mildly hypertensive, moderately overweight, with marginally raised serum cholesterol. She was on an ACE inhibitor but no aspirin and no “statin”. She had not smoked for two decades. She also gave a six week history of tiredness, minor malaise, and minimal myalgia. She was not prone to headaches but had had bi-temporal headache which was not severe, intermittently for two weeks. She had not noticed any scalp tenderness. There was no jaw claudication.

Visual acuity on the left had fallen from 6/18 at a recent optician’s examination to detecting hand movements. The optic nerve head was pale and swollen with a few splinter shaped haemorrhages. On the right side, acuity was 6/6 with a normal looking nerve head. The superficial temporal arteries were prominent and only slightly tender. There was no muscle tenderness. Blood pressure was 145/85.

Investigations revealed an ESR of 28 and a C-reactive protein (CRP) of 30. Full blood count …