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Temporal arteritis presenting as third nerve palsy - a case report and review of literature

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Abstract

Giant Cell Arteritis (GCA), also known as Temporal Arteritis, is a type of large vessel vasculitis primarily affecting the elderly population. It typically manifests with headaches, visual impairment, and jaw claudication. Although third nerve palsy as the primary presentation of GCA is rare, it has been reported in previous instances. In this report, we describe the case of a patient presenting with pupil-sparing third nerve palsy, ultimately diagnosed with GCA, and successfully managed with steroids and tocilizumab. A lady in her 80s with past medical history of well-controlled hypertension, bladder cancer in remission, a twenty-pack year smoking history, cervical and lumbar spine stenosis, and recent immunizations presented with acute onset of right-sided pupil-sparing third nerve palsy. Labs were pertinent for an elevated ESR and CRP. Brain imaging was without acute abnormalities. A temporal artery biopsy established evidence of healed arteritis and a diagnosis of GCA was made. The patient was treated with pulse-dose steroids followed by an oral steroid taper and tocilizumab. At one month follow-up, there was partial resolution in her ophthalmoplegia. We underscore the importance of considering temporal arteritis as a potential cause of third nerve palsy in the elderly before attributing it solely to microvascular ischemia, particularly in patients with constitutional features. Additionally, in our comprehensive literature review, we aim to consolidate the existing data from similar presentations, shedding light on the clinical manifestation and disease trajectory.

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All datasets for this review are included in the manuscript and the supplementary files.

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Acknowledgements

We acknowledge the contributions of all medical professionals involved researchers whose publications helped us come up with this review. We also acknowledge the kindness of the patients and their families who are helping to disseminating medical knowledge. We are grateful for our institutions who supported this work through resources and facilities.

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  1. Yale New Haven Health/Bridgeport Hospital, 267 Grant St, Bridgeport, CT, 06610, USA

    Akhila Arya PV

  2. Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA

    Krishnasai Abhishek Madathanapalli, Felipe Carrasco Tenezaca & Andrew Wang

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Conception or design of the work: AA, KM. Acquisition, analysis, or interpretation of data for the work: AA, KM, FT. Drafting the work or revising it critically for important intellectual content: AA, KM, AW. Final approval of the version to be published: AA, KM, FT, AW. All authors take full responsibility for the integrity and accuracy of all aspects of the work.

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Correspondence to Akhila Arya PV.

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Arya PV, A., Madathanapalli, K.A., Tenezaca, F.C. et al. Temporal arteritis presenting as third nerve palsy - a case report and review of literature. Rheumatol Int (2024). https://doi.org/10.1007/s00296-024-05604-6

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