Virginia Via Research Day Book 2026

Medical Student Research Case Reports

26 GIANT CELL ARTERITIS WITH MEDIUM AND SMALL VESSEL INVOLVEMENT

Miriam Hanna, OMS-III; Amanda Reece, DO Corresponding author: cwoo01@vcom.edu

VCOM - Virginia, Blacksburg, Virginia

temporal artery biopsy (1.5 x 0.3 cm) demonstrated temporal arteritis in one medium-size and one small artery; the largest artery was without diagnostic evidence of temporal arteritis. Following biopsy confirmation, Prednisone was increased to 60 mg to improve control of jaw claudication and visual symptoms. She was referred to ophthalmology and rheumatology for further evaluation. In rheumatology, PR3/MPO ANCA antibody testing was done to rule out small-vessel vasculitis, given the unusual biopsy findings; results were negative. Once her symptoms improved and inflammatory markers normalized, Prednisone was tapered by 5 mg per week. At 40 mg, jaw pain recurred and worsened during her taper to 35 mg. Patient also experienced ongoing insomnia and increased appetite with this medication. Due to relapse and steroid adverse effects, rheumatology initiated steroid-sparing therapy with Actemra (tocilizumab) 6 mg/kg IV every four weeks. Comments: While this patient’s presentation and treatment course largely reflect classic GCA, her relapse during steroid taper and atypical biopsy findings highlight important nuances. Relapse during glucocorticoid taper is common in GCA, occurring in up

to 50% of patients being treated with steroids alone. This case underscores the need for careful monitoring and timely introduction of steroid-sparing agents. The biopsy pattern in this case is atypical; GCA rarely presents with isolated medium and small vessel involvement without large vessel involvement. However, non-diagnostic findings of large-vessel involvement does not exclude GCA when medium-sized arteries show characteristic histopathology and the clinical picture is compelling. This case reinforces the importance of integrating clinical judgment with biopsy findings and maintaining vigilance when symptoms are classic but histologic results are uncommon. Diagnosis: Prompt recognition of symptoms and elevated ESR is essential, as early initiation of high-dose glucocorticoids can prevent irreversible complications such as vision loss. Diagnosis and treatment should rely on the full clinical picture rather than biopsy findings alone, especially when pathology is atypical. IRB Statement: Written consent from patient was obtained for use of clinical information in this case report.

Context: Giant Cell Arteritis (GCA) is an autoimmune vasculitis that affects medium-and large sized arteries, with glucocorticoids as the cornerstone of treatment. Although classically a large-and medium vessel vasculitis, this report presents a rare case of GCA involving only medium and small arteries. Report of Case: A 72-year-old female with hypertension and hyperlipidemia presented to the emergency department with a throbbing headache, jaw claudication, and subjective fevers beginning one week after laparoscopic cholecystectomy. She also reported night sweats and new vision changes but denied limb claudication or myalgias. Physical exam showed no acute visual changes; pupils were equal and reactive with intact extraocular movements. No periorbital edema, nystagmus, or photophobia was noted. Her head was atraumatic and normocephalic, and scalp tenderness was present (left greater than right). Initial labs revealed ESR 62 mm/hr and CRP 11.83 mg/dL. Non-contrast CT of the head showed no acute abnormalities. With concern for GCA, the hospitalist referred the patient for temporal artery biopsy and initiated 40 mg of Prednisone to prevent irreversible vision loss. A left

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64 Edward Via College of Osteopathic Medicine (VCOM)