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An unusual presentation

01 November 2004

Mrs D, a 79-year-old retired haberdasher, went to her GP practice as she’d developed a rash on her forehead and face with puffy eyes. She saw Dr Y who suspected an allergic reaction to a new perfume that Mrs D had just started using.

Mrs D had already taken an anti-histamine with no effect, so Dr Y prescribed prednisoslone 15mg daily, advising Mrs D to tail off the dose if she responded. He asked her to return in a few days if things hadn’t settled.

Six days later Mrs D saw Dr C at the practice. Her face was still puffy and itchy and she’d developed pain across her forehead. Dr C noted that her eyelids were swollen. Dr C restarted the anti-histamine, continued the prednisolone and gave a topical steroid cream.

Two weeks later Mrs D returned and saw Dr N. She had noticed deteriorating vision in her left eye and pain in the temples. Dr N noted some corneal cloudiness and a sluggish pupillary response to light in the left eye.

Dr N suspected giant cell (temporal) arteritis and took blood for an urgent ESR, giving prednisolone at a dose of 60mg daily. Dr N arranged an urgent ophthalmological opinion and the diagnosis was confirmed. Mrs D was left with blindness in her left eye due to ischaemic optic neuropathy.

Mrs D sued the doctors at her practice for negligence in failing to examine her properly, wrongly diagnosing an allergy and failing to refer for specialist advice. She alleged that the day before Dr N had seen her she had spoken to a practice receptionist and told her that she’d experienced loss of vision in her left eye, requesting an urgent appointment, but had been refused and told to come the next day.

All the doctors concerned had kept good notes and could give clear accounts of their dealings with Mrs D, specifically noting the absence of any classical features of giant cell arteritis. The receptionist concerned had logged the call from Mrs D and could find no record of a request to be seen urgently.

The practice had a policy of allowing patients to decide for themselves how urgently they wished to be seen, and the receptionist thought it highly unlikely she would ever have refused a request for an urgent appointment, especially where a patient complained of blindness.

Expert opinion

We sought expert GP, rheumatology and ophthalmology advice. The GP expert felt that the standard of care was reasonable if the practice’s account of events was correct.

Rheumatological opinion was supportive, noting that although urticarial rash and oedema are recognised features of giant cell arteritis in the literature ‘they must be regarded as extremely rare and are certainly so uncommon that they would not be recognised by the majority of practising clinicians.’

Ophthalmological opinion concurred and pointed out that, even if the high-dose steroids had been given a day earlier when Mrs D allegedly requested an urgent appointment, it was unlikely to have materially affected the outcome with respect to her visual loss.

Our medicolegal team had some concern about the reported forehead pain at the second appointment (with Dr C) but felt that the doctors’ approach to an unusual and uncommon presentation was defensible.

The case went to trial and the claim was dismissed, costs being awarded against the complainant.

Learning points

Failure to diagnose giant cell arteritis is an important and relatively frequent cause for legal claims. It should always be considered in older patients presenting with headache, visual symptoms, myalgia or unexplained weight loss.

See our previous article on acute headaches in Casebook 2003 (3) August 2003. Where a condition presents atypically and the standard of clinical practice is acceptable to a reasonable body of similar clinicians we will strongly defend our members.