S4340 A Rare Case of Giant Cell Arteritis Presenting With Progressive Dysphagia and Lingual Infarction

Introduction: Giant cell arteritis (GCA) is a systemic vasculitis primarily affecting large- and medium-sized arteries, particularly in patients over 50. Classic symptoms include new-onset headache, tender temporal artery, jaw claudication, and vision loss. Rarely, GCA can present with atypical symptoms like dysphagia due to ischemia or inflammation of arteries supplying the pharynx and tongue, such as the ascending pharyngeal and lingual arteries. Early diagnosis and treatment are critical to prevent severe complications including vision loss, cerebral ischemia, and aortic aneurysm. We present a case of GCA with progressive dysphagia and lingual infarction, emphasizing the importance of recognizing this rare atypical clinical presentation. Case Description/Methods: A 76-year-old man presented with a 3-week history of progressive dysphagia to solids and liquids, slurred speech, tongue ulceration, bilateral acute vision loss, and jaw pain. On exam, he had a 3 cm thin ecchymotic lesion on the dorsal tongue, non-reactive pupils, and dysarthria. He failed bedside swallow and was made NPO. Labs revealed ESR >130 mm/hr, CRP 105 mg/L, and leukocytosis (14.9 × 10⁹/L). Carotid ultrasound showed 50–69% bilateral internal carotid artery stenosis. Brain magnetic resonance imaging/magnetic resonance angiography were unremarkable. Speech therapy found severe labial and lingual weakness, impairing bolus manipulation. A nasogastric tube was placed for feeding. Temporal artery biopsy revealed bilateral transmural inflammation, consistent with GCA, though giant cells were not seen. Treatment included prednisone 60 mg daily and aspirin 81 mg daily. Due to worsening dysphagia, vision loss, and progression of lingual necrosis, intravenous tocilizumab was initiated. Unfortunately, symptoms minimally improved, prompting gastrostomy tube placement. The patient is hospitalized for ongoing care. Discussion: This case illustrates a rare presentation of GCA with dysphagia and lingual infarction. Outside of GCA's typical symptoms, involvement of pharyngeal and lingual arteries can lead to severe oropharyngeal dysfunction, requiring interventions like gastrostomy. Diagnosis in atypical cases relies on high clinical suspicion. First-line therapy includes high-dose steroids and aspirin, but refractory cases may require advanced treatments like tocilizumab. GCA should be considered in elderly patients presenting with dysphagia and systemic symptoms, even in the absence of classic features. Prompt recognition and treatment are essential, making rare presentations valuable in improving patient care.