© 2002 European Academy of Dermatology and Venereology 615 CASE REPORT JEADV (2002) 16, 615 – 617 Blackwell Science, Ltd Temporal arteritis presenting with scalp ulceration C Monteiro,* B Fernandes, J Reis, O Tellechea, J Freitas, A Figueiredo Department of Dermatology, University Hospital, Praceta Prof Mota Pinto, 3000–075 Coimbra, Portugal. *Corresponding author, Serviço de Dermatologia, Hospitais da Universidade de Coimbra, Praceta Prof Mota Pinto, 3000–075 Coimbra, Portugal, tel. +351 239400 420; fax +351 239400 490; E-mail: c.monteiro@netc.pt ABSTRACT We report the case of a 75-year-old-woman who presented with bilateral scalp ulcerations and blindness, accompanied by severe headache and scalp tenderness, due to bilateral temporal arteritis without systemic involvement. A biopsy taken from the border of an ulceration showed evidence of giant cell arteritis. She was treated with oral prednisone, 60 mg per day. The ulcerations healed in a few weeks but the vision loss was irreversible. This case highlights for temporal arteritis the importance of accurate and timely diagnosis as well as the need for prompt therapy with systemic steroids in order to avoid major complications, namely loss of vision. It also demonstrates that scalp necrosis and ulcerations are skin signs associated with a poor prognosis. Key words: temporal arteritis, giant cell arteritis, scalp ulceration, blindness Received: 2 April 2001, accepted 26 March 2002 Introduction Temporal arteritis or giant cell arteritis is a systemic granu- lomatous vasculitis of the medium and large-sized arteries, involving most frequently the temporal artery. It is a rare disease that affects mainly elderly persons, particularly women. It presents classically with headache, fever, high ESR and anaemia. Other manifestations can include fatigue, lassitude, malaise, weight loss, depression, sweating and arthralgia. Claudication, strokes, myocardial infarction, purpuric eruptions and gangrene of the legs may also occur as a result of systemic vasculitis. Polymyalgia rheumatica syndrome is a frequently associated disease, characterized by stiffness and aching pains in the muscles of the neck, shoulders, pelvic girdle and limbs. 1,2 We report a case of temporal arteritis in a 75-year-old woman, manifested by bilateral scalp ulcerations and blindness. Case report A 75-year-old woman, presenting extensive tender scalp ulcera- tions and crusted lesions on both the right and left temporo- parietal regions (fig. 1), accompanied by bilateral vision loss, with 4 weeks of evolution, was admitted to our Department of Dermatology for further investigation and treatment. No other cutaneous or systemic signs or symptoms were noticed. Four months before she had been admitted to a neurology unit with severe headaches, where laboratory studies and brain CT disclosed only an elevated erythrocyte sedimentation rate (ESR) (61 mm/h). At that time, a diagnosis of temporal arteritis was ruled out based on an unresponsive 2-week therapeutical trial with systemic steroids. Analgesics were given for the headache. Laboratory studies done in our department, including hae- matologic and biochemical blood parameters, urine analysis, rheumatoid factors, circulating immune complexes, C3 and C4 levels, proteinogram and immunoelectrophoresis, antinuclear antibodies, cardiolipin antibodies, VDRL, chest X-ray, ECG and brain CT, were all negative or in the normal range, except C- reactive protein: 4.5 mg/dL (normal range: 0.0–1.0). The ESR was 30 mm /h (normal range: 0 –35). A 2-cm length biopsy of the left temporal superficial artery showed a lymphohistiocytic infiltrate closely related to the internal elastic lamina, inducing its focal fragmentation, and intimal proliferation with myxomatoid changes (fig. 2). A punch biopsy from the border of an ulceration disclosed multi- nucleated giant cells in the wall of a medium-sized muscular vessel (fig. 3).