Presumed Giant Cell Arteritis presenting as Sequential Bilateral 6th Nerve Palsies: Case Report and Review of Literature

Giant CELL ARTERITIS (GCA) is a systemic autoimmune disease that classically presents with jaw claudication, temporal headache and transient visual loss, affecting mostly people above the age of 50 years. However, diplopia due to cranial nerve 6 palsy (CN VI) has been rarely reported in GCA. Moreover, bilateral CN VI palsies, occurring in a sequential fashion in GCA is exceedingly rare. We report a case of a 70-year-old man who was admitted to our hospital twice within the span of one month with persistent binocular diplopia due to sequential, bilateral, CN VI palsies (right followed by left CN VI palsy) with associated eye pain, temporal headache, malaise and joint pain. The inflammatory markers including Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) were elevated at both admissions. He was treated with intravenous steroids with a complete resolution of his binocular diplopia, eye pain and temporal headache. Despite a negative biopsy of the temporal artery for evidence of inflammation, he was diagnosed with GCA by rheumatology, considering the fact that GCA pathology may have a patchy distribution, and a negative biopsy does not rule it out absolutely. This case underscores the importance of recognizing GCA as a differential diagnosis in patients presenting with binocular diplopia.