Pyrexia of Unknown Origin- An elusive diagnosis

Giant cell arteritis (GCA) is a systemic inflammatory disorder that affects large vessels. Here we present the case of a 59 year old male who presented to us with complaints of fever and generalised tiredness of 6 weeks duration. He had received 2 courses of antibiotics with no respite. Investigations from outside showed elevated erythrocyte sedimentation rate (ESR) and prostate specific antigen (PSA). He was evaluated in detail as FUO. His fever persisted despite maximal dose of antipyretics, leading to high suspicion of malignancy. However, investigations were not suggestive of any malignancy. On day 3 of admission, he complained of pain on mastication. Examination revealed prominent temporal arteries, with normal pulsations without any tenderness. Fundus examination was normal. With high index of suspicion, temporal artery was biopsied and was diagnostic of giant cell arteritis. Though GCA classically presents with headache, visual changes, masticatory claudication, and symptoms of polymyalgia rheumatica, on rare occasion, GCA may present with fever as the only dominant symptom. GCA without headache is an uncommon presentation, which occurs in nearly 20% of patients.