A 90-year-old woman presented to the emergency department complaining of a 3-month history of headache, and recent blindness of her right eye. She also reported weakness and weight loss (5 kg during the last 3 months prior to her presentation) but no fever. She had been treated symptomatically with non-steroidal anti-inflammatory drugs without noting any significant relief. There was no history of trauma or burn. Her past medical history included diabetes mellitus type II and arterial hypertension.

The physical examination on presentation was unremarkable except for a large area of scalp necrosis in the temporo-parietal region bilaterally (photos 1 and 2).

Routine laboratory testing on admission showed anemia (hematocrit = 31,1%) and elevated erythrocyte sedimentation rate (ESR = 120mm/first hour). Serological tests for varicella-zoster virus (VZV) and herpes simplex virus 1 and 2 (HSV1 and HSV2) were negative. A CT scan of the head was unremarkable.

The patient underwent biopsy of the right temporal artery, which showed typical changes of temporal arteritis. She was given treatment with oral steroids (48 mg/day). After two months, the crusting area of the scalp diminished and the ESR normalized (ESR = 20mm/h). Scalp necrosis is a rare but severe complication of temporal arteritis. It is associated with a bad prognosis since it is usually a manifestation of severe, occlusive vasculitis or a result of delayed recognition of temporal arteritis1. Adequate corticosteroid therapy is mandatory2.

References
1. R. Vamma, A. Patel. Scalp lesions in a 78-year-old woman. CMAJ 2005;173:33.
2. J. Currey. Scalp necrosis in giant cell arteritis and review of the literature. Br J Rheum 1997;36:814-816.

Acknowledgement
The case was prepared for the website by Dimitris A. Moutzouris, MD.