Ischemia of the tongue and scalp as an uncommon presentation of giant cell arteritis

Giant cell arteritis (GCA) is a chronic large-vessel vasculitis that may present with systemic, neurological or ophthalmological manifestations. Lingual and scalp ischaemia are rare but can have severe potential complications that pose a diagnostic challenge and require immediate treatment to prevent irreversible outcomes. We report the case of an 87-year-old woman who initially presented with holocranial headaches and tongue pain with partially detachable whitish plaques. She was diagnosed with GCA based on clinical features, elevated inflammatory markers and ultrasonographic findings of thickened temporal arteries. High-dose corticosteroid therapy was promptly initiated, leading to marked improvement of the reported symptoms. Nevertheless, on day 14 of hospitalisation, she developed septic shock from an abdominal source and subsequently died. This case reports an atypical presentation of GCA - lingual and scalp ischaemia - emphasising the need to maintain a high index of suspicion even before these non-classical manifestations. A holistic clinical approach is essential to identify the various possible manifestations of this complex disease. Although tongue and/or scalp necrosis are rare complications, treatment remains aligned with current GCA guidelines. Most patients respond to corticosteroid therapy, or tocilizumab in cases of steroid-refractory lingual necrosis; non-responders are typically associated with a poorer prognosis. LEARNING POINTS: This report highlights the critical importance of considering giant cell arteritis (GCA) in the differential diagnosis of lingual and scalp ischaemia, enabling the exclusion of more common causes and ensuring the early initiation of appropriate treatment.The case emphasises the value of a multidisciplinary approach and continuous clinical surveillance, reinforcing the central role of the internal medicine physician in recognising atypical manifestations and coordinating follow-up in complex cases of systemic vasculitis.The report provides practical guidance for the diagnosis and management of rare presentations of GCA, offering evidence-based tools to support clinical decision-making and prevent irreversible complications.