A woman with progressive lethargy and sudden onset of shortness of breath

A 65-year-old Caucasian woman presented to the emergency department with rapidly worsening shortness of breath. On presentation she was tachycardic and tachypnoeic with reduced (85%) oxygen saturation. Cardiovascular examination revealed elevated jugular venous pressure with positive Kussmaul's sign, pulsus paradoxus and muffled heart sounds. Her inflammatory markers were elevated; she had neutrophilia and deranged liver function tests. Imaging revealed cardiomegaly, a large fusiform thoracic aortic aneurysm, pericardial effusion and right ventricular free wall collapse during diastole (suggestive of tamponade). Urgent pericardiocentesis was performed with rapid symptomatic relief. She subsequently underwent aortic root and aortic valve replacement surgery. Histology of the resected specimen showed inflammatory infiltrate with giant cell formation indicative of giant cell arteritis (GCA). This case highlights the need to consider GCA in the differential diagnosis of patients presenting with aortic aneurysm and pericardial effusion.