Takayasu Arteritis

Gastrointestinal involvement in childhood vasculitides

AIM

The aim of this narrative review was to provide a comprehensive summary of the characteristics of gastrointestinal (GI) involvement in the most common paediatric primary vasculitides.

METHODS

We used PubMed to primarily identify papers, reviews, case series and editorials published in English from 2000 until 31 January 2020. Based on this, we report the prevalence, clinical manifestations, diagnostic approaches and management of GI involvement in each vasculitis.

RESULTS

Vasculitides are inflammatory blood vessel diseases, and the majority can affect the GI system with vascular, GI tract or solid organ involvement. GI involvement can sometimes complicate and delay the correct diagnosis. Clinical findings are usually nonspecific symptoms, such as fever, abdominal pain, nausea, vomiting and diarrhoea. Bleeding should alert paediatricians to the possibility of severe complicated vasculitis. Diagnosis relies mostly on imaging. If it goes unrecognised, GI involvement in paediatric vasculitis is a serious cause of morbidity and even mortality, related to bowel ischaemia and perforation. Treatment of GI symptoms depends on the type of vasculitis and usually involves high-dose steroids and immunosuppressants.

CONCLUSION

GI manifestations in the most common paediatric primary vasculitides were usually nonspecific, diagnosis mostly relied on imaging, and treatment usually involved high-dose corticosteroids and immunosuppressants.

Non-Infectious, Necrotizing and Granulomatous Aortitis in a Female Gorilla

A 41-year-old female captive gorilla with progressive weight loss and hydrothorax of unknown origin was euthanized and submitted for necropsy. The ascending aorta showed intimal aortic thickenings, consistent with so called 'tree bark' changes. Microscopic examination revealed a non-infectious, necrotizing and granulomatous aortitis with no evidence of systemic vasculitis or infectious disease elsewhere in the body. While rare, large vessel vasculitides should be considered as a differential diagnosis in gorillas presenting with progressive non-specific signs and vascular intimal changes.

Takayasu arteritis: a cohort of Italian patients and recent pathogenetic and therapeutic advances

Takayasu arteritis (TAK) is a rare granulomatous vasculitis of unknown etiology that mainly affects the aorta and its major branches. The aim is to describe the clinical features, diagnostic procedures, pathogenesis, and management of TAK in a longitudinal cohort of patients recruited within a single region of southern Italy. The cohort included 43 patients who were diagnosed with TAK and followed up according to a standard protocol, in a collaboration between four university tertiary referral centers and a regional hospital. Clinical and imaging classification criteria were those established by the American College of Rheumatology. Thirty-five patients (81.4%) were female, and the mean age at disease onset was 32.6 (range 16–54) years. Angiographic assessment of the vascular involvement allowed disease classification in five different types. Clinical features ranged from constitutional symptoms in the early inflammatory stage of the disease to cardiovascular ischemic symptoms in the late, chronic stage. Noninvasive imaging techniques were employed to assess the extent and severity of the arterial wall damage and to monitor the clinical course and response to therapy. Medical treatment, based on pathogenetic insights into the roles of humoral and cell-mediated immune mechanisms, included glucocorticoids mostly combined with steroid-sparing immunosuppressive agents and, in patients with relapsing/refractory disease, biologic drugs. Significant clinical and angiographic differences have been detected in TAK patients from different geographic areas. Patients with life-threatening cardiovascular and neurologic manifestations as well as sight-threatening ophthalmologic signs and symptoms should be promptly diagnosed, properly treated, and closely followed up to avoid potentially severe consequences.

[Takayusu Arteritis on the background of congenital vascular anomaly?]

The article described a female patient with high-grade arterial hypertension diagnosed at her young age. Congenital abdominal aortic hyperplasia and conformity with criteria for Takayasu arteritis were diagnosed at 10 years following the clinical manifestation.

Ayurvedic management for a rare disorder Takayasu arteritis - A case report

Takayasu arteritis (TA) is a rare disorder and it is a devastating condition of aorta. The presently available treatments for the condition in the modern medicine have limited benefits. This is case of TA which was better managed with Ayurvedic intervention. An Ayurvedic diagnosis for this case was Siragata Vata (vitiated Vata Dosha affecting the blood vessels). A 42-year-old woman was diagnosed with TA and treated on the line of management of Siragata Vata with Shastikashali Pinda Swedana (sudation with bolus of medicated cooked rice) for 16 days, Erandamuladi Niruha Basti (enema mainly with decoction) along with Ashwagandha Taila Anuvasana (enema with medicated oil) for 16 days in Kala Basti Krama (16 days in alternate order of decoction and oleation enema) followed by one day gap and then 7 days of Nasya Karma (nasal therapy) with Triphaladi Taila (oil) on alternate days along with a combination of Ayurvedic oral drugs [Brihadvatachintamani Rasa-125 mg, Dashamula Kwatha-40 ml, Narsinha Churna (powder)-3 g, Yogaraja Guggulu-1g (500mgx2tab) and Shiva Gutika-500 mg, twice a day for 1 month. Same Panchakarma procedures were repeated after 6 months. A similar combination of oral medications were continued in between and during this period. Chyavanaprasha Aveleha in the dose of 10g twice a day with milk were also added after completion of this treatment regime. Patient condition was assessed on Indian Takayasu Clinical Activity Score (ITAS-2010) for disease activity of TA. Satisfactory results were observed in the patient with improvement in ITAS-2010 scoring. TA may be managed with Ayurvedic drugs and Panchakarma procedures.

The importance of FDG PET/CT in the diagnostic process of the middle aortic syndrome in a 15-year-old boy patient with suspected systemic vasculitis and final diagnosis of Williams-Beuren syndrome

The differential diagnosis in children with the systemic vasculopathy is still a challenge for clinicians. The progress in vascular imaging and the latest recommendations improve the diagnostic process, but only single reports describe the use of new imaging tests in children. The publication aims to demonstrate the important role of 18F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography combined with anatomical computed tomography angiography (PET/CTA) imaging in the case of a 15-year-old boy with chest pain, intermittent claudication, hypertension and features of middle aortic syndrome in computed tomography angiography (CTA). The patient was suspected to have Takayasu arteritis, but was finally diagnosed with Williams–Beuren syndrome. The case indicates that the FDG PET/CT imaging might be essential in the diagnostic process of middle aortic syndrome in children. We suggest that this imaging technique should be considered in the diagnostic process of systemic vasculopathy particularly in children.

Beyond plaque: A pictorial review of non-atherosclerotic abnormalities of extracranial carotid arteries

The common carotid artery (CCA) and extracranial internal carotid artery are subject to a wide variety of non-atheromatous pathologies. These entities are often overshadowed in both research and clinical realms by atherosclerotic disease. Nevertheless, non-atherosclerotic disease of the carotid arteries may have profound, even devastating, neurologic consequences. Hence, this review will cover both common and uncommon forms of extracranial carotid artery pathologies in a pictorial format, in order to aid the diagnostician in identifying and differentiating such pathologies.

Takayasu Arteritis Mistaken for Epilepsy: A Case Presenting With Convulsive Syncope

Takayasu arteritis (TA) is a chronic inflammatory disease characterized by granulomatous vasculitis that predominantly manifests as panaortitis. This occlusive thromboaortopathy lacks pathognomonic features often resulting in a diagnostic dilemma leading to its under-recognition, misdiagnosis and delayed management. Although neurological manifestations are not uncommon in TA, convulsive syncope as an initial clinical presentation is extremely rare. We report a case of convulsive syncope as a manifesting symptom of TA. A 17-year-old male patient of African origin was referred to us from an upcountry regional hospital with a diagnosis of medically intractable epilepsy for cardiovascular review. He presented with a 28-week history of generalized tonic-clonic seizures followed by loss of consciousness. He denied history of recurrent headaches, fever, visual disturbances, arthralgias, claudication or unintentional weight loss. Physical examination revealed feeble left-sided brachial and radial pulses, elevated blood pressure, differences in blood pressure between arms and left-sided carotid and vertebral bruits. Computed tomography angiogram of his thoracic and abdominal aorta revealed changes suggestive of a diffuse arteritis. Additionally, magnetic resonance angiogram of the brain revealed total occlusion of the left common carotid, left internal carotid, left external carotid and left vertebral arteries. Based on the physical examination and radiological findings, we reached a diagnosis of TA. He was prescribed dexamethasone, methotrexate, acetylsalicylic acid and amlodipine. He had a remarkable recovery and was seizure-free for the last 5 months after discharge. TA may manifest with convulsive syncope mimicking epilepsy. Despite its rarity, presentations of this nature continue to challenge clinicians resulting in delayed diagnosis with irreversible life-threatening consequences to patients. In view of this, physicians should strive to take detailed history and perform thorough physical examination so as to timely pick the characteristic signs of TA especially in patients presenting with unanticipated symptoms.

Takayasu Arteritis – A Systematic Review

Takayasu arteritis is a chronic, progressive, idiopathic, large-vessel vasculitis that affects the aorta, its main branches and the pulmonary arteries. It typically occurs in young Asian women but can be found in any ethnic group and in men. The disease is named after Mikito Takayasu, a Japanese ophthalmologist, who first described the arteriovenous anomalies in the retina of a patient with the disease in 1908. The etiopathogenesis is not known, but studies are being conducted regarding the immunological, infection and genetic aspects of the disease. Early during the course of the disease, inflammation of the involved arteries progresses, resulting in segmental stenosis, occlusion, dilatation and/or aneurysm. The clinical presentation of Takayasu arteritis varies depending on the blood vessels involved. Early symptoms are nonspecific, making the diagnosis difficult. Subsequently, arterial occlusions occur, producing more specific ischemic symptoms. Paucity of specific symptoms and laboratory biomarkers, as well as difficulties in assessing the disease activity and progression, make it often unrecognized at onset, and its activity is frequently underestimated. The diagnosis is usually confirmed by a combination of clinical manifestations, laboratory markers, diagnostic criteria and imaging methods. The purpose of this review is to address the current knowledge on pathogenesis, investigations, classification and management, and to emphasize the need for timely diagnosis, effective therapeutic intervention, and close monitoring of this disease.

[Eye involvement in large vesssel vasculitis (giant cell arteritis and Takayasu's arteritis)]

Giant cell arteritis (GCA) and Takayasu's arteritis are both forms of large vessel vasculitis and can be manifested in the eye. While GCA affects patients over the age of 50 years, patients with Takayasu's arteritis are between 15 and 30 years old. The diagnosis is based on a combination of anamnesis, imaging and systemic inflammatory reactions. The diagnosis can be confirmed by biopsy. Typical eye involvement of GCA are anterior ischemic optic neuropathy (AION) and central retinal artery occlusion, while Takayasu's arteritis involves hypertensive retinopathy and Takayasu's retinopathy (capillary dilatation, microaneurysms and arteriovenous anastomoses). The treatment consists of steroids in combination with classical immunosuppressants or biologics.

Axillobifemoral bypass for total abdominal occlusion secondary to Takayasu's arteritis: A case report

INTRODUCTION

Takayasu's arteritis (TA) is a rare disease that mainly affects large arteries. Approximately 20% of TA patients will require surgical intervention secondary to arterial complications such as intermittent claudication, persistent hypertension refractory to treatment, and heart failure.

PRESENTATION OF CASE

The case of a 22-year-old female with TA of five years of evolution is presented. The patient deteriorated clinically after five years of corticosteroid and immunosuppressant management requiring surgical intervention with an axillobifemoral bypass for a total abdominal occlusion. Onset, pre-surgical and post-surgical Doppler ultrasonography as well as abdominal angiotomographies document and corroborate the patient's clinical and hemodynamic improvement.

DISCUSSION

Very limited literature exists regarding surgical interventions for TA patients. While most reported cases present an endovascular surgical management. Open surgical procedures have lower rates of restenosis than endovascular management. Although endovascular management is less invasive than extra-anatomical axillobifemoral bypass, the patient was not a candidate for endovascular stent graft placement due to the increased risk for vascular injury and subsequent perforation. Approximately a fifth of TA patients are candidates for surgical intervention over time.

CONCLUSION

Vascular surgery in TA cases becomes an option when the patient does not improve clinically after administration of medical treatment. Although endovascular management has fewer complications, the rate of restenosis is higher. Patients at risk of restenosis and who have increased perioperative vascular risk can benefit from open surgical procedures. Surgical management should be tailored to the patient's needs.

Association of serum high mobility group box 1 levels with disease activity and renal involvement in patients with systemic vasculitis

High mobility group box 1 (HMGB1) is a kind of proinflammatory mediator that acts as an alarmin when released by dying, injured or activated cells. Previous studies have reported that HMGB1 are closely linked to antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The present study aimed to evaluate whether serum HMGB1 levels were associated with systemic vasculitis (VAs).The study population consisted of 51 patients with VAs, 46 patients with essential hypertension (EH) and 46 healthy controls (HC). Thirty-five patients with VAs had in active stage and 16 patients with VAs in an inactive stage. Furthermore, 31 patients with VAs had renal involvement, the other 20 patients were selected for without renal involvement. Serum HMGB1 levels were measured by enzyme-linked immunosorbent assay. Associations between serum HMGB1 levels with clinical and laboratory parameters were analyzed.Serum HMGB1 levels in patients with VAs were significantly higher than in EH and HC (all P < .05), and no difference regarding serum HMGB1 levels could be found between EH and HC (P = .208). Serum HMGB1 levels in VAs patients with active stage were significantly higher than those in HC and VAs patients with inactive stage (all P < .05). Patients with renal involvement and non-renal involvement had increased HMGB1 levels compared with HC (all P < .05). In addition, serum HMGB1 levels were significantly higher in patients with renal involvement compared with non-renal involvement patients (P = .001). Correlation analysis showed that serum HMGB1 levels were positive significant correlated with the Birmingham Vasculitis Activity Score, hypersensitive C reactive protein (Hs-CRP), serum creatinine (Scr) and 24-hour proteinuria (all P < .05). Among the subsets of VAs, serum HMGB1 levels were significantly higher in AAV, polyarteritis nodosa (PAN) and takayasu arteritis (TA) than in HC (all P < .05). More interestingly, serum HMGB1 were significantly higher in patients with PAN compared with AAV and TA patients (all P < .05). Furthermore, there was positive correlation between serum HMGB1 levels and Hs-CRP, Scr, and 24-hour proteinuria in patients with PAN (all P < .05).Serum HMGB1 levels are increased in patients with VAs compared with HC and EH and can reflect the disease activity and renal involvement.