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Thomas KN, Aggarwal A. Childhood rheumatic diseases: bites not only the joint, but also the heart. Clin Rheumatol 2023; 42:2703-2715. [PMID: 37160484 PMCID: PMC10169151 DOI: 10.1007/s10067-023-06621-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 05/11/2023]
Abstract
Cardiovascular involvement in juvenile rheumatic diseases is the primary manifestation in paediatric vasculitis and a major organ manifestation in paediatric connective tissue diseases. Though coronary vasculitis is the prototypical manifestation of Kawasaki disease, it can also be seen in patients with polyarteritis nodosa. Pericarditis is the most common manifestation seen in juvenile rheumatic diseases like systemic onset JIA, and lupus. Cardiac tamponade, valvular insufficiency, aortic root dilatation and arrhythmias are seen rarely. Cardiac involvement is often recognized late in children. The development of cardiac disease in juvenile systemic sclerosis is associated with a poor outcome. In long term, childhood onset of rheumatic diseases predisposes to diastolic dysfunction and premature atherosclerosis during adulthood. Key Points • Pericarditis is the most common cardiac manifestation in SLE and can lead to tamponade. • Conduction defects are common in juvenile mixed connective tissue disease and systemic sclerosis. • Pulmonary hypertension is a significant contributor to mortality in juvenile systemic sclerosis. • In Kawasaki disease, early treatment can reduce risk of coronary artery aneurysms.
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Affiliation(s)
- Koshy Nithin Thomas
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.
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besar M, Salem AAE, Eleshra A, Khafagy T, Saad E. A Case Report Resistant hypertension as presenting manifestation of abdominal Takayasu’s Arteritis.. [DOI: 10.21203/rs.3.rs-1938889/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Abstract
Introduction: We report an unusual presentation of Takayasu’s Arteritis in young female with resistant hypertension to usual antihypertensive medication that discovered to extensive renal artery
Case presentation:
We report a 17 years old female with 2years history of hypertension that was difficult to control despite different type of antihypertension. Abdominal Ultrasound Abdominal us showed right kidney 12*5 cm, relatively small left kidney 8.3*3.8 cm, color duplex on normal low impedance flow in both renal and intrarenal arteries with no area of abnormal high velocity or damped flow. Investigation relieved ESR 50, CRP 26, ANA, ANCA serology were negative,S.NA 155, S.K 3.4, Serum aldosterone was 305 pg/ml (13.6-261.7) , renin activity was 254 pg/ml (4-45.98).
The patient diagnosed as secondary hypertension to secondary hyperaldosternoism mostly renal artery stenosis, so CT angiography detected diffuse mural thickness with enhancement of the abdominal aorta and extending into proximal segments of superior and inferior mesenteric arteries, ostium of right renal artery and marked stenosis of the left renal artery (2 cm), relative small sized left kidney with hypo enhancement in comparison to the right kidney, finding suggestive to large vessel vasculitis, Takayasu’s Arteritis
Conclusion: Resistant hypertension due to renal artery stenosis in young female can be a presenting manifestation of Takayasu’s Arteritis.
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Affiliation(s)
| | | | | | | | - Ehab Saad
- Mansoura University Faculty of Medicine
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Haslak F, Yildiz M, Sahin S, Adrovic A, Barut K, Kasapcopur O. Pediatric Takayasu Arteritis: A Review of the Literature. Curr Pediatr Rev 2022; 18:243-250. [PMID: 35249495 DOI: 10.2174/1573396318666220304205518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 11/03/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022]
Abstract
Takayasu arteritis (TA) is the third most common vasculitis of childhood and is extremely rare. It is mainly characterized by chronic, autoimmune, and granulomatous inflammation of the aorta and its major branches. Women under 40 years of age are mostly affected. It occurs for the first time in childhood in about 30% of affected individuals. Initially, it presents nonspecific constitutional findings. Since there is no specific laboratory finding, diagnosis is challenging. The gold standard imaging method for diagnosis is conventional angiography. Delay in diagnosis can cause devastating consequences. Therefore, in cases presenting with nonspecific findings, with hypertension and high acute phase reactants, the diagnosis should be suspected and confirmed with appropriate imaging method, and treatment should be started immediately. Immunosuppressive agents are the mainstay of the treatment. Biological agents are successful in refractory cases, and endovascular revascularization methods are used in the treatment of complications.
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Affiliation(s)
- Fatih Haslak
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
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Shankar G, Gowda I, Walimbe A, Sarangi B, Oswal J, Kalra R. Renal angioplasty for refractory renovascular hypertension in an adolescent with Takayasu's arteritis: A case report. JOURNAL OF PEDIATRIC CRITICAL CARE 2022. [DOI: 10.4103/jpcc.jpcc_97_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Misra DP, Rathore U, Patro P, Agarwal V, Sharma A. Disease-modifying anti-rheumatic drugs for the management of Takayasu arteritis-a systematic review and meta-analysis. Clin Rheumatol 2021; 40:4391-4416. [PMID: 33932173 PMCID: PMC8087890 DOI: 10.1007/s10067-021-05743-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 01/17/2023]
Abstract
The pharmacotherapy of Takayasu arteritis (TAK) with disease-modifying anti-rheumatic drugs (DMARDs) is an evolving area. A systematic review of Scopus, Web of Science, Pubmed Central, clinical trial databases and recent international rheumatology conferences for interventional and observational studies reporting the effectiveness of DMARDs in TAK identified four randomized controlled trials (RCTs, with another longer-term follow-up of one RCT) and 63 observational studies. The identified trials had some concern or high risk of bias. Most observational studies were downgraded on the Newcastle-Ottawa scale due to lack of appropriate comparator groups. Studies used heterogenous outcomes of clinical responses, angiographic stabilization, normalization of inflammatory markers, reduction in vascular uptake on positron emission tomography, reduction in prednisolone doses and relapses. Tocilizumab showed benefit in a RCT compared to placebo in a secondary per-protocol analysis but not the primary intention-to-treat analysis. Abatacept failed to demonstrate benefit compared to placebo for preventing relapses in another RCT. Pooled data from uncontrolled observational studies demonstrated beneficial clinical responses and angiographic stabilization in nearly 80% patients treated with tumour necrosis factor alpha inhibitors, tocilizumab or leflunomide. Certainty of evidence for outcomes from RCTs ranged from moderate to very low and was low to very low for all observational studies. There is a paucity of high-quality evidence to guide the pharmacotherapy of TAK. Future observational studies should attempt to include appropriate comparator arms. Multicentric, adequately powered RCTs assessing both clinical and angiographic responses are necessary in TAK.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Upendra Rathore
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Pallavi Patro
- School of Telemedicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Aman Sharma
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), -160012, Chandigarh, India
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Advancements in medical and surgical treatments of Takayasu arteritis-induced renal arteritis: a systematic review. Chin Med J (Engl) 2021; 133:975-981. [PMID: 32187045 PMCID: PMC7176450 DOI: 10.1097/cm9.0000000000000704] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Takayasu arteritis-induced renal arteritis (TARA), commonly seen in Takayasu arteritis (TA), has become one of the main causes of poor prognosis and early mortality in patients with TA. TARA progressing into Takayasu arteritis-induced renal artery stenosis (TARAS), could lead to severe complications including malignant hypertension, cardiac-cerebral vascular disease, and ischemic nephropathy. Since there existed no guidelines on treatments, this study aimed to review the comprehensive treatments for TARA. Methods We searched systematically in databases including PubMed, Ovid-Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and SinoMed, from inception to May 2018. Literature selection, data extraction, and statistical analysis were performed. Results Eighty-two literatures were recruited focusing on medical treatments (n = 34) and surgical treatments (n = 48). We found that combined medical treatments of glucocorticoids and conventional synthetic disease-modifying anti-rheumatic drugs could reach high rates of remission in patients with TARA, and biological disease-modifying anti-rheumatic drugs were preferred for refractory patients. After remission induction, surgical treatment could help reconstruct renal artery and recover renal function partly. Percutaneous transluminal angioplasty was the first choice for patients with TARAS, while open surgery showed a good long-term survival. Conclusions Patients with TARA should benefit both from medical treatments and from surgical treatments comprehensively and sequentially. Multidisciplinary team coordination is recommended especially in patients with severe complications.
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Gupta H, Kaur N, Saxena A, Jagia P, Kumar S, Gupta SK, Sharma S, Kothari SS, Ramakrishnan S. Non-specific aortoarteritis (NSAA) in children: a prospective observational study. BMJ Paediatr Open 2021; 5:e001106. [PMID: 34435143 PMCID: PMC8354261 DOI: 10.1136/bmjpo-2021-001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Prospective data on clinical profile, natural history and outcomes of NSAA (non-specific aortoarteritis) in children is limited. We initiated this prospective study to evaluate the short-term and medium-term outcomes of NSAA in children. DESIGN Prospective observational study. SETTING Tertiary care hospital in India. PATIENTS We included 28 consecutive children (<15 years) with a diagnosis of NSAA. MAIN OUTCOME MEASURES Clinical profile, symptoms, left ventricular ejection fraction (LVEF), the pattern of vessel involvement, complications and markers of disease activity were assessed at the time of diagnosis. All the patients underwent treatment and interventions as per the current guidelines and were followed up for a mean duration of 13.5±6.7 months for disease activity and outcomes. RESULTS The mean age of the cohort was 10±2.9 years (14 boys). Twenty (71%) patients had hypertension. Half of the children presented with acute decompensated heart failure (ADHF). Only 21 patients (75%) met Sharma et al modified Ishikawa criteria for the diagnosis. The children with active disease (36%) were managed with immunosuppressive drugs. Percutaneous and surgical interventions were performed in 26 (93%) children. New York Heart Association functional class, LVEF and control of hypertension improved in most children on follow-up. Four children developed vascular restenosis requiring reinterventions. There was no death during mid-term follow-up. CONCLUSIONS Children with NSAA, unlike adults seldom present with classical features of the disease. ADHF and ventricular dysfunction are strikingly common in children. Appropriate immunosuppressive therapy for active disease and timely intervention improves clinical outcomes over a medium term follow-up. Future studies assessing long-term outcome are needed.
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Affiliation(s)
- Himanshu Gupta
- Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navjyot Kaur
- Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anita Saxena
- Cardiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Priya Jagia
- Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Sanjeev Kumar
- Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Saurabh Kumar Gupta
- Cardiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Sanjeev Sharma
- Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Shyam S Kothari
- Cardiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Dai X, Cui X, Sun Y, Ma L, Jiang L. Effectiveness and safety of leflunomide compared with cyclophosphamide as induction therapy in Takayasu's arteritis: an observational study. Ther Adv Chronic Dis 2020; 11:2040622320922019. [PMID: 32551033 PMCID: PMC7278326 DOI: 10.1177/2040622320922019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 03/31/2020] [Indexed: 01/09/2023] Open
Abstract
Aims The objective of this study was to investigate the outcomes of leflunomide (LEF) compared with those of cyclophosphamide (CYC) as induction against active Takayasu's arteritis (TA) in Chinese patients. Methods This was an observational study based on a prospective cohort that included TA patients diagnosed in large third-level first-class general hospitals in East China from January 2009 to September 2018. LEF- or CYC-induced active patients were enrolled for comparative effectiveness analysis. One-to-more paired cohorts of LEF versus CYC were derived by propensity-score matching (PSM). The primary outcome was complete remission (CR) at 9-month follow up, and secondary endpoints included partial remission (PR) and effectiveness rate (ER). Multivariable logistic regression was used to identify statistical significance. Results A total of 131 enrolled patients with at least 3-months treatment included 53 receiving a regimen of glucocorticoid (GC) and LEF and 78 receiving GC and CYC. Compared with the CYC group, the LEF group showed higher CR rate {LEF versus CYC: 84.6% [95% confidence interval (CI) 74.5-94.8%] versus 59.0% (47.8-70.1%); relative risk (RR) = 0.3 (0.1-0.6), p = 0.002} and lower daily GC dose [10.0 (5.0-12.5) versus 12.5 (10.0-15.0) mg, p = 0.043] at the end of the 9-month induction. In the matched analysis, the LEF group (n = 23) still indicated a higher CR rate than the CYC group (n = 54) after PSM [RR = 0.1 (0.0-0.6), p = 0.003]. Four LEF-treated patients had mild side effects, and one died unrelated to LEF. Conclusion LEF could be an alternative induction therapy against TA, showing good effectiveness and tolerance compared with CYC.
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Affiliation(s)
- Xiaomin Dai
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaomeng Cui
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Sun
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lili Ma
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, No. 180, Road Fenglin, Xuhui District, Shanghai 200032, P. R. China Evidence-Based Medicine Center, Fudan University, Shanghai, China
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Ying S, Xiaomeng C, Xiaomin D, Jiang L, Peng L, Lili M, Rongyi C, Zongfei J, Huiyong C, Lindi J. Efficacy and safety of leflunomide versus cyclophosphamide for initial-onset Takayasu arteritis: a prospective cohort study. Ther Adv Musculoskelet Dis 2020; 12:1759720X20930114. [PMID: 32536986 PMCID: PMC7268110 DOI: 10.1177/1759720x20930114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/07/2020] [Indexed: 01/24/2023] Open
Abstract
Background Leflunomide (LEF) has been considered as an alternative treatment for Takayasu arteritis (TA); however, data on its efficacy are still scanty. Objective To investigate the efficacy and safety of LEF versus cyclophosphamide (CYC) for initial-onset TA. Methods Initial-onset TA patients with active disease were enrolled in this research. Patients enrolled from 1 January 2009 to 31 December 2015 were treated with glucocorticoids and CYC, while patients enrolled from 1 January 2016 to 31 October 2018 received glucocorticoids and LEF. Treatment response including complete remission (CR), partial remission (PR), and effectiveness rate (ER) and side effects were evaluated at 6 and 12 months. Results and conclusion In total, 92 patients were enrolled. A total of 47 patients were treated with LEF, while 45 patients were treated with CYC. The CR and ER rates were 75.55%, and 88.89% at 6 months, and 85.37% and 95.12% at 12 months in the LEF group. The CR and ER rates were 39.02% and 70.73% at 6 months, and 56.41% and 82.05% at 12 months in the CYC group. The CR rate was significantly higher in the LEF group than in the CYC group both at 6 months (75.61% versus 38.24%, p < 0.01) and 12 months (77.42% versus 53.33%, p < 0.05) after adjustment for propensity scores. The incidence of side effects in the LEF group was much lower than that in the CYC group (21.28% versus 44.44%). In conclusion, LEF provided a better treatment response, along with lower reproductive toxicity, compared with CYC in initial-onset TA.
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Affiliation(s)
- Sun Ying
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Cui Xiaomeng
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Dai Xiaomin
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Lin Jiang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Lv Peng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Ma Lili
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Chen Rongyi
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Ji Zongfei
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Chen Huiyong
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Jiang Lindi
- Department of Rheumatology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road Shanghai, 200032, P. R. China Centre of Evidence-based Medicine, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
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Aeschlimann FA, Twilt M, Yeung RSM. Childhood-onset Takayasu Arteritis. Eur J Rheumatol 2020; 7:S58-S66. [PMID: 35929861 PMCID: PMC7004266 DOI: 10.5152/eurjrheum.2019.19195] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/04/2019] [Indexed: 09/02/2023] Open
Abstract
Childhood-onset Takayasu Arteritis (cTAK) is a rare, large-vessel type of vasculitis seen in children, mainly affecting the aorta and its major branches. Clinical manifestations are often severe and arise as a result of systemic and local inflammation, along with end-organ ischemia. Disease flares are common and the disease burden is high, with a significant rate of morbidity and mortality. Recent advances in understanding the underlying disease pathobiology resulted in the use of pathway-targeting agents, such as TNF- or IL-6 inhibitors with improved disease control. Nonetheless, the prognosis often remains guarded and the accrued damage is significant. This review aims at summarizing the recent evidence and observations regarding this condition, with a focus on pediatric publications.
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Affiliation(s)
- Florence A Aeschlimann
- Paediatric Immunology, Hematology and Rheumatology Unit, Hôpital Necker - Enfants Malades, Paris, France; Division of Paediatrics, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Marinka Twilt
- Division of Rheumatology, Department of Paediatric, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Alberta, Canada; Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rae S M Yeung
- Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Immunology, University of Toronto, Toronto, Ontario, Canada
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Cui X, Dai X, Ma L, Yang C, Tan W, Zhang L, Zhang Z, Feng X, Wu R, Zou Y, Zhou Z, Lu Y, Wang Y, Wu M, Li S, Wang L, Lin H, Dong Z, Fu W, Sun X, Wang C, Ding J, Lv P, Lin J, Jiang L. Efficacy and safety of leflunomide treatment in Takayasu arteritis: Case series from the East China cohort. Semin Arthritis Rheum 2020; 50:59-65. [DOI: 10.1016/j.semarthrit.2019.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/05/2019] [Accepted: 06/10/2019] [Indexed: 12/26/2022]
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Bharuthram N, Tikly M. Pregnancy and Takayasu arteritis: case-based review. Rheumatol Int 2019; 40:799-809. [PMID: 31858208 DOI: 10.1007/s00296-019-04499-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 12/11/2019] [Indexed: 11/30/2022]
Abstract
Takayasu arteritis (TA) is a rare large vessel vasculitis that particularly affects women of child-bearing age. Management of pregnant patients with TA is often challenging due to the cardiovascular and cerebrovascular complications of the disease. We report two new cases of pregnancy in patients with TA and review all published cases from sub-Saharan Africa. Analysis of 16 pregnancies in 15 patients (including our two cases) showed that seven patients had radiographic Type V TA disease, namely involvement of the entire length of the aorta. Four patients were newly diagnosed with TA during pregnancy and two pregnancies were unbooked at time of first presentation. Seven pregnancies were complicated by disease flares (n = 4) and/or hypertension (n = 6). Four pregnancies resulted in preterm delivery and six required caesarean sections. There was one documented case of pre-eclampsia resulting in the only maternal death. Intrauterine growth restriction was documented in two of six pregnancies in which foetal ultrasonography was performed. There were four low birth weight infants and one fresh stillbirth (associated with the maternal death). In the handful of case reports of pregnancy in TA from sub-Saharan Africa, both maternal and foetal outcomes were generally good and similar to international findings. In a substantial proportion of patients, the diagnosis of TA was made in pregnancy, reflecting challenges of access to appropriate health care in resource constrained sub-Saharan Africa.
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Affiliation(s)
- Nirvana Bharuthram
- Division of Rheumatology, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Mohammed Tikly
- Division of Rheumatology, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Pavić R, Blažeković R, Divković D, Marjanović K, Sipl M. Aggressive progression of Takayasu's arteritis in infancy: a case report. Acta Clin Croat 2019; 58:535-539. [PMID: 31969768 PMCID: PMC6971795 DOI: 10.20471/acc.2019.58.03.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Takayasu’s arteritis (TA) affects the aorta and its branches. Immunosuppressants are the usual course of therapy, while surgery has been used in acute cases. There is only scant information on TA in infancy, and the nonspecific symptoms in the initial stage of the disease make the diagnosis difficult and delayed, thus increasing the mortality rate. We describe a case of aggressive progression of TA in an infant. This child was the youngest to be affected with the disease as reported in the literature. A 3.5-month-old boy presented with cyanosis of both legs, tachycardia and antithrombin III deficiency. Computed tomography angiography (CTA) revealed thrombosis of distal aorta and both iliac arteries. Thrombectomy was performed at the level of both common femoral arteries. In addition, thigh amputation of the left leg had to be performed. TA was diagnosed postmortem with thrombosis of the distal aorta, its branches and upper mesenteric artery which was not occluded on previous CTA, glomerulonephritis and pulmonary parenchymal granulomatous infiltrations.
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Affiliation(s)
| | - Robert Blažeković
- 1Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 2Department of Traumatology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Department of Surgery, Dubrava University Hospital, Zagreb, Croatia; 4Department of Pediatric Surgery, Osijek University Hospital Centre, Osijek, Croatia; 5Department of Pathology and Forensic Medicine, Osijek University Hospital Centre, Osijek, Croatia; 6Department of Pediatrics, Osijek University Hospital Centre, Osijek, Croatia
| | - Dalibor Divković
- 1Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 2Department of Traumatology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Department of Surgery, Dubrava University Hospital, Zagreb, Croatia; 4Department of Pediatric Surgery, Osijek University Hospital Centre, Osijek, Croatia; 5Department of Pathology and Forensic Medicine, Osijek University Hospital Centre, Osijek, Croatia; 6Department of Pediatrics, Osijek University Hospital Centre, Osijek, Croatia
| | - Ksenija Marjanović
- 1Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 2Department of Traumatology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Department of Surgery, Dubrava University Hospital, Zagreb, Croatia; 4Department of Pediatric Surgery, Osijek University Hospital Centre, Osijek, Croatia; 5Department of Pathology and Forensic Medicine, Osijek University Hospital Centre, Osijek, Croatia; 6Department of Pediatrics, Osijek University Hospital Centre, Osijek, Croatia
| | - Mirna Sipl
- 1Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; 2Department of Traumatology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Department of Surgery, Dubrava University Hospital, Zagreb, Croatia; 4Department of Pediatric Surgery, Osijek University Hospital Centre, Osijek, Croatia; 5Department of Pathology and Forensic Medicine, Osijek University Hospital Centre, Osijek, Croatia; 6Department of Pediatrics, Osijek University Hospital Centre, Osijek, Croatia
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Sahin S, Hopurcuoglu D, Bektas S, Belhan E, Adrovic A, Barut K, Canpolat N, Caliskan S, Sever L, Kasapcopur O. Childhood-onset Takayasu arteritis: A 15-year experience from a tertiary referral center. Int J Rheum Dis 2018; 22:132-139. [PMID: 30397997 DOI: 10.1111/1756-185x.13425] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/09/2018] [Accepted: 09/28/2018] [Indexed: 01/30/2023]
Abstract
AIM To describe clinical manifestations, angiographic findings, treatment, activity and damage of our Takayasu arteritis patients. METHOD The patients who met European League Against Rheumatism/Paediatric Rheumatology International Trials Organisation/Paediatric Rheumatology European Society classification criteria for childhood-onset Takayasu arteritis were reviewed in a retrospective longitudinal manner from 2002 to 2017. Extent of the disease was assessed by Disease Extent Index for Takayasu Arteritis (DEI.Tak), activity by Pediatric Vasculitis Activity Score and Indian Takayasu's Arteritis Activity Score (ITAS 2010) and damage by Pediatric Vasculitis Damage Index and Takayasu Arteritis Damage Score (TADS). RESULTS Sixteen subjects (75% female) with a median disease duration of 3.1 years were enrolled in this study. While the median age at disease onset was 12.1 years, there was only a 2.5 months diagnostic delay. Treatment regime included corticosteroids (100%), which were combined with azathioprine or methotrexate in 93.8% and 37.5% of the subjects, respectively. Severe and refractory cases were treated with cyclophosphamide (62.5%) and subsequently with tocilizumab (37.5%). Seven patients (43.8%) required either percutaneous endovascular intervention or bypass for severe disease refractory to medications. The correlation of the activity and damage scores with each other was fairly good. Damage was found to be associated only with high disease activity and extensive disease at disease onset, but not with other parameters. CONCLUSION Despite high usage rates of aggressive immunosuppressive therapy and biologic agents, almost half of the patients underwent interventional procedures. When medications failed, endovascular and surgical interventions were of great importance to avoid end-organ ischemia. The performance of the new activity (DEI.Tak and ITAS2010) and damage indices (TADS) seems satisfactory.
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Affiliation(s)
- Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Duhan Hopurcuoglu
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Sule Bektas
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ezgi Belhan
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Nur Canpolat
- Department of Pediatric Nephrology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Salim Caliskan
- Department of Pediatric Nephrology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Lale Sever
- Department of Pediatric Nephrology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Affiliation(s)
- Maria Josefina Sanchez
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Medical Center, Children's Health, Dallas, TX, USA
| | - Benjamin C Lee
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Medical Center, Children's Health, Dallas, TX, USA
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Abstract
UNLABELLED IntroductionTakayasu's arteritis is a rare idiopathic arteritis causing stenosis or aneurysms of the aorta, pulmonary arteries, and their branches. It usually occurs in women, but has been described in children. OBJECTIVE The objective of this study was to determine the clinical presentation, demographic profile, vascular involvement, origins, management, and outcome of children diagnosed with Takayasu's arteritis at a Southern African tertiary care centre between 1993 and 2015. METHODS This is a retrospective analysis of all children with Takayasu's arteritis captured on a computerised electronic database during the study period. RESULTS A total of 55 children were identified. The female:male ratio was 3.2:1, and the mean age was 9.7±3.04 years. Most originated outside the provincial borders of the study centre. The majority presented with hypertension and heart failure. In all, 37 (67%) patients had a cardiomyopathy with a mean fractional shortening of 15±5%. A positive purified protein derivative test was documented in 73%. Abdominal aorta and renal artery stenosis were the predominant angiographic lesions. A total of 23 patients underwent 30 percutaneous interventions of the aorta, pulmonary, and renal arteries: eight stents, 22 balloon angioplasties, and seven had nephrectomies. All patients received empiric tuberculosis treatment, immunosuppressive therapy, and anti-hypertensive agents as required. Overall, there was a significant reduction in systolic blood pressure and improvement in fractional shortening (p<0.05) with all treatments. CONCLUSION Takayasu's arteritis is more common in girls and frequently manifests with hypertension and heart failure. The abdominal aorta and renal arteries are mostly affected. Immunosuppressive, anti-hypertensive, and vascular intervention therapies improve blood pressure control and cardiac function.
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Sukharomana M, Viravan S, Piyaphanee N, Charuvanij S. Takayasu arteritis with an initial presentation of chronic monoarthritis mimicking oligoarticular juvenile idiopathic arthritis. Pediatr Rep 2018; 10:7648. [PMID: 30069294 PMCID: PMC6050474 DOI: 10.4081/pr.2018.7648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/24/2018] [Indexed: 11/22/2022] Open
Abstract
Patients with Takayasu arteritis (TA) generally present with non-specific symptoms that, if unrecognized and untreated, may develop vessel stenosis and/or aneurysm. There is limited data regarding chronic monoarthritis as the initial presentation in children with TA. We report a 6-yearold girl diagnosed and treated as oligoarticular juvenile idiopathic arthritis (JIA). She later developed stroke with malignant hypertension and was definitively diagnosed with TA. She additionally developed proteinuria secondary to focal segmental glomerulosclerosis. This is the report of a patient with chronic monoarthritis mimicking oligoarticular JIA which chronic monoarthritis was the presentation of TA. Since JIA is a diagnosis of exclusion, any atypical features of oligoarticular JIA should illuminate the possibility of an alternative diagnosis. Our literature review focused on musculoskeletal presentations of children with TA.
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Affiliation(s)
| | | | - Nuntawan Piyaphanee
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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18
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Clemente G, Silva CA, Sacchetti SB, Ferriani VPL, Oliveira SK, Sztajnbok F, Bica BERG, Cavalcanti A, Robazzi T, Bandeira M, Terreri MT. Takayasu arteritis in childhood: misdiagnoses at disease onset and associated diseases. Rheumatol Int 2018; 38:1089-1094. [PMID: 29687155 DOI: 10.1007/s00296-018-4030-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/12/2018] [Indexed: 11/24/2022]
Abstract
Juvenile-Takayasu arteritis (j-TA) is a difficult diagnosis and some patients develop uncommon manifestations and associated diseases that may contribute to the delayed diagnosis. Our aim was to identify the misdiagnoses, the associated diseases and the atypical manifestations observed in a j-TA Brazilian multicentre study. 71 children and adolescents who met the classification criteria for j-TA were included. The misdiagnoses, the associated diseases and the atypical manifestations were evaluated. 19 (26.8%) patients had misdiagnoses. The most common of them was aortic coarctation in six (8.4%) patients, followed by rheumatic fever in five (7.0%) and one patient presented with both former diagnoses. Limb pain (two patients), spondyloarthropathy, juvenile idiopathic arthritis (JIA), spinal arteriovenous malformation, polyarteritis nodosa (PAN) and fever of unknown origin (FUO) were other misdiagnoses. Patients who had misdiagnoses previously to j-TA diagnosis presented a trend to have a longer diagnosis delay. 11 (15.5%) patients had 14 TA-associated diseases, such as pulmonary tuberculosis (5 patients), rheumatic fever (2 patients), spondyloarthropathy, polyarticular JIA, Crohn's disease, Prader-Willi disease, diabetes mellitus, Moyamoya and primary immunodeficiency. 7 (9.9%) patients presented 10 atypical manifestations, such as pyoderma gangrenosum, erythema nodosum, myositis, chorea, enthesitis, episcleritis, uveitis, hepatomegaly, splenomegaly and necrosis of extremities. Our study emphasizes the main misdiagnoses, associated diseases and atypical manifestations that occur in patients with j-TA and warns of the features that may alert paediatricians to this diagnosis, such as constitutional symptoms and elevated inflammatory markers.
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Affiliation(s)
- Gleice Clemente
- Pediatrics Rheumatoloy Unit, Department of Pediatrics, São Paulo Federal University, São Paulo, SP, Brazil.
| | - Clovis A Silva
- Pediatrics Rheumatology Unit, Children's Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Silvana B Sacchetti
- Pediatrics Rheumatology Unit, Pediatric Department of Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Virginia P L Ferriani
- Pediatrics Rheumatology Division, Department of Pediatrics, Ribeirao Preto Medical School, Sao Paulo University, Ribeirao Preto, SP, Brazil
| | - Sheila K Oliveira
- Pediatric Rheumatology Unit, Rio de Janeiro Federal University (IPPMG-UFRJ), Rio de Janeiro, RJ, Brazil
| | - Flavio Sztajnbok
- Pediatric Rheumatology Unit, Pedro Ernesto University Hospital, Rio de Janeiro, RJ, Brazil
| | - Blanca E R G Bica
- Hospital Universitário Clementino Fraga Filho-Rheumatology Division-Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - André Cavalcanti
- Pediatrics Rheumatology Unit, Department of Materno-Infantil, Federal University of Pernambuco, Recife, PE, Brazil
| | - Teresa Robazzi
- Pediatrics Rheumatology Unit, Bahia Federal University, Salvador, BA, Brazil
| | | | - Maria Teresa Terreri
- Pediatrics Rheumatoloy Unit, Department of Pediatrics, São Paulo Federal University, São Paulo, SP, Brazil
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Abstract
Takayasu arteritis is an idiopathic granulomatous vasculitis of the aorta and its main branches and it constitutes one of the more common vasculitides in children. Inflammation and intimal proliferation lead to wall thickening, stenotic or occlusive lesions, and thrombosis, while destruction of the elastica and muscularis layers originates aneurysms and dissection. Carotid artery tenderness, claudication, ocular disturbances, central nervous system abnormalities, and weakening of pulses are the most frequent clinical features. The diagnosis is usually confirmed by the observation of large vessel wall abnormalities: stenosis, aneurysms, occlusion, and evidence of increased collateral circulation in angiography, MRA or CTA imaging. The purpose of this revision is to address the current knowledge on pathogenesis, investigations, classification, outcome measures and management, and to emphasize the need for timely diagnosis, effective therapeutic intervention, and close monitoring of this severe condition.
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Affiliation(s)
- Ricardo A G Russo
- Service of Immunology & Rheumatology, Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - María M Katsicas
- Service of Immunology & Rheumatology, Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
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20
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Aeschlimann FA, Eng SWM, Sheikh S, Laxer RM, Hebert D, Noone D, Twilt M, Pagnoux C, Benseler SM, Yeung RSM. Childhood Takayasu arteritis: disease course and response to therapy. Arthritis Res Ther 2017; 19:255. [PMID: 29166923 PMCID: PMC5700506 DOI: 10.1186/s13075-017-1452-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/09/2017] [Indexed: 02/03/2023] Open
Abstract
Background Takayasu arteritis (TAK) is a large vessel vasculitis that rarely affects children. Data on childhood TAK are scarce. The aim of this study was to analyze the presenting features, course and outcome of children with TAK, compare efficacy of treatment regimens and identify high-risk factors for adverse outcome. Methods A single-center cohort study of consecutive children fulfilling the EULAR/PRINTO/PReS criteria for childhood TAK between 1986 and 2015 was performed. Clinical phenotypes, laboratory markers, imaging features, disease course and treatment were documented. Disease activity was assessed using the Pediatric Vasculitis Disease Activity Score at each visit. Outcome: disease flare defined as new symptoms and/or increased inflammatory markers necessitating therapy escalation and/or new angiographic lesions, or death. Analysis: logistic regression tested relevant variables for flare. Kaplan-Meier analyses compared treatment regimens. Results Twenty-seven children were included; 74% were female, median age at diagnosis was 12.4 years. Twenty-two (81%) children presented with active disease at diagnosis. Treatment regimens included corticosteroids alone (15%), corticosteroids plus methotrexate (37%), cyclophosphamide (19%), or a biologic agent (11%). Adverse outcomes were documented in 14/27 (52%) children: two (7%) died within 6 months of diagnosis, and 13 (48%) experienced disease flares. The 2-year flare-free survival was 80% with biologic treatments compared to 43% in non-biologic therapies (p = 0.03); at last follow-up, biologic therapies resulted in significantly higher rates of inactive disease (p = 0.02). No additional outcome predictor was identified. Conclusions Childhood TAK carries a high disease burden; half of the children experienced flares and 7% died. Biologic therapies were associated with better control of disease activity.
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Affiliation(s)
- Florence A Aeschlimann
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Simon W M Eng
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Shehla Sheikh
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Ronald M Laxer
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Diane Hebert
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Damien Noone
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Marinka Twilt
- Rheumatology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Christian Pagnoux
- Vasculitis clinic, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Susanne M Benseler
- Rheumatology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Rae S M Yeung
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Immunology, University of Toronto, Toronto, ON, Canada.
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21
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Cattalini M, Soliani M, Caparello MC, Cimaz R. Sex Differences in Pediatric Rheumatology. Clin Rev Allergy Immunol 2017; 56:293-307. [DOI: 10.1007/s12016-017-8642-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
The idiopathic vasculitides are a group of inflammatory and immune-mediated conditions associated with inflammation of blood vessels. They affect multiple organ and body systems, and vary in their clinical manifestations, severity, prognosis, and pathology. They frequently present a diagnostic challenge for clinicians because of their complexity, overlapping features, and similar findings to other noninflammatory, genetic, or infectious conditions. This article summarizes some of the common pediatric vasculitides, emphasizing both the characteristic and unusual clinical manifestations of these diseases.
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24
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Aeschlimann FA, Grosse-Wortmann L, Benseler SM, Laxer RM, Hebert D, Yeung RS. Arterial dissection in childhood Takayasu Arteritis: not as rare as thought. Pediatr Rheumatol Online J 2016; 14:56. [PMID: 27658465 PMCID: PMC5034589 DOI: 10.1186/s12969-016-0115-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 09/15/2016] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Arterial vessel wall dissection is a rare, life-threatening and rarely described complication in childhood Takayasu Arteritis (cTA). Prevalence and risk factors for arterial dissection in cTA are unknown. We sought to study the prevalence and analyse risk factors for arterial dissection in cTA. FINDINGS A single center retrospective review of all children with cTA was performed. Patients with arterial dissection at cTA diagnosis were reported in detail and compared to the remaining single center retrospective cohort of children without dissection. Disease activity was assessed by the Pediatric Vasculitis Disease Activity Score (PVAS). A total of 27 cTA patients (74 % girls) were included. Three children (11 %) presented with dissection at diagnosis of cTA. They had higher PVAS (median 21 versus 10, p = 0.26), increased neutrophils (p < 0.0001) and lower albumin levels (p = 0.05). Arterial hypertension was common in both groups: in 67 % of children with dissection and 54 % of those without. CONCLUSIONS Arterial dissection was more frequent in our cTA cohort than previously reported. Careful vascular imaging assessment is crucial to document this complication. High disease activity and markers of inflammation especially in combination with arterial hypertension, may be associated with the risk for vessel wall dissection in children with cTA.
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Affiliation(s)
- Florence A. Aeschlimann
- Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Lars Grosse-Wortmann
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Susanne M. Benseler
- Rheumatology, Department of Paediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, AB Canada
| | - Ronald M. Laxer
- Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Diane Hebert
- Division of Nephrology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Rae S.M. Yeung
- Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON Canada ,Department of Immunology and Institute of Medical Science, University of Toronto, Toronto, ON Canada
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Khemiri M, Douira W, Barsaoui S. Co-occurrence of Takayasu's arteritis and tuberculosis: Report of a Tunisian pediatric case. Ann Pediatr Cardiol 2016; 9:75-8. [PMID: 27011699 PMCID: PMC4782475 DOI: 10.4103/0974-2069.171398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Few reports on co-occurrence of Takayasu's arteritis (TA) and tuberculosis (Tb) have been published in childhood. A 12-year-old girl presented with 4-month's history of a dry cough, persistent fever, marked weakness, and weight loss. Physical examination revealed impalpable peripheral pulses and unrecordable blood pressure (BP) on upper limbs. In lower limbs, peripheral pulses were normal and BP reached respectively 160/90 and 140/87 mmHg. Laboratory investigations showed an erythrocyte sedimentation rate at 140 mm in the 1st h and microcytic anemia (8.6 g/dl). Doppler ultrasound and computed tomography angiography revealed significant thickening of the aortic-arch and both common carotid arteries wall, with luminal narrowing of the right common carotid and its branches and severe stenosis of the left subclavian artery. Simultaneously, the diagnosis of active pulmonary Tb was achieved based on radiological data, positive Mantoux test and successful response to antitubercular drugs. During follow-up, corticostetroids and methotrexate were required to control TA relapses.
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Affiliation(s)
- Monia Khemiri
- Department of Pediatric, Faculty of Medicine, University of Tunis El Manar, Tunis - 1007, Tunisia, North Africa
| | - Wiem Douira
- Department of Pediatric Radiology, Faculty of Medicine, University of Tunis El Manar, Tunis - 1007, Tunisia, North Africa
| | - Sihem Barsaoui
- Department of Pediatric, Faculty of Medicine, University of Tunis El Manar, Tunis - 1007, Tunisia, North Africa
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Clemente G, Hilário MO, Len C, Silva CA, Sallum AM, Campos LM, Sacchetti S, Santos MCD, Alves AG, Ferriani VP, Sztajnbok F, Gasparello R, Oliveira SK, Lessa M, Bica B, Cavalcanti A, Robazzi T, Bandeira M, Terreri MT. Estudo multicêntrico brasileiro de 71 pacientes com arterite de Takayasu juvenil: características clínicas e angiográficas. REVISTA BRASILEIRA DE REUMATOLOGIA 2016. [DOI: 10.1016/j.rbr.2015.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Brazilian multicenter study of 71 patients with juvenile-onset Takayasu's arteritis: clinical and angiographic features. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:145-51. [PMID: 27267528 DOI: 10.1016/j.rbre.2016.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 09/05/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To describe the clinical and angiographic characteristics of Takayasu's arteritis in Brazilian children and adolescents. METHODS A retrospective data collection was performed in 71 children and adolescents followed in 10 Brazilian reference centers in Pediatric Rheumatology. The evaluation was carried out in three different time points: from onset of symptoms to diagnosis, from the 6th to 12th month of diagnosis, and in the last visit. RESULTS Of 71 selected patients, 51 (71.8%) were girls. The mean age of onset of symptoms and of time to diagnosis was 9.2 (±4.2) years and 1.2 (±1.4) years, respectively. At the end of the study, 20 patients were in a state of disease activity, 39 in remission and 5 had evolved to death. The most common symptoms in baseline assessment, second evaluation, and final evaluation were, respectively: constitutional, musculoskeletal, and neurological symptoms. A decrease in peripheral pulses was the most frequent cardiovascular signal, and an increase in erythrocyte sedimentation rate was the most frequent laboratory finding in all three evaluation periods. The tuberculin test was positive in 41% of those tested. Stenosis was the most frequent angiographic lesion, abdominal artery was the most affected segment, and angiographic type IV the most frequent. Most (90%) participants were treated with glucocorticoids, 85.9% required another immunosuppressive drug, and 29.6% underwent angioplasty. CONCLUSION This is the largest study on juvenile-onset Takayasu arteritis, and a high number of patients under the age of 10 years, with predominance of constitutional symptoms early in the disease, was observed.
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Mathew AJ, Goel R, Kumar S, Danda D. Childhood-onset Takayasu arteritis: an update. Int J Rheum Dis 2015; 19:116-26. [DOI: 10.1111/1756-185x.12718] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ashish J. Mathew
- Department of Clinical Immunology and Rheumatology; Christian Medical College; Vellore India
| | - Ruchika Goel
- Department of Clinical Immunology and Rheumatology; Christian Medical College; Vellore India
| | - Sathish Kumar
- Department of Child Health and Pediatric Rheumatology; Christian Medical College; Vellore India
| | - Debashish Danda
- Department of Clinical Immunology and Rheumatology; Christian Medical College; Vellore India
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Lim AY, Lee GY, Jang SY, Gwag HB, Choi SH, Jeon ES, Cha HS, Sung K, Kim YW, Kim SM, Choe YH, Koh WJ, Kim DK. Comparison of clinical characteristics in patients with Takayasu arteritis with and without concomitant tuberculosis. Heart Vessels 2015; 31:1277-84. [PMID: 26266634 DOI: 10.1007/s00380-015-0731-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 08/05/2015] [Indexed: 10/23/2022]
Abstract
Because of frequent tuberculosis in patients with Takayasu arteritis (TA), a possible relationship between TA and tuberculosis has been proposed. However, there are no studies to date that have examined clinical manifestations in patients diagnosed with TA with or without tuberculosis. Two hundred sixty-seven patients were diagnosed with TA according to the 1990 American College of Rheumatology criteria between September 1994 and April 2014. Patients with TA were classified into groups with or without tuberculosis. Among the 267 patients with TA studied, 47 patients (17.7 %) who had a history of previous treatment of tuberculosis (34 patients), concurrent diagnosis of tuberculosis with TA (10 patients), or diagnosis of tuberculosis during the follow-up period for TA (3 patients) were included in the group with tuberculosis. The group with tuberculosis comprised of 33 patients (70.2 %) with pulmonary tuberculosis, 12 patients (25.5 %) with tuberculous lymphadenitis, and 2 patients (4.3 %) with tuberculosis of the skin and colon, respectively. Comorbid disease and patients' signs and symptoms were not significantly different between TA patients with and without tuberculosis. Additionally, the site of disease involvement in angiographic findings and distribution of angiographic type were similar between the two groups. In conclusion, tuberculosis including tuberculous lymphadenitis was frequently observed in patients with TA. Clinical features and angiographic findings in TA were not different according to the presence or absence of concomitant tuberculosis.
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Affiliation(s)
- A Young Lim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea
| | - Ga Yeon Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea
| | - Shin Yi Jang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea
| | - Hye Bin Gwag
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea
| | - Seung Hyuk Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea
| | - Hoon-Suk Cha
- Division of Rheumatology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Mok Kim
- Department of Radiology and Center for Imaging Science, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yeon Hyeon Choe
- Department of Radiology and Center for Imaging Science, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won-Jung Koh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Duk-Kyung Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea.
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Ladapo TA, Gajjar P, McCulloch M, Scott C, Numanoglu A, Nourse P. Impact of revascularization on hypertension in children with Takayasu's arteritis-induced renal artery stenosis: a 21-year review. Pediatr Nephrol 2015; 30:1289-95. [PMID: 25648879 DOI: 10.1007/s00467-015-3049-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 12/31/2014] [Accepted: 01/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgery for reno-vascular hypertension (RVH) is complex, and the techniques utilized vary with anatomical presentations of the disease. The long-term outcome of revascularization on RVH in children with Takayasu's arteritis (TA)-induced renal artery stenosis (RAS) at our centre was reviewed. METHODS This study was a 21-year retrospective review of pre- and post-intervention RVH in children with angiographically confirmed RAS. The outcome of hypertension was defined as follows: (1) cured (normotensive off anti-hypertensives), (2) improved (normotensive on same or reduced number of medications), or (3) failure (no cure or improvement in number of medications). RESULTS The medical histories of 59 children (median age 9.98 years) were reviewed, of whom 20 (44 %) had revascularization procedures. All were hypertensive, with a mean systolic and diastolic blood pressure of 161.5 ± 36 and 106.5 ± 31 mmHg, respectively. RAS was present in 45 (76.3 %) children. Twenty-four revascularization procedures were performed in 20 children (44 %), of whom five had contralateral nephrectomies. Outcome was available for 17 patients at the 3- and 6-months follow-up, with cure, improvement and failure rates at 3 months of 2/17 (11.8 %), 7/17 (41.2 %) and 8/19 (47 %), respectively, and similar rates at 6 months. Associations between outcome and age (p = 0.51), sex (p = 0.32), number of pre-surgery anti-hypertensives (p = 0.18) and stenosis sites (p = 0.22) were not statistically significant. CONCLUSIONS Revascularization was beneficial to the management of blood pressure control in about half of our RVH patients.
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Affiliation(s)
- Taiwo Augustina Ladapo
- Pediatric Nephrology, Department of Pediatrics, College of Medicine, University of Lagos and Lagos University Teaching Hospital, PMB 12003, Idi-Araba, Lagos, Nigeria,
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Treatment of Pediatric Takayasu arteritis with infliximab and cyclophosphamide: experience from an American-Brazilian cohort study. J Clin Rheumatol 2015; 20:183-8. [PMID: 24847743 DOI: 10.1097/rhu.0000000000000106] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pediatric Takayasu arteritis (pTA) is difficult to treat and can lead to significant morbidity and mortality. OBJECTIVES The objective of this study was to describe clinical characteristics for pTA and determine the safety and efficacy of cyclophosphamide (CYC) and infliximab (IFX) in pTA. METHODS This was a retrospective analysis of 23 pTA patients seen at Children's Hospital Los Angeles and Universidade Federal de São Paulo-Brazil from 1990 to 2011. All patients fulfilled the 1990 American College of Rheumatology criteria for Takayasu arteritis. Disease activity was assessed using a modified National Institutes of Health score. RESULTS Twenty-three patients (14 female and 9 male patients), mean age of 15.7 ± 6.0 years, were included. Cyclophosphamide was used before IFX treatment in 17 of 23 and IFX before CYC in 2 of 23 patients. The average time from disease onset to treatment initiation was 2.6 ± 2.4 years for CYC and 4.1 ± 2.4 years for IFX. Nine (60%) of 15 patients failed CYC, and of these 6 were changed to IFX with subsequent clinical stabilization in 5 (83%) of 6. Two patients initially treated with IFX were switched to CYC because of lack of appropriate response: 1 patient later worsened, and the other was lost to follow-up. Five opportunistic infections requiring hospitalization occurred in the CYC group, whereas none were observed in the IFX group. Patients in the IFX group were more likely to decrease or stop their corticosteroids when compared with the CYC patients. CONCLUSIONS Cyclophosphamide is often used as initial treatment but has many adverse effects. In this retrospective case series, IFX was equivalent to CYC with fewer adverse effects, making IFX an alternative therapeutic option for pTA.
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Abstract
Childhood vasculitis is a complex and fascinating area in pediatric rheumatology that has experienced an unprecedented surge in research, leading to new knowledge over the past several years. Vasculitis is defined as the presence of inflammatory cell infiltration in blood vessel walls, usually with multisystemic involvement. The most frequent forms of vasculitis in childhood are the small-size vasculitides, of which Henoch-Schoenlein Purpura and other leucocytoclastic vasculitis are the best examples, followed by Kawasaki disease, a midsize vasculitis, and Takayasu arteritis, a large-size vasculitis, both of which are topics in this article.
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Abstract
With the ever increasing younger population in tropical countries, the number of children with heart failure is increasing. However, the etiology of heart failure in this region varies considerably from that in the temperate region, with infectious causes leading the list. In this review, we have summarized the important causes of heart failure seen in the pediatric population in tropical regions.
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Szugye HS, Zeft AS, Spalding SJ. Takayasu Arteritis in the pediatric population: a contemporary United States-based single center cohort. Pediatr Rheumatol Online J 2014; 12:21. [PMID: 24955077 PMCID: PMC4065084 DOI: 10.1186/1546-0096-12-21] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 04/18/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Takayasu Arteritis is an idiopathic, chronic, large vessel vasculitis involving the aorta and its primary branches. Few studies have been done in pediatric patients to date with the largest case series of US patients published in 2003 consisting of only 6 patients. METHODS A retrospective chart review was performed on all patients seen at Cleveland Clinic Children's up until 2012 who met EULAR/PRINTO/PRES classification criteria for childhood Takayasu Arteritis. RESULTS Twenty-one patients with a mean follow up of 2.3 years were studied. Weight loss, fatigue, and anorexia were the most common presenting complaints. 57.1% of patients were hypertensive at first visit. The most common examintation finding was diminished pulses (61.9%), followed by bruits, and then murmurs. Thoracic aorta stenosis was the most common vascular abnormality. Seven of twenty-one patients responded well to methotrexate and prednisone alone. Ten of twenty-one patients required an additional medication for symptom and disease control (infliximab most commonly). About two-thirds of patients required at least one anti-hypertensive medication. Eight of the twenty-one patients required surgical intervention for severe disease refractory to medications (renal artery stenosis being the most common indication). Almost all patients reported symptomatic improvement after surgical intervention. Two of the eight patients required a second surgery for return of symptoms. Disease sequelae included arterial aneurysms, resolved heart failure, and hypertensive emergencies. CONCLUSION Our study emphasizes that constitutional symptoms coupled with objective findings of diminished pulses, bruits, and hypertension should raise clinical suspicion for Takayasu Arteritis in pediatric patients. Pharmacologic therapy alone can be successful in controlling disease progression, however surgery was successful in minimizing symptoms when medical therapies failed.
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Affiliation(s)
| | - Andrew S Zeft
- Center for Pediatric Rheumatology, Cleveland Clinic Children’s, Cleveland, Ohio, USA
| | - Steven J Spalding
- Center of Pediatric Rheumatology, Center for Pediatric Rheumatology, Cleveland Clinic Children’s, 9500 Euclid Avenue/Desk A111, Cleveland, OH 44195, USA
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Goel R, Kumar TS, Danda D, Joseph G, Jeyaseelan V, Surin AK, Bacon P. Childhood-onset Takayasu Arteritis — Experience from a Tertiary Care Center in South India. J Rheumatol 2014; 41:1183-9. [DOI: 10.3899/jrheum.131117] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To study the clinical profile and outcome of Asian Indian children with childhood-onset Takayasu arteritis (c-TA).Methods.Records were studied of patients with c-TA onset prior to age 16. Disease Extent Index-Takayasu (DEI.TAK), Indian Takayasu Arteritis Score 2010, and Takayasu Arteritis Damage Score (TADS) were calculated retrospectively from electronic records. Cumulative incidence of sustained remission was estimated using the Kaplan-Meier curve.Results.There were 40 patients with c-TA, with median age of onset of 12.5 years (range 1–16) and median diagnostic delay of 11.3 months (range 1–60). The most common presenting features were hypertension, headache, malaise, and fever. Pulseless disease was observed in 25 cases (62.5%). The majority (n = 28) had active disease with raised inflammatory markers, high baseline median DEI.TAK score of 10 (range 3–24), and high median TADS of 7 (range 1–14). Of the 34 patients followed for 21.5 months (range 3–192), remission was attained in 30. However, cumulative sustained remission was achieved in only 29% of them at 5 years. Median period of sustained remission was 22.5 months (95% CI 17.1–26.8). New areas of vessel involvement were observed in 13 patients (38%). Disease progression was arrested in the majority (n = 22, 66%) through aggressive medical management and endovascular intervention. All 11 patients with an increment in TADS of ≥ 4 during followup had persistently active or relapsing disease. There was a single fatality.Conclusion.Despite aggressive immunosuppression, damage progressed in one-third of patients with c-TA in association with persistent inflammation, warranting surveillance with clinical instruments and followup imaging.
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Tullus K. Renovascular hypertension--is it fibromuscular dysplasia or Takayasu arteritis. Pediatr Nephrol 2013; 28:191-6. [PMID: 22453736 DOI: 10.1007/s00467-012-2151-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 03/02/2012] [Accepted: 03/05/2012] [Indexed: 10/28/2022]
Abstract
Renovascular hypertension (RVH) can be caused by many different diseases, with the most common being fibromuscular dysplasia (FMD) and Takayasu arteritis (TA). A strikingly different diagnostic pattern is seen in children with RVH from different parts of the world. In Europe and North America, these children are mainly diagnosed as having FMD while in Asia and South Africa they will most often get a diagnosis of TA. When comparing the clinical diagnosis for FMD and TA, it becomes obvious that there is a great deal of overlap between the definitions of these two conditions. Different ways to come to the most accurate diagnosis using imaging of the blood vessel wall and positron emission tomography (PET) will be discussed. How an accurate diagnosis should influence the treatment of the children with these conditions will also be addressed.
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Affiliation(s)
- Kjell Tullus
- Great Ormond St Hospital - Paediatric Nephrology, Great Ormond Street, London, WC1N 3JH, UK.
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Sadurska E, Jawniak R, Majewski M, Czekajska-Chehab E. Takayasu arteritis as a cause of arterial hypertension. Case report and literature review. Eur J Pediatr 2012; 171:863-9. [PMID: 22290282 PMCID: PMC3327834 DOI: 10.1007/s00431-012-1674-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Accepted: 01/11/2012] [Indexed: 11/04/2022]
Abstract
UNLABELLED We report a 16-year-old girl in whom Takayasu arteritis (TA) was manifested mainly by severe arterial hypertension on her right arm, which was detected during a routine examination at school. Her systolic blood pressure on the right arm was significantly higher than that on the left one. There was also a pressure difference between the right arm and legs. The pulse of the left external carotid artery and that of the left radial artery was absent. Vascular bruits over interscapular and right supra- and subclavian areas were heard on auscultation. The diagnosis of TA was confirmed by a spiral computed tomography angiography, which showed a thickened thoracic aortic wall and narrowing of its lumen. In addition, complete occlusion of the left common carotid artery and the left subclavian artery was observed. CONCLUSION The rarity of the disorder and the heterogeneous nature of its clinical manifestation predispose to a late diagnosis and delayed treatment. Our report highlights the fact that the condition can and does occur in a pediatric population in Europe and hence must be considered in patients presenting with suggestive symptoms and signs, especially in young patients with unexplained hypertension. Clinical suspicion and proper imaging are crucial for the correct diagnosis and management of patients with TA. A brief review of literature completes this report.
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Affiliation(s)
- Elżbieta Sadurska
- Department of Pediatric Cardiology, Medical University of Lublin, ul. Chodźki 2, 20-093 Lublin, Poland.
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Zhu WH, Shen LG, Neubauer H. Clinical characteristics, interdisciplinary treatment and follow-up of 14 children with Takayasu arteritis. World J Pediatr 2010; 6:342-7. [PMID: 21080146 DOI: 10.1007/s12519-010-0234-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 02/09/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pediatric patients with Takayasu arteritis were studied by analyzing clinical presentation, diagnostic images, response to multimodal therapy, and long-term outcome. METHODS Fourteen consecutive children and adolescents (mean age: 10 years) were diagnosed with Takayasu arteritis at our institution between 1995 and 2007. They were subjected to clinical and diagnostic studies including color ultrasonography, MRI and angiography, and received interdisciplinary treatment. RESULTS The median time lag between the first onset of symptoms and diagnosis was 7.7 weeks. The majority of patients presented with acute severe clinical symptoms and extensive vascular lesions. Hypertension was the most common finding on first presentation (93%), followed by headache (64%), nausea (64%) and palpitation (50%). Ten patients (71%) had reduced or absent carotid, brachial or femoral pulses in one or more locations. C-reactive protein was elevated in 79% of the patients and erythrocyte sedimentation rate in 64%. Cardiovascular imaging showed extensive vasculitis of both sides of the diaphragm in 86%. Complications included renal artery stenosis (n=7), aortic dissection, thoracic aortic aneurysm and infrarenal aneurysm (all n=1). Conservative drug treatment was effective in 50%. Interventional dilatation of stenosis and surgical therapy, including aortic bypass, resection of aneurysms and nephrectomy, were necessary in the remaining patients. Follow-up for 25 months to 12 years showed that all children are well without disease-related mortality. CONCLUSIONS Takayasu arteritis is a rare and potentially life-threatening disease in children, likely with a prolonged subclinical course. Rapid diagnosis and interdisciplinary management help to prevent life-threatening complications.
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Affiliation(s)
- Wei-Hua Zhu
- Department of Cardiology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
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Jales-Neto LH, Levy-Neto M, Bonfa E, de Carvalho JF, Pereira RMR. Juvenile-onset Takayasu arteritis: peculiar vascular involvement and more refractory disease. Scand J Rheumatol 2010; 39:506-10. [DOI: 10.3109/03009741003742730] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Brunner J, Feldman BM, Tyrrell PN, Kuemmerle-Deschner JB, Zimmerhackl LB, Gassner I, Benseler SM. Takayasu arteritis in children and adolescents. Rheumatology (Oxford) 2010; 49:1806-14. [PMID: 20562196 DOI: 10.1093/rheumatology/keq167] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Takayasu arteritis is a devastating vasculitis of the aorta and its major branches. The clinical manifestations in paediatric patients are less specific than in adults: in children the disease presents with fever, arthralgias and hypertension. Intramural inflammation results in narrowing of the blood vessel lumen and therefore hypoperfusion of the parenchyma. Conventional angiography is the gold standard diagnostic procedure. Corticosteroids, cyclophosphamide, MTX and biological therapies such as TNF-α blocking agents are treatment options.
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Affiliation(s)
- Juergen Brunner
- Department of Pediatrics, Pediatric Rheumatology, Medical University Innsbruck, Innsbruck, Austria.
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Abstract
Takayasu arteritis is a chronic granulomatous disease of the aorta and its major branches that usually affects women during the second and third decades of life, but it has been reported in young children. This review details the clinical, pathological and radiological features, differential diagnoses and management of the condition, focusing chiefly on the disease in children. The recent definition of Takayasu arteritis is discussed. The condition should be considered in patients with unexplained arterial hypertension or unexplained inflammatory syndromes without signs of localization. Since the disease may be life-threatening and progressive, early recognition is necessary to initiate appropriate therapy. Patients with persistent ischaemic symptoms including hypertension might benefit from revascularization procedures.
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Affiliation(s)
- Ashima Gulati
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
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Arnaud L, Haroche J, Limal N, Toledano D, Gambotti L, Chalumeau NC, Boutin DLTH, Cacoub P, Cluzel P, Koskas F, Kieffer E, Piette JC, Amoura Z. Takayasu arteritis in France: a single-center retrospective study of 82 cases comparing white, North African, and black patients. Medicine (Baltimore) 2010; 89:1-17. [PMID: 20075700 DOI: 10.1097/md.0b013e3181cba0a3] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We conducted a single-center retrospective study to compare the characteristics of Takayasu arteritis (TA) among white, North African, and black patients in a French tertiary care center (Hospital Pitié-Salpêtrière, Paris). Eighty-two patients were studied (82.9% female) during a median follow-up of 5.1 years (range, 1 mo to 30 yr). Among these 82 patients, 39 (47.6%) were white, 20 (24.4%) were North African, and 20 (24.4%) were black patients. Median age at diagnosis was 39.3 years (range, 14-70 yr) in white patients vs. 28.4 years (range, 12-54 yr) in North African (p = 0.02), and 28.0 years (range, 13-60 yr) in black patients (p = 0.08). Patients aged >40 years at TA onset were more frequently white than non-white (40.0% vs. 18.6%, p = 0.03). North African patients had more frequent occurrence of ischemic stroke (p = 0.03) and poorer survival (p = 0.01) than white patients. Type V of the Hata classification was the most frequent type among white (38.5%), North African (65.0%), and black patients (40.0%). Corticosteroids were used in 96.1% of patients. Fifty-three percent of white and North African patients, and 44% of black patients required a second line of immunosuppressive treatment (p = 0.60). Vascular surgical procedures were respectively performed in 46.1%, 50.0%, and 55.0% of white, North African, and black patients, p = 0.81. The 5-year and 10-year survival rates were 100% and 95.0%, respectively, in white patients; 67.4% at both 5 years and 10 years in North African patients; and 100% at both 5 years and 10 years in black patients. This study is one of the first direct comparisons of TA profiles among patients of distinct ethnic backgrounds. Our data support the idea that late-onset TA or an overlap between TA and large-vessel giant cell arteritis may be observed in white patients. North African patients have a higher occurrence of ischemic stroke and poorer survival than white patients.
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Affiliation(s)
- Laurent Arnaud
- From Service de Médecine Interne (LA, JH, NL, NCC, DB, P Cacoub, JCP, ZA), Service de Radiologie (DT, P Cluzel), Service de Santé Publique (LG), and Service de Chirurgie Vasculaire (FK, EK); and Hôpital Pitié-Salpêtrière, AP-HP, Université Paris 6, Paris, France
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Yavuz H, Chee R. A review on the vascular features of the hyperimmunoglobulin E syndrome. Clin Exp Immunol 2009; 159:238-44. [PMID: 19912258 DOI: 10.1111/j.1365-2249.2009.04044.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Autosomal recessive, autosomal dominant and the sporadic forms of hyperimmunoglobulin E syndrome (HIES) are multi-system disorders. Although HIES patients may present with cold abscesses, the vascular features of HIES are not well recognized. The objective of this review is to characterize the nature and spectrum of vascular abnormalities in HIES patients. Vascular abnormalities in HIES patients were reviewed with Medline and Google Scholar-based searches. In brief, the searches combined terms related to HIES with the terms related to vasculature. Furthermore, reference lists from the original studies and review papers identified were screened. There were vascular abnormalities in 25 patients with HIES. These abnormalities were identified as aneurysms (coronary, aortic, carotid and cerebral), pseudoaneurysms, congenital patent ductus venosus, superior vena cava syndrome, vasculitides, vascular ectasia, thrombosis and others. They may be congenital or acquired, in the veins and arteries, affecting both sexes. These abnormalities can be seen in all subtypes of HIES. They could be also fatal in children and adults. Limited pathological investigations revealed the presence of vasculitis. Three of the patients were found to have overlap diseases. In this review, the spectrum of vascular abnormalities in HIES are documented and discussed in detail for the first time. They highlight a previously under-recognized and potentially devastating complication of these disorders. These vascular abnormalities constitute one of the major clinical characteristics in HIES. The presence of hypereosinophilia, vasculitis and defective angiogenesis in HIES may contribute to the formation of vascular abnormalities in HIES.
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Affiliation(s)
- H Yavuz
- Department of Pediatrics, Selçuk University, Faculty of Medicine, Konya, Turkey.
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Borazan A, Sevindik OG, Solmaz D, Gulcu A, Cavdar C, Sifil A, Celik A, Akar S, Goktay Y, Camsari T. A rare cause of renovascular hypertension: Takayasu arteritis with only renal artery involvement. Ren Fail 2009; 31:327-31. [PMID: 19462284 DOI: 10.1080/08860220902780093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Takayasu arteritis is a chronic inflammatory disease that affects mainly the aorta, main branches of aorta, and pulmonary arteries with unknown etiology. Disease affecting solely the renal arteries is rare. We will present a case that had hypertension, hypokalemia, and metabolic alkalosis where the etiology was type 2 Takayasu arteritis, affecting renal arteries.
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Affiliation(s)
- Ali Borazan
- Mustafa Kemal University Faculty of Medicine, Department of Nephrology, Hatay, Turkey.
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Risque de tuberculose au cours des maladies systémiques. Presse Med 2009; 38:274-90. [DOI: 10.1016/j.lpm.2008.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 11/25/2008] [Indexed: 11/20/2022] Open
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Vargas-Alarcón G, Soto ME, Pérez-Hernández N, Cicero-Sabido R, Ramírez E, Alvarez-León E, Reyes PA. Comparative study of the residues 63 and 67 on the HLA-B molecule in patients with Takayasu's arteritis and tuberculosis. Cell Biochem Funct 2008; 26:820-3. [DOI: 10.1002/cbf.1505] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Al abrawi S, Fouillet-Desjonqueres M, David L, Barral X, Cochat P, Cimaz R. Takayasu arteritis in children. Pediatr Rheumatol Online J 2008; 6:17. [PMID: 18822174 PMCID: PMC2567964 DOI: 10.1186/1546-0096-6-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Accepted: 09/28/2008] [Indexed: 11/29/2022] Open
Abstract
Takayasu arteritis (TA) is a large vessel vasculitis that usually affects young female patients during the second and third decades of life, but has been reported in children as young as 24 months of age. Aim of this report was to describe four children (two girls) with TA, as well as summarizing main published studies. The mean age at presentation of our cases was 11 years (range 8-15). Three patients were Caucasians and one Asian. Arterial hypertension was the commonest mode of presentation followed by systemic symptoms. Other related symptoms were due to ischemia and consisted of abdomen, chest, and limb pain. An abdominal bruit was noted in only one patient. Inflammation markers were always abnormal. Angiography was performed in all cases; left subclavian artery and common carotid artery were more frequently involved. Renal artery stenosis was observed in two patients. One boy was diagnosed as having an associated immune deficiency (Wiskott-Aldrich syndrome). Treatment modalities included prednisone (n = 4), methotrexate (n = 3), and mycophenolate mofetil (MMF) (n = 1). Surgery was required in two patients. Follow-up ranged from 3 to 10 years since diagnosis. In three cases antihypertensive drugs and methotrexate were stopped, and prednisone was reduced to 7.5 mg/day.
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Affiliation(s)
- Safia Al abrawi
- Département de pédiatrie, Hôpital Edouard-Herriot and Université Claude-Bernard Lyon1, Lyon, France
| | | | - Louis David
- Département de pédiatrie, Hôpital Edouard-Herriot and Université Claude-Bernard Lyon1, Lyon, France
| | - Xavier Barral
- Service de chirurgie vasculaire, CHU Saint-Etienne, France
| | - Pierre Cochat
- Département de pédiatrie, Hôpital Edouard-Herriot and Université Claude-Bernard Lyon1, Lyon, France
| | - Rolando Cimaz
- Département de pédiatrie, Hôpital Edouard-Herriot and Université Claude-Bernard Lyon1, Lyon, France
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