Diagnostic Approaches for Large Vessel Vasculitides

A rare case of Takayasu arteritis with aortic dissection in a young male patient presented with hypertensive urgency

Introduction and importance

Takayasu arteritis (TA) is a granulomatous, large vessel inflammation characterized by occlusion, stenosis or aneurysm of the aorta and its branches. Aortic dissection (AD) is one of the rare manifestations of TA, which can present as uncontrolled hypertension. This case illustrates the severe rare cardiovascular complication that arises in a 21-year male patient with TA, including hypertensive urgency, AD and significant renal artery involvement.

Case presentation

A 21-year-old male presented with complaints of fever, malaise and dizziness. On clinical examinations, a discrepancy in blood pressure was noted in bilateral arms. All the laboratory parameters were within normal limits. Echocardiography confirmed moderate concentric hypertrophy with Grade II diastolic dysfunction and a preserved ejection fraction. To rule out secondary causes of hypertension, an arterial Doppler was done, which showed features of renal artery stenosis and stenosis in the descending aorta. CTA revealed an intimal tear/dissection in the thoracoabdominal aorta consistent with Stanford Type B AD.

Clinical discussion

Based on clinical presentation and imaging findings, large vessel vasculitis such as TA or giant cell arteritis (GCA) was suspected. Later, TA was diagnosed using the 2022 American College of Rheumatology/EULAR classification criteria for TA. The patient had rapid symptomatic improvement using antihypertensive drugs, corticosteroids and immunosuppressants.

Conclusion

This explains rare manifestation of TA in a young male patient with normal inflammatory markers and underlying AD with hypertensive urgency. In those suspected with TA, screening for life threatening conditions such as AD should be done.

FDG PET/CT in large vessel vasculitis

Large vessel vasculitides (LVV) such as giant cell arteritis, Takayasu arteritis and aortitis/periaortitis are characterised by immune-mediated inflammation of medium to large arteries. Clinical disease manifestations can be non-specific and diagnostic imaging plays an important role in the diagnostic pathway. In recent years, FDG PET/CT has proven to be a powerful metabolic tool that can provide a wholed body, non-invasive assessment of vascular inflammation. This review outlines the clinical features of large vessel vasculitis and the closely related entity of polymyalgia rheumatica, summarises the evidence for FDG PET/CT in the assessment of these conditions, and provides guidance for patient preparation, image acquisition and interpretation.

Imaging Challenges and Developments in Large-vessel Vasculitis

Vascular imaging is an integral part of large-vessel vasculitis (LVV) evaluation and management. Several imaging modalities are currently employed in clinical practice including vascular ultrasound, computed tomography angiography, MRI and magnetic resonance angiography, and 18F-fluorodeoxyglucose PET. Well-established roles for imaging in LVV include disease diagnosis and assessment of luminal lesions reflecting vascular damage. The ability of imaging to determine treatment response, monitor disease activity, and predict future arterial damage is an area of active research.

Effectiveness Of Tocilizumab In Aortitis And Aneurysms Associated With Giant Cell Arteritis

OBJECTIVE

Aortitis in Giant Cell Arteritis (GCA-aortitis) is a frequent complication that may lead to aneurysms. Tocilizumab (TCZ) was approved in GCA, but the efficacy in GCA-aortitis and aneurysms has not been analyzed to date. Our aim was to assess the effectiveness and safety of TCZ in a wide series of GCA-aortitis and aneurysms.

METHODS

Multicentre observational study with GCA-aortitis treated with TCZ. GCA was diagnosed by: a) ACR criteria, b) temporal artery biopsy, and/or c) imaging techniques. Aortitis was diagnosed mainly by PET/CT. Main outcomes were EULAR and imaging remission. Others were clinical remission, analytical normalization, corticosteroid-sparing effect, and the prevention and improvement of aneurysms.

RESULTS

196 patients with GCA-aortitis treated with TCZ. After 6 months, 72.2% reached EULAR remission but only 12% an imaging remission; increasing up-to 81.4% and 31.8%, respectively, at 24 months. A rapid clinical remission, ESR and CRP normalization was observed in 47.4%, 84.3% and 55.6%, at 1 month, increasing to 89.6%, 85.3% and 80.3% at 24 months, respectively. Aneurysms were present in 10 (5%) patients. Five of them required early surgery, while 3 others enlarged. No patient on TCZ therapy developed aneurysms during follow-up.

CONCLUSION

In patients with GCA-aortitis treated with TCZ, a rapid and maintained clinical and analytical improvement was observed. However, there was an uncoupling between clinical and EULAR remission with imaging remission.

Successful Treatment of Diffuse Large B-cell Lymphoma Involving Multiple Renal and Bone Infiltrations Presenting with Giant Cell Arteritis-like Manifestations

We herein report a case of diffuse large B-cell lymphoma (DLBCL) involving multiple renal and bone infiltrations presenting with giant cell arteritis (GCA)-like manifestations. One month prior, the present patient had left-sided temporal headache, jaw claudication, and renal failure. The patient was diagnosed with DLBCL based on a renal biopsy. After rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone plus intrathecal methotrexate/cytarabine/prednisone and rituximab, high-dose methotrexate, and cytarabine chemotherapy, the patient's clinical manifestations improved, and complete remission was achieved. DLBCL rarely but occasionally presents with GCA-like manifestations or multiple renal and bone infiltrations, highlighting the need for prompt and aggressive combination chemotherapy.

Takayasu's Arteritis: A Special Case Report and Review of the Literature

Background: Takayasu's arteritis is a rare type of vasculitis with severe complications like stroke, ischemic heart disease, pulmonary hypertension, secondary hypertension, and aneurysms. Diagnosis is achieved using clinical and angiographic criteria. Treatment is medical and surgical, but unfortunately, the outcome is limited. Case presentation: A 34-year-old Caucasian woman had an ischemic stroke (2009). She was diagnosed with Takayasu's arteritis and received treatment with methotrexate, prednisolone, and antiplatelet agents, with a mild improvement in clinical state. After 6 years (2015), she experienced an ascending aorta aneurysm, pulmonary hypertension, and mild aortic regurgitation. Surgical treatment solved both the ascending aorta aneurysm and left carotid artery stenosis (ultrasound in 2009 and computed tomography angiogram in 2014). Morphopathology revealed a typical case of Takayasu's arteritis. Tumor necrosis factor inhibitors (TNF inhibitors) were prescribed with methotrexate. At 48 years old (2023), she developed coronary heart disease (angina, electrocardiogram); echocardiography revealed severe pulmonary hypertension, and angiography revealed normal coronary arteries, abdominal aorta pseudoaneurysm, and arterial-venous fistula originating in the right coronary artery with drainage in the medium pulmonary artery. The patient refused surgical/interventional treatment. She again received TNF inhibitors, methotrexate, antiplatelet agents, and statins. Conclusions: This case report presented a severe form of Takayasu's arteritis. Our patient had multiple arterial complications, as previously mentioned. She received immunosuppressive treatment, medication targeted to coronary heart disease, and surgical therapy.

Vasculitis: When to Consider this Diagnosis?

Vasculitis is a diverse group of disorders involving inflammation of the blood vessels. Approaching the diagnosis of vasculitis can be challenging, given the differing clinical presentation and organ manifestations. Often vasculitis is a diagnosis that is considered too late, given the heterogeneous presentation and various mimics. This article aims to provide physicians with a diagnostic approach to vasculitis.

A Rare Case of Takayasu Arteritis Presenting as Pericarditis with Effusion

Takayasu arteritis (TAK) is a rare large-vessel vasculitis that is seen primarily in young females of Asian descent and is infrequently diagnosed in the United States. Pericardial effusion with or without pericarditis as a presenting feature of TAK is rare, with only about five percent of cases of pericarditis attributable to any autoimmune etiology. We present a case of a 22-year-old Caucasian woman who presented with a large, symptomatic pericardial effusion of unclear etiology, who after extensive laboratory workup and imaging to include whole-body positron emission tomography (PET) was diagnosed with TAK. In our patient, the use of whole-body PET showing characteristic hypermetabolism within the aortic arch helped secure our diagnosis while avoiding the need for pericardiocentesis. The patient had rapid symptomatic and radiographic improvement with the use of high-dose oral steroids in addition to colchicine and ibuprofen for her pericarditis and associated pericardial effusion. At follow-up just 1 week after initiation of steroids, only trace effusion was identified on transthoracic echocardiogram.

The role of 18F-fluorodeoxyglucose PET/computed tomography in the diagnosis and monitoring of large vessel vasculitides - a review article

In the last two decades, advancements in positron emission tomography (PET) technology have increased the diagnostic accuracy of patients with large-vessel vasculitis (LVV). Numerous systematic reviews and meta-analyses have been conducted, and patients suspected of having LVV can be diagnosed earlier with 18F-FDG PET. Two subtypes, giant cell arteritis (GCA) and Takayasu arteritis (TA), will progress when their response to corticosteroids and enhanced immunosuppression is inadequate. In the majority of patients, disease activity cannot be monitored solely through laboratory procedures; consequently, glucose metabolism may be a source of potential biomarkers. In this article, we discuss the current state of 18F-FDG PET/CT imaging standards.

Imaging of giant cell arteritis - recent advances

Imaging is increasingly being used to guide clinical decision-making in patients with giant cell arteritis (GCA). While ultrasound has been rapidly adopted in fast-track clinics worldwide as an alternative to temporal artery biopsy for the diagnosis of cranial disease, whole-body PET/CT is emerging as a potential gold standard test for establishing large vessel involvement. However, many unanswered questions remain about the optimal approach to imaging in GCA. For example, it is uncertain how best to monitor disease activity, given there is frequent discordance between imaging findings and conventional disease activity measures, and imaging changes typically fail to resolve completely with treatment. This chapter addresses the current body of evidence for the use of imaging modalities in GCA across the spectrum of diagnosis, monitoring disease activity, and long-term surveillance for structural changes of aortic dilatation and aneurysm formation and provides suggestions for future research directions.

Diagnostik und Therapie der Großgefäßvaskulitiden – Wo stehen wir aktuell?

Die beiden Großgefäßvaskulitiden unterscheiden sich in mehrfacher Hinsicht, vor allem aber durch das Alter der betroffenen Patienten bei Erstmanifestation. Die Riesenzellarteriitis (RZA) ist eine Erkrankung des älteren Patienten wohingegen die Takayasu Arteriitis per definitionem vor dem 40 Lebensjahr auftritt. Die Diagnosen sind in den letzten Jahren durch verbesserte Bildgebung und Therapieoptionen mehr ins Bewusstsein gerückt. Neben der klassischen Steroidtherapie – welche bis heute Mittel der ersten Wahl ist – steht uns mit Tocilizumab, einem monoklonalen Antikörper gegen IL6-Rezeptor, zumindest für die RZA, eine zusätzliche hocheffektive Therapie zur Verfügung. Andere vielversprechende Substanzen befinden sich derzeit in Erprobung. Dieser Artikel soll einen Überblick zu Diagnostik und Therapie, aber auch einen Ausblick zu möglicherweise kommenden medikamentösen Optionen bieten.

Cardiovascular magnetic resonance in autoimmune rheumatic diseases: a clinical consensus document by the European Association of Cardiovascular Imaging

Autoimmune rheumatic diseases (ARDs) involve multiple organs including the heart and vasculature. Despite novel treatments, patients with ARDs still experience a reduced life expectancy, partly caused by the higher prevalence of cardiovascular disease (CVD). This includes CV inflammation, rhythm disturbances, perfusion abnormalities (ischaemia/infarction), dysregulation of vasoreactivity, myocardial fibrosis, coagulation abnormalities, pulmonary hypertension, valvular disease, and side-effects of immunomodulatory therapy. Currently, the evaluation of CV involvement in patients with ARDs is based on the assessment of cardiac symptoms, coupled with electrocardiography, blood testing, and echocardiography. However, CVD may not become overt until late in the course of the disease, thus potentially limiting the therapeutic window for intervention. More recently, cardiovascular magnetic resonance (CMR) has allowed for the early identification of pathophysiologic structural/functional alterations that take place before the onset of clinically overt CVD. CMR allows for detailed evaluation of biventricular function together with tissue characterization of vessels/myocardium in the same examination, yielding a reliable assessment of disease activity that might not be mirrored by blood biomarkers and other imaging modalities. Therefore, CMR provides diagnostic information that enables timely clinical decision-making and facilitates the tailoring of treatment to individual patients. Here we review the role of CMR in the early and accurate diagnosis of CVD in patients with ARDs compared with other non-invasive imaging modalities. Furthermore, we present a consensus-based decision algorithm for when a CMR study could be considered in patients with ARDs, together with a standardized study protocol. Lastly, we discuss the clinical implications of findings from a CMR examination.

Vascular Imaging Techniques to Diagnose and Monitor Patients with Takayasu Arteritis: A Review of the Literature

Takayasu arteritis (TA) is a large vessel vasculitis that causes stenosis, occlusion, and sometimes the aneurysm of the aorta and its major branches. TA often occurs in young women, and because the symptoms are not obvious in the early stages of the disease, diagnosis is difficult and often delayed. In approximately 10% to 20% of patients, TA is reportedly complicated by ischemic stroke or transient ischemic attack. It is important to diagnose TA early and provide appropriate treatment to prevent complications from stroke. Diagnostic imaging techniques to visualize arterial stenosis are widely used in clinical practice. Even if no signs of cerebrovascular events are present at the time of the most recent evaluation of patients with TA, follow-up vascular imaging is important to monitor disease progression and changes in the cerebrovascular risk. However, the optimal imaging technique for monitoring of TA has not been established. Therefore, the purpose of this review is to describe newly available evidence on the usefulness of conventional imaging modalities (digital subtraction angiography, computed tomography angiography, magnetic resonance imaging/angiography, duplex ultrasound, and positron emission tomography) and novel imaging modalities (optical coherence tomography, infrared thermography, contrast-enhanced ultrasonography, and superb microvascular imaging) in the diagnosis and monitoring of TA.