Case presentation:-
A 22-year-old female presented to the outpatient department with complaints of persistent headaches, vision problems, recurrent dizziness, and easy fatigability. She reported that her headaches worsened in crowded areas during the daytime and were accompanied by nausea. These symptoms had been ongoing for the past year. She had previously undergone ophthalmologic evaluation and was prescribed glasses and eye drops. Additionally, the patient had experienced episodes of dizziness, leading to falls while performing daily tasks, such as working in a hot oven or buying vegetables. Despite investigations, no abnormal findings were detected, and the patient was unable to provide any available test reports. Over time, she noticed a gradual decline in her vision specifically during exertion, which improved after rest and head bending. Walking or engaging in activities would induce dizziness, requiring her to take frequent breaks.
Her undiagnosed illness had a negative impact on her mental health, resulting in decreased sleep, feelings of worthlessness, hopelessness, and guilt. She was subsequently diagnosed with depression. In a fit of anger and rage, the patient described an episode of unconscious self-harm where she cut her left wrist. Although she was promptly taken to a nearby hospital, there was no evidence of bleeding at the site of the cut. She received three months of medication for her depression, which significantly improved her symptoms. A healed scar remained visible on her left wrist.
The patient had no significant family history, and her past medical history included right nephrolithiasis, pneumonia, and pelvic inflammatory disease (PID) uterine infection. She had no history of pulmonary tuberculosis (PTB). She did not engage in smoking or drinking.
On examination, pulse and blood pressure could not be recorded on the upper extremities, but pulses were palpable in the lower extremities. A silent right carotid area and the presence of bruits in the left carotid area were noted. However, pulsations of the aorta, femoral artery, and popliteal artery were normal.
Initial laboratory tests revealed a white blood cell count (WBC) of 10,500 with differential counts: neutrophils (N) 50%, lymphocytes (L) 38%, eosinophils (E) 3%, monocytes (M) 8%, and basophils (B) 1%. Hemoglobin (Hb) was 10.0 g/dL, and random blood sugar (RBS) was 95 mg/dL. Venereal Disease Research Laboratory (VDRL) test results were non-reactive. Due to suspicion of Takayasu arteritis, the patient was referred to a tertiary care center for further management.
Computed Tomography (CT) angiography of the aorta and its branches was carried out. CT angiography of the neck revealed diffuse symmetrical circumferential arterial thickening of the ascending aorta, aortic arch, and their branches, with significant luminal narrowing, consistent with Takayasu arteritis (figure no.1). However, the brain CTA showed normal findings (figure no. 2). Her laboratory findings are summarized in Table 1. The patient was prescribed a combination of medications to manage her condition while awaiting surgery. The treatment regimen included Prednisolone 40 mg/day orally; aspirin 75 mg/day, and pantoprazole 40 mg /day.