Discussion:-
Takayasu arteritis is presently classified as systemic granulomatous
large-vessel vasculitis according to the Chapel Hill Consensus
Conference 2012 3. This condition typically impacts
young to middle-aged individuals of Asian descent and primarily affects
large blood vessels such as the aorta and its main branches1. Our patient, like many others, is a young female
who exhibits the predominant occurrence of Takayasu arteritis in this
demographic. The clinical manifestation of this disease can vary greatly
and may resemble other disorders, thus posing diagnostic difficulties.
The diagnosis of Takayasu arteritis can be challenging due to the wide
range of clinical presentations, particularly in its early stages. In
around 84-96% of patients, characteristic symptoms such as diminished
or absent pulses, limb claudication, and differences in blood pressure
are observed 4,5. Vascular bruits are frequently found
in 80-94% of individuals, often impacting multiple regions,
particularly the carotid arteries, subclavian arteries, and abdominal
vessels 4,6,7. The aorta can be affected throughout
its entire extent, and while any of its branches can be afflicted, the
subclavian and common carotid arteries are the most commonly involved5,7–9.
In this case, the patient presented with a constellation of symptoms
that were indicative of vascular involvement. The initial complaints of
headache and vision problems aggravated in crowded areas and associated
with nausea, raised suspicion of involvement of the carotid arteries and
cerebral circulation. The gradual diminishment of vision with exertion,
which improved with rest and head bending, is consistent with the
phenomenon of ”ocular ischemic syndrome” often seen in Takayasu
arteritis.
Furthermore, the patient reported recurrent dizziness, falls, and easy
fatiguability, particularly in the upper extremities. These symptoms can
be attributed to subclavian artery involvement and impaired blood flow
to the arms. The difficulty in obtaining blood pressure measurements and
absence of pulses in the upper extremities, along with the presence of
bruits in the left carotid area, further support the suspicion of large
vessel involvement. The normal pulsations observed in the aorta, femoral
artery, and popliteal artery suggest sparing of the distal vessels in
this case.
Preferably, early diagnosis of Takayasu arteritis is essential during
the prestenotic phase. The diagnosis primarily relies on clinical
features and imaging findings. Elevated levels of acute phase reactants
like erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
may be observed, but these tests do not consistently indicate the
severity of the disease and can appear normal even when the disease is
active 7. . In our particular case, the ESR level was
within the normal range. Over the last decade, significant progress has
been made in the field of medical imaging, leading to a better
understanding of how large vessel vasculitides affect the vascular
system. These advancements have also become increasingly vital in
clinical management 10,11. Various imaging techniques,
such as high-resolution ultrasound (US), magnetic resonance imaging
(MRI), magnetic resonance angiography (MRA), CT angiography (CTA), and
positron emission tomography (PET), have been investigated in
individuals diagnosed with Takayasu arteritis. The existing small and
typically retrospective studies suggest that, although there is no
single modality that provides all the required information, they might
have distinct and complementary roles in patient care12,13.
Early initiation of medical treatments is generally recommended to
minimize vascular injuries, particularly the combination of
corticosteroids and immunosuppressive agents 2.
Corticosteroids remain the primary treatment option and have shown
effectiveness in 20-75% of patients with ”active aortitis”14,15. Steroid therapy often leads to a positive
response in the erythrocyte sedimentation rate (ESR), which serves as a
reliable indicator of disease activity 16.
Anti-platelet therapy is commonly recommended to prevent further
ischemic events 3. n cases of severe and symptomatic
aortic branch arterial disease, patients should be considered for either
endovascular procedures or surgery 9,17.
In our case, the patient exhibited signs of depression, which is not
uncommon in chronic illnesses. The presence of depression further
underscores the importance of providing comprehensive care, including
psychological support and addressing the patient’s emotional well-being.
While our patient responded well to medical management, it is essential
to acknowledge the limitations of this case report. The follow-up period
was relatively short, and long-term outcomes were not evaluated.
Furthermore, due to resource constraints, some investigations and
laboratory reports were not available, which may have provided
additional insights into the disease course.