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.