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.