The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis

Takayasu's disease: a review

Takayasu's disease is a rare chronic vasculitis of unknown aetiology. Initial symptoms and signs are non-specific, and a high index of suspicion is needed to make the correct diagnosis. The disease is associated with a high incidence of morbidity, and a significant risk of premature death. Serological tests have proved unreliable in distinguishing active from quiescent disease, with non-invasive imaging currently offering the best option for early diagnosis, and monitoring the response to treatment. In this review, we detail the epidemiology, pathophysiology, clinical features, imaging characteristics, and currently available treatments.

Takayasu's arteritis treated by percutaneous transluminal angioplasty with stenting in the descending aorta

A 17-yr-old young woman was referred to our hospital with a 2-yr history of claudication of the lower extremities and severe arterial hypertension. Physical examination revealed significantly different blood pressures between both arms (160/92 and 180/95 mmHg) and legs (92/61 and 82/57 mmHg). The hematological and biochemical values were within their normal ranges, except for the increased erythrocyte sedimentation rate (83 mm/hr) and C-reactive protein (6.19 mg/L). On 3-dimensional computed tomographic angiography, the ascending aorta, the aortic arch and its branches, and the thoracic and, descending aorta, but not the renal artery, were shown to be stenotic. The diagnosis of type IIb Takayasu's arteritis was made according to the new angiographic classification of Takayasu's arteritis, Takayasu conference 1994. Percutaneous transluminal angioplasty with stenting was performed on the thoracic and abdominal aorta. After the interventional procedures, the upper extremity blood pressure improved from 162/101 mmHg to 132/85 mmHg, respectively. She has been free of claudication and there have been no cardiac events during 2-yr of clinical follow-up.

Takayasu disease with prominent pulmonary artery involvement: confusion with pulmonary disease leading to delayed diagnosis

Pulmonary artery involvement as the initial predominant clinical manifestation in Takayasu arteritis (TA) is rare. We describe a young adult female who presented with life-threatening complications of proximal pulmonary arterial involvement of Takayasu arteritis. In our case, atypical presentation of TA with pulmonary symptoms due to pulmonary artery involvement resulted in an erroneous initial diagnosis of sarcoidosis and then tuberculosis. The frequency of such a clinical form could be underestimated given the difficulties involved in its diagnosis and because its features are similar to those of pulmonary disease.

Successful treatment of a patient with Takayasu arteritis using a humanized anti-interleukin-6 receptor antibody

Takayasu arteritis (TA) is a chronic inflammatory disease that involves the aorta and its major branches. Since overproduction of interleukin-6 (IL-6) seems to play a pathogenic role in TA, we used the anti-IL-6 receptor (IL-6R) antibody tocilizumab to treat a 20-year-old woman with refractory active TA complicated by ulcerative colitis (UC). Treatment with tocilizumab improved the clinical manifestations of TA and the abnormal laboratory findings in this patient and ameliorated the activity of UC. These results indicate that IL-6R inhibition with tocilizumab might be a future treatment option for TA.

A case of Takayasu arteritis causing subclavian steal and presenting as syncope

The American Heart Association website defines syncope as "temporary loss of consciousness and posture." Syncope is a common presentation to the Emergency Department (ED). Although case reports of subclavian steal syndrome (SSS) from Takayasu arteritis (TA) and of TA causing syncope have been rarely reported in the literature, our MEDLINE search revealed no published description of the three entities of SSS, TA, and syncope presenting simultaneously. We then describe a case of a 48-year-old woman who presented to our ED with syncope and was found to have SSS. We describe the patient's hospital course leading to the diagnosis of TA, which is a rare form of vasculitis. Finally, we briefly discuss TA, explain the mechanism of SSS in TA, and outline the diagnostic criteria established by the American College of Rheumatology for TA.

Giant cell arteritis: a systemic vascular disease

Abstract

Giant cell arterits (GCA) is increasingly being recognized as a systemic vascular disease, not confined to the cranial arteries. Epidemiological studies have shown that almost one-third of the patients with GCA develop serious peripheral vascular complications during long-term follow up, and there is growing evidence that unrecognized extracranial involvement may be even more common. GCA of large- and medium-sized peripheral arteries typically leads to long tapering and occlusion of the arterial lumen due to concentric intimal thickening, sometimes accompanied by spontaneous dissection. Depending on the extent of the arterial obliteration and on the anatomy of the involved arterial segment, this may result in severe ischemia of the limbs during the acute phase of the disease. GCA of the aorta usually remains asymptomatic for many years, and leads to a markedly increased risk of aneurysms and dissections, particularly of the thoracic aorta. Evolving vascular imaging techniques such as duplex ultrasound, computer tomography (CT), magnetic resonance imaging (MRI), and fluorine-18-desoxyglucose positron emission tomography (18F-FDG-PET) have greatly improved our ability to detect and study arterial changes in large-artery vasculitis. Boosted by these advances in vascular imaging, vascular specialists are increasingly involved in the early diagnosis, follow-up and treatment of patients with large-vessel vasculitis.

Renovascular hypertension in children

Renovascular disease is an uncommon but important cause of hypertension in children. It is usually diagnosed after a long delay because blood pressure is infrequently measured in children and high values are generally dismissed as inaccurate. Many children with renovascular disease have abnormalities of other blood vessels (aorta, cerebral, intestinal, or iliac). Individuals suspected of having the disorder can be investigated further with CT, MRI, or renal scintigraphy done before and after administration of an angiotensin-converting-enzyme inhibitor, but angiography is still the gold standard. Most children with renovascular disease will need interventional or surgical treatment. Endovascular treatment with or without stenting will cure or reduce high blood pressure in more than half of all affected children. Surgical intervention, if needed, should be delayed preferably until an age when the child is fully grown. Modern treatment provided by a multidisciplinary team of paediatric nephrologists, interventional radiologists, and vascular surgeons offers good long-term treatment results.

[Severe pulmonary hypertension and Takayasu arteritis]

Takayasu arteritis is an inflammatory disease that affects large vessels, especially the aorta and its branches. The clinical features of the disease depend on which arteries are affected. Although pulmonary artery involvement is common, only rarely is this the main clinical manifestation. We describe the case of a young woman with dyspnea who had severe pulmonary hypertension secondary to Takayasu arteritis of the pulmonary artery. She was administered corticosteroid (methylprednisolone) and immunosuppressant (azathioprine) therapy and a stent was implanted in the left pulmonary artery. Both hemodynamic and clinical signs improved.

Renal involvement in childhood vasculitis

BACKGROUND/AIMS

Renal involvement comprises one of the major organ involvements in childhood vasculitis and has also an important role in the long term prognosis. The aim of this retrospective study was to analyze the demographic, clinical, laboratory features, and the treatment modalities of patients with vasculitis who had renal involvement.

METHODS

Patients with the diagnosis of vasculitis who had been followed in two pediatric nephrology centers between 1990 and 2005 were analyzed retrospectively. Patients with renal involvement were selected and further evaluated.

RESULTS

The study population consisted of 152 of 816 patients with vasculitis. Renal involvement was seen in 134 patients (17%) with Henoch-Schonlein purpura(HSP), 14 patients (45%) with polyarteritis nodosa(PAN), 3 patients with Takayasu arteritis (TA) (50%) and in 1 Wegener granulomatosis (WG) patient. The mean age of patients with renal involvement was 9.2 +/- 0.91 years in the HSP group. Hematuria with proteinuria was the most common renal finding and joint manifestations were seen less in this group. During the follow-up, only 1 patient developed chronic renal failure. Proteinuria, hematuria and aneurysms were seen in 26, 35 and 57% respectively in the PAN group. Only 1 patient (3.2%) had developed chronic renal failure. All 3 patients with TA had bilateral renal arterial involvement.

CONCLUSION

Renal involvement constitutes an important part of childhood vasculitides. With the institution of early and aggressive immunosuppressive treatment significant improvement in the long-term survival of these patients can be achieved.

Takayasu arteritis: what is the long-term prognosis?

Takayasu arteritis (TA) is a form of idiopathic large vessel vasculitis that predominantly affects women of reproductive age. Although TA is a rare disease, the interpretation of longitudinal data from several countries provides new insights into the clinical course and outcomes in TA across different racial and ethnic groups. Contemporary studies belie prior perceptions of TA as a disease with a self-limited, benign course. We now recognize this disease as one that often relapses, leaves the patient chronically dependent on glucocorticoids for disease control, and frequently leads to disability. Limited data suggest that the targeted inhibition of tumor necrosis factor (TNF) might be an effective therapy for TA.

Takayasu arteritis presenting as cerebral aneurysms in an 18 month old: A case report

BACKGROUND

Central nervous system involvement occurs in as many as twenty percent of Takayasu arteritis cases. When central nervous system disease is present, it typically manifests as cerebral ischemia or stroke. There are rare reports of intracranial aneurysms in adults with Takayasu arteritis, but none in children.

CASE PRESENTATION

We describe a case of Takayasu arteritis in an 18 month old girl who presented with a ruptured cerebral aneurysm. Full body magnetic resonance angiography revealed bilateral iliac, pelvic and intragluteal aneurysms, irregular terminal aorta, and stenotic renal arteries. Iliac vessel biopsy showed a lymphocytic infiltrate and giant cells localized to the internal elastica.

CONCLUSION

This case highlights cerebral aneurysm as a highly unusual initial manifestation of Takayasu arteritis and demonstrates the challenges of diagnosis, treatment, and assessment of response to therapy in TA in children.

Multiple ruptured cerebral aneurysms in a child with Takayasu arteritis

The authors report the case of an 18-month-old girl who presented with a ruptured anterior communicating artery aneurysm, and who was later diagnosed with Takayasu arteritis. Her initial aneurysm was successfully treated with clip application. However, over a 6-month period she had multiple ruptures from new and rapidly recurring aneurysms adjacent to the clips. These aneurysms were treated with repeated craniotomy and clip application and then with endovascular coil placement. Aneurysmal subarachnoid hemorrhage is a rare presentation of Takayasu arteritis. To the authors' knowledge, this is the youngest reported patient with Takayasu arteritis to present with a ruptured cerebral aneurysm.

Polymyalgia rheumatica as the manifestation of unclassified aortitis

Polymyalgia rheumatica (PMR) frequently occurs with giant cell arteritis (GCA). We report here two cases of PMR with aortitis in the absence of diminished pulse and manifestations related to GCA. Contrasted CT, MR angiography, and F-18-deoxyglucose positron emission tomography showed aortitis without stenosis that is not classified into any of large vasculitides. It should be acknowledged that aortitis might present as PMR and imaging studies are recommended.

Quality of life in patients with Takayasu's arteritis is impaired and comparable with rheumatoid arthritis and ankylosing spondylitis patients

The aims of the study were to assess the health-related quality of life (QOL) in patients with Takayasu's arteritis (TA) by two different generic QOL instruments and to compare the results with those patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and healthy controls (HC). A cross-sectional study was performed in 51 patients with TA (41 women; mean age 38.4 +/- 13.5), 43 RA (36 women; 55.2 +/- 9.6), 31 AS (12 women; 41.2 +/- 13.1), and 75 HC (53 women; 38.8 +/- 10.9). Quality of life was assessed by using Short-Form 36 (SF-36) and Nottingham Health Profile (NHP). Separate dimensions of SF-36 and NHP and physical and mental summary scores of SF-36 as well were compared between patients and control groups. Physical and mental health summary scores and all SF-36 subscales, except for social functioning, were significantly lower in patients with TA than healthy controls. No significant differences between TA, RA, and AS patients were found in all SF-36 subscales and summary scores. NHP scores for energy level, pain, emotional reactions, and physical mobility were significantly higher in TA patients than controls. All NHP subscales, except for pain, were comparable in patients with TA, RA, and AS. Pain score was worse in RA patients. The NHP scores for sleep and social isolation were not different between patients and controls. Many aspects of QOL in patients with TA are significantly impaired in comparison with local healthy controls and similar to those in patients with RA and AS.

Classification criteria in rheumatic diseases: a review of methodologic properties

OBJECTIVE

To identify classification criteria for the rheumatic diseases and to evaluate their measurement properties and methodologic rigor using current measurement standards.

METHODS

We performed a systematic review of published literature and evaluated criteria sets for stated purpose, derivation and validation sample characteristics, methods of criteria generation and reduction, and consideration of validity, and reliability.

RESULTS

We identified 47 classification criteria sets encompassing 13 conditions. Approximately 50% of the criteria sets were developed based on expert opinion rather than patient data. Of the 47 criteria sets, control samples were derived from patients with rheumatic disease in 15 (32%) sets, from patients with nonrheumatic diseases in 4 (9%) sets, and from healthy participants in 2 (4%) sets. Where patient data were used, the number of cases ranged from 20-588 and the number of controls from 50-787. In only 1 (2%) criteria set was there a distinct separation between investigators who derived the criteria set and clinicians who provided cases and controls. Authors commented on the need for individual criterion to be reliable in 5 (11%) sets, precise in 5 (11%) sets; authors noted the importance of content validity in 12 (26%) sets, and construct validity in 12 (26%) sets.

CONCLUSION

The variation in methodologic rigor used in sample selection affects the validity and reliability of the criteria sets in different clinical and research settings. Despite potential deficiencies in the methods used for some criteria development, the sensitivity and specificity of many criteria sets is moderate to strong.

Imaging characteristics of Takayasu arteritis

Takayasu arteritis is a rare, large-vessel vasculitis in which the nonspecific systemic inflammatory symptoms are followed by inflammation of the aorta and its major branches. The inflammation of this vessel leads to progressive luminal stenosis or aneurysm formation resulting in limb or organ ischemia. Although conventional angiography is still accepted as the gold standard modality, the information obtained is limited to the vessel lumen. Multidetector computed tomographic angiography and magnetic resonance angiography can provide valuable information not only regarding intraluminal pathologies but also concerning the thickening of the vessel wall, which may be the earliest manifestation of the disease.

Follow-up CT evaluation of the mural changes in active Takayasu arteritis

Objective

We wanted to evaluate the mural changes by CT on the follow-up examination of patients with active Takayasu arteritis.

Materials and Methods

The study included 18 patients, (4 males and 14 females), with active Takayasu arteritis. A total of 44 CT examinations were done during the follow-up period (mean: 55.6 months). At the time of the last follow-up CT, the disease, on the basis of the erythrocyte sedimentation rate (ESR), was found to be inactive in five patients and the disease was active and persistent in 13 patients. The thickness and CT attenuation of the aortic wall on the precontrast, arterial and venous phases were measured on the initial and the follow-up CT examinations. The ratio of the mural attenuation over that of the back muscle on the initial CT was compared with the ratio found on the follow-up CT.

Results

The initial CT findings included high density and calcifications of the aortic wall in the precontrast images and a thickened wall with enhancements in the arterial and the venous phases. A low-attenuation ring was demonstrated in the venous phase in 15 patients (83%). On the follow-up evaluation, the mean mural thickness decreased significantly from 4.1 mm to 2.4 mm. The mean mural attenuation ratio in the venous phase decreased significantly from 1.9 to 1.3 (p = 0.001). The low attenuation ring was identified in seven patients (39%) who had only with active, persistent Takayasu arteritis.

Conclusion

The mural changes demonstrated by the follow-up CT evaluations for the patients with active Takayasu arteritis included a decrease of the mural thickness and enhancement, disappearance of the low-attenuation ring on the venous phase, and an increase of the mural attenuation and calcification on the precontrast phase.

Tc-99m sestamibi/F-18 FDG myocardial SPECT in Takayasu arteritis with coronary artery involvement

Coronary arteries may be involved in some patients with Takayasu arteritis. Evaluation of myocardial involvement due to coronary lesions may provide important information in the clinical management of these patients. We report Tc-99m sestamibi and F-18 FDG myocardial single photon emission computed tomography in 3 cases of such patients.

Reactivity of gamma/delta T cells to human 60-kd heat-shock protein and their cytotoxicity to aortic endothelial cells in Takayasu arteritis

OBJECTIVE

Increased numbers of circulating gamma/delta T cells with a restricted T cell receptor repertoire, as well as colocalization of the expression of heat-shock protein Hsp60/65 and gamma/delta T cells in the arterial lesions of patients with Takayasu arteritis (TA), indicate that gamma/delta T cells may react to Hsp60 and cause damage to the arterial endothelium. In this study we investigated the proliferative responses of gamma/delta T cells to human Hsp60 and their cytotoxicity to human aortic endothelial cells (ECs) in patients with TA.

METHODS

Blood samples were obtained from 12 patients with TA, 8 patients with systemic lupus erythematosus (SLE) (as disease controls), and 10 healthy control subjects. Proliferative responses of circulating gamma/delta T cells to human Hsp60 were detected by flow cytometry-based bromodeoxyuridine incorporation assay. Cytotoxicity of the gamma/delta T cells to human aortic ECs was analyzed by colorimetric lactate dehydrogenase release assay.

RESULTS

The gamma/delta T cells of 11 of 12 patients with TA exhibited reactivity to Hsp60, whereas none of the gamma/delta T cells from patients with SLE or healthy controls showed reactivity (both P < 0.001). The mean +/- SD proliferative response of gamma/delta T cells in patients with TA was 21.4 +/- 11.3%, compared with 4.2 +/- 1.2% in patients with SLE and 4.01 +/- 1.82% in healthy controls (both P < 0.001). In addition, compared with the control groups, the gamma/delta T cells of patients with TA had increased spontaneous cytotoxicity to aortic ECs (22.1 +/- 15.0% versus 9.6 +/- 2.13% in SLE patients and 8.1 +/- 4.7% in healthy controls; both P < 0.005), which was further enhanced following stimulation of gamma/delta T cells with Hsp60. The cytotoxicity of the gamma/delta T cells was significantly inhibited by treatment of these cells with concanamycin A and anti-Fas ligand-blocking antibodies.

CONCLUSION

The results show that gamma/delta T cells in patients with TA are reactive to Hsp60 and exhibit cytotoxicity to aortic ECs, suggesting a key role of Hsp60 and gamma/delta T cells in the pathogenesis of TA.

Conditions mimicking coarctation of the aorta

Coarctation of the aorta is a cause of right arm hypertension in children and of heart failure in infants after ductal closure. We present two cases with these presentations that were initially thought to be coarctation of the aorta. They were subsequently diagnosed as Takayasu's arteritis in the older child and a large cerebral arteriovenous malformation in the infant. These conditions should be in the differential of right arm hypertension and of aortic flow reversal on echocardiography.

Mid-Aortic Syndrome and Renovascular Hypertension in a 14-Year-Old Iraqi Girl: Pitfalls in Diagnosis and Surgical Management

Mid-aortic syndrome remains an uncommon cause of hypertension in the pediatric population. Reported management options include percutaneous intervention, medical management, renal autotransplantation, and bypass of diseased portions of the aorta with prosthetic or autologous conduits. We report a case of a 14-year-old Iraqi female with mid-aortic syndrome, confirmed by both computed tomographic angiography and magnetic resonance angiography. The patient underwent a successful aorto-aortic, aorto-mesenteric, and aorto-birenal artery bypass with a polytetrafluoroethylene graft. Optimal management for this condition is surgical bypass.

Reno-vascular hypertension in childhood: a nationwide survey

Renovascular disease accounts for 8-10% of all cases of paediatric hypertension, whereas, in adults, its incidence is approximately 1%. The Turkish Paediatric Hypertension Group aimed to create the first registry database for childhood renovascular hypertension in Turkey. Twenty of the 28 paediatric nephrology centres in Turkey responded to the survey and reported 45 patients (27 girls, 18 boys) with renovascular hypertension between 1990 and 2005. The age at presentation ranged from 20 days to 17 years. The mean blood pressure at the diagnosis was 169/110 mmHg. Chief complaints of symptomatic patients were headache (38%), seizure (18%), epistaxis (4%), growth retardation (4%), cognitive dysfunction (4%), polyuria (2%), palpitation (2%), and hemiplegia (2%). Renovascular hypertension was found incidentally in 11 children. The diagnosis of renovascular hypertension was established with conventional angiography in 39 patients, MR angiography in three, CT angiography in two, and captopril diethylene triamine penta-acetic acid (DTPA) scintigraphy in one patient. Twenty-one children had bilateral renal artery stenosis and 24 had unilateral renal artery stenosis. Of these, 14 (31%) had fibromuscular dysplasia; 12 (27%) Takayasu's arteritis; six (13%) neurofibromatosis; two (5%) Williams syndrome; one (2%) Kawasaki disease; one (2%) mid-aortic syndrome; one (2%) extrinsic compression to the renal artery, and eight (18%) unspecified bilateral renal artery stenosis. Hypertension was controlled with antihypertensive drugs in 17 patients. Percutaneous transluminal angioplasty (PTRA) or surgery had to be performed in 28 patients: PTRA in 16 patients, PTRA + surgery in one patient and surgery in 11 patients (four nephrectomies). The importance of vasculitic disease, especially Takayasu's arteritis, should not be underestimated in children with renovascular hypertension.

[18F]Fluorodeoxyglucose PET in Large Vessel Vasculitis

[(18)F]fluorodeoxyglucose (FDG) PET is a noninvasive metabolic imaging modality based on the regional distribution of [18F]FDG that is highly effective in assessing the activity and extent of giant cell arteritis and Takayasu's arteritis, respectively. Metabolic imaging using [18F]FDG-PET has been shown to identify more affected vascular regions than morphologic imaging with MRI in both diseases. The visual grading of vascular [18F]FDG uptake helps to discriminate arteritis from atherosclerosis and therefore provides high specificity. High sensitivity is attained by scanning during the active inflammatory phase. Thus, [18F]FDG-PET has the potential to develop into a valuable tool in the diagnostic workup of giant cell arteritis and Takayasu's arteritis.

Takayasu's arteritis in a young Caucasian female: case report and review

We report a case of a 24-year-old Caucasian woman presenting with fatigue, weight loss, a cardiac murmur, anaemia and biochemical markers of inflammation due to Takayasu's arteritis (TA), a vasculitis of the aorta and large vessels that typically affects young women. The rarity of the disease, the great variability in presentation together with the absence of specific symptoms as well as the absence of specific biochemical markers, makes early diagnosis difficult. Besides (magnetic resonance) arteriography, new promising diagnostic tools are discussed, including transoesophageat echocardiography (TEE) and Positron Emission Tomography (PET). Nevertheless, a high index of suspicion remains the key to an early diagnosis, and hence a better prognosis, of TA.

Patterns of aortic involvement in Takayasu arteritis and its clinical implications: Evaluation with spiral computed tomography angiography

OBJECTIVE

Although the luminal changes of Takayasu arteritis are well depicted with conventional angiography, its mural changes can be best evaluated with spiral computed tomography (CT) angiography. Here, the authors investigated the patterns of aortic involvement in Takayasu arteritis by using CT angiography.

METHODS

CT angiography was performed from the carotid bifurcation to the iliac bifurcation in a consecutive 85 patients (M:F = 10:75, mean age: 37 years) with Takayasu arteritis. Two radiologists interpreted axial images and three-dimensional reconstructed images by consensus with respect to disease extent, lesion continuity, and disease activity based on mural and luminal changes on CT angiography.

RESULTS

Eighty-one (95%) patients had aortic involvement with or without aortic branch involvement, and the other four (5%) patients had only aortic branch involvement. In terms of aortic branches, the left common carotid artery (77%) and the left subclavian artery (76%) were most commonly involved. Extent of disease involvement assessed by mural change was wider than that assessed by luminal change in 52 (61%) patients. Although arterial involvement was contiguous in 69 (81%) patients, skipped lesions were identified in 16 (19%) patients. An analysis of mural findings revealed the coexistence of active and inactive lesions in nine (11%) patients.

CONCLUSIONS

Aortic involvement in Takayasu arteritis can occur from the aortic root to below the iliac bifurcation, and isolated branch vessel involvement is also possible. In most patients, aortic involvement occurs in a contiguous, synchronous fashion. However, skipped involvement and the coexistence of active and inactive lesions also occur.

Endovascular repair of thoracic stent-graft bulging rupture in a patient with multiple thoracic aneurysms due to Takayasu disease

Isolated aortic aneurysms in Takayasu arteritis (TA) are rare. Reported operative mortality and operative complication rates seem low, with an infrequent need for surgical revision, even though most reports concern occlusive disease. Treatment of aneurysms in TA requires therapeutic strategies that are different from the ones used for atherosclerotic vessel dilatations because the pathology and the extensive, progressive, relapsing nature of the disease are deeply different from the atherosclerotic process. We report a case of thoracic stent-graft bulging rupture, a device previously implanted to exclude a thoracic aneurysm, associated with two small aneurysms near the distal implantation site. Both were treated with three new-generation stent grafts implanted in a telescope fashion.

A case of common variable immunodeficiency syndrome associated with Takayasu arteritis

BACKGROUND

Association of common variable immunodeficiency (CVID) with Takayasu arteritis has rarely been reported.

OBJECTIVE

To describe a case of Takayasu arteritis in a 53-year-old Hispanic woman with CVID undergoing long-term (3-year) intravenous immunoglobulin (IVIG) treatment.

METHODS

The patient's serum immunoglobulin levels and antibody titers to measles, mumps, and rubella were measured. She also underwent angiography of the large vessels.

RESULTS

Low to undetectable serum IgA, IgM, and IgG levels and low antibody titers to mumps, measles, and rubella were consistent with the diagnosis of CVID. The angiogram showed narrowing of the proximal left subclavian artery (2-3 mm in diameter).

CONCLUSIONS

This patient developed Takayasu arteritis while receiving IVIG for CVID. She clinically improved after her IVIG dose was increased. To our knowledge, this is the second reported case of Takayasu arteritis associated with CVID.

Acute myocardial infarction and rapid development of coronary aneurysms in a young woman--unusual presentation of Takayasu arteritis?

The present report describes a young female patient with acute myocardial infarction and inflammatory lesions limited to proximal and midsegments of the left anterior descending coronary artery. Based on the presence of positive inflammatory markers, an angiographically confirmed coronary artery lesion and the young age of the patient, an atypical presentation of Takayasu arteritis was diagnosed.

Mycophenolate mofetil reduces disease activity and steroid dosage in Takayasu arteritis

Mycophenolate mofetil (MMF) has recently been reported as a useful alternative immunosuppressive drug in autoimmune diseases including in Takayasu arteritis (TA). The aim of this study was to verify the efficacy and tolerability of MMF administration in controlling TA disease activity and allowing glucocorticosteroid reduction. Ten consecutive active TA patients followed at the Vasculitis Clinic were enrolled from January 2003 to 2006 and received oral MMF (2 g/day) for an average of 23.3 months. Disease activity assessed using the National Institutes of Health criteria, clinical features, and inflammatory laboratory findings were evaluated. Five patients had received at least one immunosuppressive drug before administration of MMF (four methotrexate, two azathioprine, and one chlorambucil) but had not achieved clinical and laboratory remission. The other five patients received MMF as their first immunosuppressive drug because of an important disease flare during steroid dose reduction. Clinical activity disappeared in all patients with MMF therapy, except in one patient who abandoned the study because of an important headache, attributed to the drug. Moreover, the MMF therapy allowed significant tapering of the prednisone dose in the rest of the nine patients (24.5 +/- 17.1 vs 5.8 +/- 7.8 mg/day; p = 0.0019). Reinforcing this finding, a significant reduction in inflammatory laboratory parameters, erythrocyte sedimentation rate (24.7 +/- 15.5 vs 12.8 +/- 10.8 mm/h; p = 0.036) and C-reactive protein (24.0 +/- 14.9 vs 11.2 +/- 10.7 mg/l; p = 0.0167), was observed. In summary, MMF therapy reduced clinical and laboratory parameters of TA disease activity, suggesting that this drug is a promising immunosuppressive drug, particularly in refractory cases and as a steroid-sparing agent.

Childhood vasculitides in Turkey: a nationwide survey

AIM

The aims of this study were to evaluate the characteristics of childhood vasculitides and to establish the first registry in Turkey, an eastern Mediterranean country with a white population.

PATIENTS AND METHODS

A questionnaire was distributed to the main referral centers asking for the registration of the Henoch-Schönlein purpura (HSP) patients in the last calendar year only and 5 years for other vasculitides. Demographic, clinical, and laboratory data were assessed.

RESULTS

Vasculitic diseases were registered from 15 pediatric centers. These centers had a fair representation throughout the country. In the last calendar year, incidences were as follows: HSP 81.6%, Kawasaki disease (KD) 9.0%, childhood polyarteritis nodosa (C-PAN) 5.6%, Takayasu arteritis (TA) 1.5%, Wegener's granulomatosis 0.4%, and Behçet disease 1.9%. There was no clear gender dominance. The mean age was 11.05+/-4.89 years. Acute phase reactants were elevated in almost all, highest figures being in C-PAN. Renal involvement was present in 28.6% of HSP and 53% of the C-PAN patients. Abdominal aorta was involved in all TA patients. Among the C-PAN patients, 25% had microscopic PAN with necrotizing glomerulonephritis; antineutrophil cytoplasmic antibody was positive in those who were studied. Among the patients, 12.5% and 15% had classic PAN and cutaneous PAN, respectively. The remaining majority were classified as systemic C-PAN diagnosed with biopsies and/or angiograms demonstrating small to midsize artery involvement. The overall prognosis was better than reported in adult series.

CONCLUSION

This is the largest multicenter study defining the demographic data for childhood vasculitides. The distribution of childhood vasculitides was different in our population where KD is much less frequent, whereas HSP constitutes an overwhelming majority. C-PAN was more frequent as well.

Feasibility of angioplasty and stenting for abdominal aortic lesions adjacent to previously stented visceral artery lesions in patients with Takayasu arteritis

Two young female patients with Takayasu arteritis presented with symptomatic long-segment abdominal aortic stenosis in the vicinity of previously deployed celiac and renal artery stents that projected markedly into the narrowed aortic lumen. Crushing or distortion of the visceral artery stents during aortic angioplasty was avoided by performing simultaneous or alternating balloon dilatations in the aorta and in the visceral artery stents. Consequently, the visceral artery stents remained patent and shortened longitudinally, allowing unhindered deployment of Wallstents in the adjacent aorta and abolition of a pressure gradient across the aortic lesions. Access to side branches covered by the Wallstent was obtained without difficulty, enabling the performance of balloon dilatation in multiple side branches and ostial stent deployment in a renal artery. These techniques could increase the scope of endovascular therapy in the treatment of patients with Takayasu arteritis.

Left main stem disease in a patient with Takayasu's arteritis

Takayasu's arteritis is a chronic vasculitis of unknown aetiology involving the aorta and its main branches, the pulmonary and coronary tree. Women are affected more often than men (80 to 90% of the cases) with an age onset between 10 and 40 years. This case report demonstrates the limitations of exercise testing and stress echocardiography in diagnosing the extent of coronary artery disease in patients with inflammatory disease in the left main stem coronary artery. (Neth Heart J 2007;15:260-2.).