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

Correlation of neurological manifestations of Takayasu's arteritis with cerebral angiographic findings

For categorizing the presenting neurological symptoms in Takayasu's arteritis (TA) and correlating to the imaging findings of cerebral angiography, we retrospectively reviewed the angiographies of 27 patients presented with stroke, transient ischemic attack (TIA), visual disturbance, and/or dizziness. Neurological manifestations of TA resulted from decreased blood flow due to a steno-occlusive lesion and/or shifting of blood flow, thromboembolism, or hypertension. The pattern analysis of neurological manifestations related to specific arterial involvement is mandatory in understanding neurological manifestations of this systemic disease.

Outras vasculites pulmonares

A poliangeíte microscópica, a arterite de Takayasu, a síndrome de Behçet, a púrpura de Henoch-Schönlein e as vasculites associadas às doenças do colágeno incluem-se entre as vasculites pulmonares. Seu diagnóstico é realizado associando-se as manifestações clínicas aos achados radiológicos e anatomopatológicos.

Vasculites pulmonares: quando suspeitar e como fazer o diagnóstico

As vasculites pulmonares primárias são caracterizadas por processo inflamatório na parede dos vasos pulmonares que leva a isquemia e hemorragia pulmonar com as conseqüentes expressões clínicas e radiológicas. As vasculites pulmonares primárias são acompanhadas de expressão sistêmicas cutâneas, em nervos periféricos, rins, seios da face, olhos e ouvidos, além do trato gastrintestinal, e sistemas cardíaco e nervoso central. O diagnóstico é feito através da associação das informações clínicas, radiológicas e anatomopatológicas. O tratamento com corticosteróides e imunossupressores deve ser instituído precocemente e apresenta altas taxas de remissão.

Delayed Contrast-Enhanced MRI of the Aortic Wall in Takayasu's Arteritis: Initial Experience

OBJECTIVE

Delayed contrast-enhanced MRI is increasingly being used for cardiac viability imaging. Takayasu's arteritis is a rare inflammatory disorder of unknown cause that affects the aorta, its major branches, and the pulmonary artery; it is characterized by inflammation and fibrosis in the arterial wall. We report our initial experience with seven patients (six women, one man; age range, 25-62 years) with delayed (20 min) gadolinium-enhanced MRI (inversion recovery prepared gated fast gradient-echo pulse sequence) in patients with known Takayasu's arteritis.

CONCLUSION

Patients with Takayasu's arteritis (particularly those with abnormal laboratory values) have evidence of delayed hyper-enhancement on delayed contrast-enhanced MRI. Thus, delayed contrast-enhanced MRI might be a useful technique to identify inflammation in arterial wall.

Cerebrovascular manifestations of Takayasu arteritis in Europe

OBJECTIVES

Takayasu arteritis is well known as a cause of stroke in Asia but has rarely been described in the Western world. Here we report the clinical and neuroimaging follow-up of a series of patients with Takayasu arteritis from Europe.

METHODS

Seventeen consecutive patients who fulfilled the diagnostic criteria for Takayasu arteritis of the American College of Rheumatology were evaluated on follow-up by standardized neurological examination, sonography and MRI.

RESULTS

At follow-up almost 20 yr after onset of symptoms, the subclavian artery and the common carotid artery were often affected. In addition, evidence of intracranial pathology was found in seven patients. In contrast to the severe vessel involvement, the neurological state was stable. Two patients had suffered from stroke before the diagnosis was made and therapy was initiated, and one patient had recurrent transient ischaemic attacks. Intermittent dizziness was associated with pathology of the vertebral and basilar arteries. However, clinical symptoms of subclavian steal syndrome were rare.

CONCLUSION

This case series shows that the clinical neurological course of Takayasu arteritis on treatment is benign in most cases despite the severe vascular involvement.

Vasculitis in the gastrointestinal tract

The primary systemic vasculitides are a rare group of inflammatory disorders, where damage is directed against the blood vessels. They range in severity from acute self-limiting illness to chronic life and organ threatening diseases requiring long-term treatment with toxic immunosuppressive regimes. None of them have specific tests and few have hard diagnostic criteria. This review summarises the gastrointestinal features of these diseases, along with their general clinical and epidemiological features and the evidence available to guide in their management.

Classification and diagnostic criteria in systemic vasculitis

Approximately 20 different primary forms of vasculitis are recognized, not all of which have been included in classification schemes or consensus statements regarding nomenclature. A variety of classification schemes have been proposed over the past 50 years, many predicated upon the size of the primary type of vessel involved in a given disease, as well as other considerations that include demographic features, organ tropism, the presence or absence of granulomatous inflammation, the role of immune complexes in pathophysiology and the association of autoantibodies with some forms of vasculitis. All classification schemes to date have had shortcomings owing to the substantial gaps in knowledge about vasculitis, but the American College of Rheumatology criteria for the classification of some forms of vasculitis are useful for the purpose of including patients in research studies. The Chapel Hill Consensus Conference has clarified some existing controversies in nomenclature of the systemic vasculitides. Robust diagnostic criteria for the various forms of vasculitis have, however, remained elusive.

A case of Takayasu arteritis complicated with glomerulonephropathy mimicking membranoproliferative glomerulonephritis

We report on a 65-year-old Japanese woman with Takayasu arteritis who developed severe proteinuria, hypertension, and renal dysfunction. Renal angiography demonstrated moderate irregular narrowing of both renal arteries. Renal biopsy showed glomerulonephropathy mimicking membranoproliferative glomerulonephritis (MPGN) with glomerular capillary wall thickening ("double contour") accompanied by mesangial cell proliferation and moderate increase of mesangial matrix without deposits of C3. Electron microscopy showed no subendothelial deposit and no circumferential mesangial interposition (CMI), and these findings are different from MPGN. In this report we present a case of Takayasu arteritis associated with glomerulonephropathy mimicking MPGN.

Takayasu's arteritis: A study of 104 Italian patients

OBJECTIVE

Takayasu's arteritis (TA) is a rare vasculitis. The Italian Takayasu's Arteritis study group was established with the aim to describe a large cohort of patients.

METHODS

Data were collected by means of an ad hoc form. Demographic information, clinical history, vascular findings, treatment, risk factors, and comorbidities were analyzed.

RESULTS

Data of 104 patients were collected. The median delay in diagnosis was 15.5 months (range 0-325 months). Age at onset <15 years was associated with a higher probability, whereas elevated erythrocyte sedimentation rate with a lower probability, of a delay in diagnosis. The majority of patients experienced nonspecific signs and symptoms indicative of an inflammatory disease in the early phase. Among vascular involvement, stenosis was the most frequent lesion, being present in 93% of patients, followed by occlusion (57%), dilatation (16%), and aneurysm (7%). Glucocorticoids were the mainstay of treatment in our series; however, treatment with cytotoxic agents was required in about half of the patients. Fifty-two patients underwent at least 1 surgical procedure. The main indications for intervention were renal vascular hypertension, cerebral hypoperfusion, and limb claudication.

CONCLUSION

As with many rare diseases, delay in diagnosis is an important issue for patients with TA. The increasing occurrence of vascular lesions along with the disease progression put to question the long-term effectiveness of contemporary treatment. These data may be helpful in increasing physicians' awareness to prevent diagnosis delay, update guidelines, and plan future research projects.

Cellular and humoral immune responses to mycobacterial heat shock protein-65 and its human homologue in Takayasu's arteritis

Expression of heat shock protein (HSP)-65 as well as infiltration of T-cells in arterial lesions and raised levels of circulating antibodies against mycobacterial HSP65 (mHSP65) led us to the concept that mHSP65 or its human homologue (hHSP60) might be involved in the etiopathogenesis of Takayasu's arteritis (TA). Therefore, we investigated mHSP65 and hHSP60 reactive peripheral blood T-cell subsets by BrdU incorporation assay and flow cytometry as well as investigating the different isotypes of anti-mHSP65 and hHSP60 antibodies by ELISA. Eighty-four percent (22/26) of the TA patients were observed to show T-cell proliferation to mHSP65 and hHSP60 whereas only 16% (3/18) healthy controls showed such proliferation (P <0.001). Both HSPs induced proliferation of exclusively CD4+ T-cells and not CD8+ T-cells. We also observed a significantly higher prevalence of only the IgG isotype reactive to mHSP65 and hHSP60 in TA as compared to HC (mHSP65: 92% TA versus 11% HC, P <0.0001 and hHSP60: 84% versus 22%, P <0.001). Our data show a significant correlation between mHSP65 and hHSP60 reactive T-cells (CD3+: r=0.901; CD4+: r=0.968) as well as anti-mHSP65 and anti-hHSP60 IgG antibodies (r=0.814) suggesting an infection induced autoimmunity in TA, possibly induced by molecular mimicry between mHSP65 and hHSP60 or other tissue specific antigens.

The value of [18F]FDG-PET in the diagnosis of large-vessel vasculitis and the assessment of activity and extent of disease

PURPOSE

This study was performed to investigate the value of( 18)F-fluorodeoxyglucose positron emission tomography ([(18)F]FDG-PET) in the diagnosis of large-vessel vasculitis and the assessment of activity and extent of disease.

METHODS

Twenty-six consecutive patients (21 females, 5 males; median age - years, range 17-86 years) with giant cell arteritis or Takayasu's arteritis were examined with [(18)F]FDG-PET. Follow-up scans were performed in four patients. Twenty-six age- and gender-matched controls (21 females, 5 males; median age 71 years, range 17-86 years) were included. The severity of large-vessel [(18)F]FDG uptake was visually graded using a four-point scale. C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were measured and correlated with [(18)F]FDG-PET results by logistic regression.

RESULTS

[(18)F]FDG-PET revealed pathological findings in 18 of 26 patients. Three scans were categorised as grade I, 12 as grade II and 3 as grade III arteritis. Visual grade was significantly correlated with both CRP and ESR levels (p=0.002 and 0.007 respectively; grade I: CRP 4.0 mg/l, ESR 6 mm/h; grade II: CRP 37 mg/l, ESR 46 mm/h; grade III: CRP 172 mg/l, ESR 90 mm/h). Overall sensitivity was 60% (95% CI 40.6-77.3%), specificity 99.8% (95% CI 89.1-100%), positive predictive value 99.7% (95% CI 77-100%), negative predictive value 67.9% (95% CI 49.8-80.9%) and accuracy 78.6% (95% CI 65.6-88.4%). In patients presenting with a CRP <12 mg/l or an ESR <12 mm/h, logistic regression revealed a sensitivity of less than 50%. In patients with high CRP/ESR levels, sensitivity was 95.5%/80.7%.

CONCLUSION

[(18)F]FDG-PET is highly effective in assessing the activity and the extent of large-vessel vasculitis. Visual grading was validated as representing the severity of inflammation. Its use is simple and provides high specificity, while high sensitivity is achieved by scanning in the state of active inflammation.

Successful stenting for congenital coarctation of the distal thoracic aorta (middle aortic syndrome) in an adult

We report a successful stent implantation for a coarctation lesion of the lower thoracic aorta in a 44-year-old male. This patient had suffered from claudication of both legs for 30 years. An aortogram revealed a coarctation of the distal thoracic aorta at T11 level with 60 mmHg peak systolic pressure gradient of across the lesion. A balloon angioplasty followed by an 18 mm x 40 mm sized stent implantation was performed successfully. The peak systolic gradient across the coarctation decreased from 60 to 15 mmHg. The patient's symptom was relieved immediately after stenting. No significant or adverse events were observed during 7 months clinical follow-up. Follow-up aortogram after 7 months revealed no restenosis with an improved pressure gradient. Adults with congenital coarctation of the descending thoracic aorta can be successfully treated by stent implantation.

Endovascular Therapy Combined With Immunosuppressive Treatment for Occlusive Arterial Disease in Patients With Takayasu's Arteritis

PURPOSE

To evaluate the feasibility and efficacy of endovascular therapy combined with immunosuppression for the treatment of arterial occlusive disease in patients with Takayasu's arteritis (TA).

METHODS

From January 1998 to June 2003, 25 patients (22 women; age 37.8+/-15.5 years) with TA were treated with angioplasty for symptomatic lesions or with a hemodynamically significant aortic narrowing. The patients with active disease, defined as an increase in inflammatory markers (e.g., erythrocyte sedimentation rate [ESR]), were treated with immunosuppressive agents before intervention. Angioplasty was performed after the ESR had been normalized.

RESULTS

In the 25 patients, 58 vascular territories (7 aortic, 9 carotid, 3 vertebral, 11 subclavian, 2 superior mesenteric, 18 renal, 4 iliac, and 4 coronary arteries) were treated with angioplasty only (19 lesions) or with stents (39 lesions). The mean ESR when the vascular lesions were initially diagnosed was 35.6+/-26.2 mm/h, which fell to 18.5+/-7.8 mm/h after immunosuppressive therapy. The endovascular procedure was performed successfully in 52 (90%) of 58 lesions. During the mean 23.7+/-18.4-month follow-up, 9 (17%) treated segments restenosed; 4 were treated with repeat angioplasty. The overall cumulative primary clinical success rate was 82%; secondary clinical success was 90%.

CONCLUSIONS

Endovascular therapy for stenotic lesions in patients with TA is safe and effective when disease activity is strictly controlled with immunosuppressive treatment.

Sensorineural hearing loss combined with Takayasu's arteritis

A 49-year-old woman complained of hearing loss and diminution of left radial arterial pulsation. She had been diagnosed with sudden deafness and treated with corticosteroids. Her audibility deteriorated again after the cessation of the therapy. Angiograms showed stenosis in the bilateral carotid arteries, the left vertebral artery, the left subclavian artery, and the pulmonary arteries. She was diagnosed with Takayasu's arteritis. After steroid therapy was restarted, there were improvements in her audibility, radial arterial pulsation, and levels of inflammatory markers (erythrocyte sedimentation rate, C-reactive protein, and gamma-globulin), fibrinogen, interleukin-6, and RANTES (regulated on activation, normal T cell expressed and secreted).

Vaskulitiden der gro�en Gef��e als Ursache eines Fiebers unklarer Genese (FUO) oder unklarer Entz�ndungskonstellationen

BACKGROUND

Diagnosis and treatment of FUO or systemic inflammation with unknown reason are still a great challenge for the treating physician. We used (18)F-FDG-PET for further diagnostic work in patients in whom a diagnosis could not be established despite intensive diagnostic efforts.

METHODS/RESULTS

We studied nine patients with (18)F-FDG-PET. Two female patients with known Takayasu's arteritis but undefined disease activity, and seven patients with the clinical suspicion of an underlying large vessel vasculitis. The diagnosis of active vasculitis could be confirmed by the PET-results in eight patients. Active vasculitis could be nearly ruled out in one. The diagnoses could be confirmed by follow-up visits.

CONCLUSION

(18)F-FDG-PET is a useful diagnostic tool in patients with unclear systemic inflammation and FUO. Especially when large vessel vasculitis is suspected, further diagnostic work by PET seems to be of benefit. Furthermore, it offers the opportunity to evaluate disease activity and to check which vessels are involved.

Standardised work-up programme for fever of unknown origin and contribution of magnetic resonance imaging for the diagnosis of hidden systemic vasculitis

BACKGROUND

Fever of unknown origin (FUO) is a diagnostic challenge. Rheumatologists are often in charge of patients with FUO because the vasculitides, especially, are potential and common causes of FUO.

OBJECTIVE

To evaluate the value of a standardised investigation to identify the cause of FUO.

METHODS

A standardised work-up programme for patients with FUO was started at the beginning of September 1999. The rate of identified causes of FUO was compared between all patients with FUO admitted to a tertiary care centre of rheumatology between January 1996 and August 1999 (control group) and September 1999 and January 2003 (work-up group). In January 2002 magnetic resonance imaging (MRI) was added to the investigation.

RESULTS

67 patients with FUO were identified--32 before and 35 after institution of the work-up programme. Before implementation 25% of all patients with FUO remained undiagnosed, after implementation 37%. After institution of the investigation the percentage of patients with vasculitides increased significantly from 6% (n = 2) to 26% (n = 9, p = 0.047, Fisher's exact test). This increase could be attributed to the addition of MRI in 2002. When all patients with FUO before 2002 (n = 55) and thereafter (n = 12) were compared the prevalence of systemic vasculitis increased from 11% (n = 6) to 42% (n = 5, p = 0.021).

CONCLUSION

Implementation of a standardised work-up programme for FUO did not improve the overall rate of diagnosis. Addition of MRI significantly increased the diagnosis of systemic vasculitis as the underlying cause of FUO. MRI should be included in the investigation of patients with FUO when vasculitis is suspected.

Cytokine mRNA repertoire of peripheral blood mononuclear cells in Takayasu's arteritis

We have investigated constitutive and phytohaemagglutinin (PHA) + phorbol 12-myristate 13-acetate (PMA)-induced gene expression of tumour necrosis factor (TNF)-alpha, interferon (IFN)-gamma, interleukin (IL)-2, IL-3, IL-4, IL-10, IL-12 and granulocyte macrophage colony-stimulating factor (GM-CSF) in peripheral blood mononuclear cells (PBMCs) of 10 patients with Takayasu's arteritis (TA) and 10 healthy controls by semiquantitative reverse transcriptase polymerase chain reaction (RT-PCR). The constitutive mRNA expression of TNF-alpha (69.0 +/- 4.0%versus 27.5 +/- 18.0%; P = 0.001) and IL-4 (60.0 +/- 10.0%versus 0%; P = 0.001) was significantly higher in patients than controls; that of IL-3 was comparable in both groups (38.0 +/- 6.0%versus 32.0 +/- 5.0%; P = 0.651) while no constitutive mRNA expression was observed for the other cytokines studied. The stimulated PBMCs of patients, as compared with the controls, had higher mRNA gene expression of TNF-alpha (127.0 +/- 16.0%versus 54.0 +/- 6.0%; P = 0.001), IFN-gamma (93.0 +/- 13.0%versus 57.0 +/- 5.0%; P = 0.032), IL-2 (109.0 +/- 13.0%versus 68.0 +/- 6.0%; P = 0.015), IL-3 (60.0 +/- 8.0%versus 21.2 +/- 3.0%; P = 0.045) and IL-4 (68.0 +/- 7.0%versus 27.0 +/- 7.2%; P = 0.01) The mRNA expression of IL-10 was lower in patients than controls (35.0 +/- 8.0%versus 75.0 +/- 12.0%; P = 0.022). The GM-CSF mRNA was similar (102.0 +/- 6.0%versus 89.0 +/- 5.0%; P = 0.475) in both groups. Stimulation of cells with PHA + PMA showed no IL-12 expression but stimulation with lipopolysaccharide induced higher IL-12 mRNA in patients than controls (83.0 +/- 14.0%versus 33.0 +/- 4.0%; P = 0.005). Our data suggest that an inflammatory cytokine signature exists in TA with a key role for TNF-alpha, IL-4, IL-10 and IL-12 in different pathological processes of the disease.

Direct medical costs of monitoring and treating patients with Takayasu arteritis in Italy

The study provides the first overall estimate of the costs of Takayasu arteritis (TA) monitoring and treatment in Italy and highlights the differences in cost components across defined subgroups of patients. We estimated resource consumption and direct costs from the Italian National Health Service perspective. We conducted a multicenter, prospective study in 12 medical departments. All the 67 patients recruited met the American College of Rheumatology 1990 criteria for the classification of TA and were followed up for 1 year. For the purpose of analysis they were divided into two groups: "active TA" (patients who had taken at least one drug specific for TA treatment, i.e., corticosteroids and/or cytotoxics), and "inactive TA" (all the remaining patients). The average cost per year was Euro 4,079. Patients with active TA (Euro 5,055) had a significantly higher mean cost per year than those with inactive TA (Euro 1,328). In particular, significant differences were found for costs in general practitioner consultations, laboratory tests, and hospital admissions. These findings suggest that patients not only experience more complications requiring hospital admissions but also see general practitioners more often during the active stage of the disease, presumably in order to obtain a prescription for laboratory tests.

Takayasu's arteritis: results of a university hospital of 45 patients in Turkey

BACKGROUND

Takayasu's arteritis (TA) is a rare disease which appears to be most common in East Asia. However, the disease has been reported to be worldwide. The clinical features of the disease can show variations in different geographical areas. The aim of this study is to evaluate clinical, laboratory and radiological features and the outcome of patients with TA in our hospital.

METHODS

The hospital files of patients who were followed with the diagnosis of TA between the years 1973 and 2003 in Hacettepe University Hospital were retrospectively evaluated.

RESULTS

Male/female ratio was 5/40, and the mean age was 34 years (18-59). Constitutional symptoms were present in 71% of the patients. Claudication and pallor of the extremity, decreased extremity pulsations, arterial hypertension, and arterial bruits were present in 44%, 56%, 58%, and 27% of the patients, respectively. Aortic valvular insufficiency, abdominal aortic aneurism, and cardiomegaly were present in four, one, and four patients, respectively. The initial complaint of six patients was cerebrovascular events. The distribution of the patients according to the angiographic findings was as follows, 56% Type I, 18% Type II, 22% Type III, and 4% Type IV arteritis. The need for vascular surgical interventions were significantly less common in patients who were treated with immunosuppressives plus alternate dose steroids (6%) compared to patients who were treated only with antiaggregant agents (33%).

CONCLUSIONS

The demographic and angiographic findings of our patients were similar to previous observations from Japan and Italy, and disclose distinct clinical features in comparison to other Asian countries. Alternate-day glucocorticoids plus cytotoxic drugs may be beneficial and safe in patients with TA.

Takayasu?s arteritis and chronic autoimmune thyroiditis in a patient with type 1 diabetes mellitus

Takayasu's arteritis is a rare, chronic inflammatory disease of unknown origin, affecting the walls of the aorta and its main branches, as well as coronary and pulmonary arteries. The inflammation of the arteries may lead to stenosis, occlusions, dilatations, and aneurysms of involved vessels. It is relatively common in Asia and the Far East but is rare in the Western Hemisphere. We present the case of a 36-year-old white woman with a history of type 1 diabetes mellitus and chronic autoimmune thyroiditis who complained of easy fatigability in the upper limbs, with absent arterial pulses in the upper limbs and audible bruits over both subclavian and left common carotid arteries. Intra-arterial digital subtraction angiography revealed complete or subtotal obliteration of the aortic arch's branches, with the brain supplied with blood only by the left vertebral artery originating directly from the aortic arch. We diagnosed Takayasu's arteritis with abnormal origin of the left vertebral artery. To the best of our knowledge, our case of Takayasu's arteritis and chronic autoimmune thyroiditis in a type 1 diabetic patient with abnormal origin of the left vertebral artery is the first one ever described.

Les aortites inflammatoires

PRINCIPLE AND OTHER CAUSES: Takayasu's arteritis, giant cell arteritis and Behçet's disease are the three main causes of inflammatory aortitis. More rarely, aortitis can be observed in Cogan's syndrome, atrophic polychondritis, sarcoidosis, ankylosing spondylitis and in rheumatoid arthritis. RISKS OF PROGRESSION: Takayasu's arteritis is distinct with the development of stenotic lesions of the aorta. With the other causes, aortitis can be complicated by ectasia or even aneurysm, with the risk of rupture. Indeed, during giant cell arteritis, patients are 17 times more likely to develop thoracic aortic aneurysm. Aortic regurgitation is a frequent complication of inflammatory aortitis. Sometimes, aortitis is only manifested by general signs such as fever or an inflammatory syndrome. SUPPLEMENTARY EXPLORATIONS: Recent advances in diagnosis and follow-up of patients with inflammatory aortitis concern the use of non-invasive imaging techniques: Doppler ultrasonography, computed tomography with injection of a contrast product and magnetic resonance imaging, which currently replace the aortography.

DIAGNOSTIC PROBLEMS

Infectious aortitis, inflammatory atheromatous aneurysm and retroperitoneal fibrosis are sometimes misleading differential diagnoses.

[33-year old patient with thoraco-abdominal pain and differences of blood pressure]

We report on a 33-year-old women with ulcerative colitis, who presented with inspiratory thoracic pain due to perimyocarditis. Furthermore, postprandial abdominal pain associated with diarrhea and different blood pressure values on both arms were recorded. Computed tomography revealed embolism of the pulmonal arteries and angiography demonstrated stenoses of the subclavian and renal arteries and the celiac trunc suggesting the diagnosis of Takayasu's arteritis. A coronary or infectious etiology could be excluded. Since a coincidence of Takayasu's arteritis and ulcerative colitis has been reported in the literature, abdominal pain and diarrhea can either be explained by the inflammatory bowel disease or by chronic ischemia due to intestinal vasculitis. Differential diagnosis will be facilitated by the future course of the disease.

Aortoarteritis and sensorineural hearing loss in an adolescent black male

We describe an adolescent male having sudden onset of sensorineural hearing loss. Evaluation led to the discovery of marked aortoarteritis. This patient exhibited findings of both Takayasu arteritis and Cogan syndrome. This report emphasizes the importance of ensuring a thorough systemic evaluation in individuals having sudden hearing loss.

Anti-tumor necrosis factor therapy in patients with difficult to treat Takayasu arteritis

OBJECTIVE

Granulomatous inflammation is a typical feature of Takayasu arteritis (TA), and tumor necrosis factor (TNF) is important in the formation of granulomas. In this study, we assessed therapy with anti-TNF agents in patients with TA that was not controlled by glucocorticoid therapy or other immunosuppressants.

METHODS

We conducted an open-label trial of anti-TNF therapy at 3 academic medical centers over a period of 4.25 years. Fifteen patients with active, relapsing TA (median 6 years) were selected. Seven received etanercept (later changed to infliximab in 3 patients), and 8 received infliximab. Relapses had occurred in all patients while they were receiving glucocorticoids and, in 13 patients, additional immunosuppressive drugs. No other agents were added to the treatment regimen concurrently with anti-TNF. If patients were receiving cytotoxic agents, the dosage was not increased. Clinical symptoms were recorded, and physical examinations, laboratory studies, and serial magnetic resonance imaging were performed.

RESULTS

The median daily dose of prednisone required to maintain remission prior to anti-TNF therapy was 20 mg. Ten of the 15 patients achieved complete remission that was sustained for 1-3.3 years without glucocorticoid therapy. Four patients achieved partial remission, with a >50% reduction in the glucocorticoid requirement. At a median of 12 months of followup, the median dose of prednisone was 0. Therapy failed in 1 patient. In 9 of the 14 responders, an increase in the anti-TNF dosage was required to sustain remission. Two relapses occurred during periods when anti-TNF therapy (etanercept) was interrupted, but remission was reestablished upon reinstitution of therapy.

CONCLUSION

In this pilot study of relapsing TA, addition of anti-TNF therapy resulted in improvement in 14 of 15 patients and sustained remission in 10 of 15 patients, who were able to discontinue glucocorticoid therapy. Anti-TNF may be a useful adjunct to glucocorticoids in the treatment of TA. Our results justify a randomized, controlled clinical trial of anti-TNF therapy for TA.

[Aortitis after G-CSF injections]

INTRODUCTION

Aortitis consists in aortic wall inflammation from infectious or non infectious cause. It may lead to aortic aneurysm with a risk of rupture, which is life-threatening and may justify surgical procedures. The cause of the aortitis is sometimes obscure.

CASE REPORT

We report the case of a 55 years old woman who developed acute aortitis of the descending aorta after G-CSF (granulocyte-colony stimulating factor) injections for blood stem cells graft. No cause was found to the aortitis, the evolution was favorable after corticosteroid treatment, without aneurysm at six months.

CONCLUSION

The present case rises the question of G-CSF (Neupogen responsibility in aortic lesions. Neutrophilic mediated diseases (Sweet's syndrome, pyoderma gangrenosum) and leukocytoclastic vasculitis were reported after G-CSF therapy. Neutrophils induced by G-CSF injections present functional abnormalities which may play a role in the pathogenesis of these diseases.

Subclavian Artery Stenosis: Prevalence, Risk Factors, and Association With Cardiovascular Diseases

OBJECTIVES

The objective was to assess the prevalence of subclavian artery stenosis (SS) in four cohorts (two free-living and two clinical populations) and determine both risk factors for this condition and the association with other cardiovascular conditions.

BACKGROUND

The prevalence of SS in the general population is unknown, and its association with risk factors and other cardiovascular diseases is not well-established.

METHODS

A total of 4,223 subjects (2,975 from two free-living cohorts and 1,248 from two clinical cohorts) were included in this cross-sectional analysis. Subclavian artery stenosis was defined as > or =15 mm Hg interarm pressure difference.

RESULTS

The prevalence of SS was 1.9% in the free-living cohorts and 7.1% in the clinical cohorts; SS was significantly (p < 0.05) associated with past smoking (odds ratio [OR] = 1.80), current smoking (OR = 2.61), and higher levels of systolic blood pressure (OR = 1.90 per 20 mm Hg). Higher levels of high-density lipoprotein (HDL) cholesterol were inversely and significantly associated with SS (OR = 0.87 per 10 mg/dl). In regression analyses relating SS to other cardiovascular diseases, the only significant finding was with peripheral arterial disease (PAD) (OR = 5.11, p < 0.001).

CONCLUSIONS

Significant SS is present in approximately 2% of the free-living population and 7% of the clinical population. Additionally, SS is correlated with current and past smoking histories, systolic blood pressure, HDL levels (inversely), and the presence of PAD. These findings suggest that bilateral brachial blood pressure measurements should routinely be performed in patients with an elevated risk profile, both to screen for SS, and to avoid missing a hypertension or PAD diagnosis because of unilateral pressure measurement in an obstructed arm.

Non-invasive imaging in the diagnosis and management of Takayasu's arteritis

OBJECTIVES

Takayasu's arteritis (TA) is a rare disease, in which early diagnosis and assessment of treatment efficacy remain a problem. Signs and symptoms may be non-specific and conventional blood tests unreliable, with vascular inflammation often persisting in the face of a normal acute phase response. The current "gold standard" investigation, x ray angiography, is invasive and only identifies late, structural changes in vessels. Recently, non-invasive imaging methods have shown promise in the assessment of patients with TA.

METHODS

The invasive and non-invasive imaging performed on all patients in the rheumatology department at the Hammersmith Hospital between May 1996 and May 2002 who fulfilled the ACR criteria for TA were reviewed. All patients were clinically active at diagnosis and were treated with high dose oral prednisolone and additional oral or intravenous immunosuppression.

RESULTS

Non-invasive imaging methods ([(18)F]fluorodeoxyglucose positron emission tomography ([(18)F]FDG-PET) and magnetic resonance imaging (MRI)) provided important additional information about disease activity ([(18)F]FDG-PET) and progression of vessel wall thickening (MRI) when compared with x ray angiography.

CONCLUSIONS

Non-invasive imaging methods provide useful additional information towards the diagnosis and management of TA. Such techniques may allow earlier diagnosis and more accurate assessment of response to treatment than conventional clinical assessment and/or angiography. Non-invasive imaging is likely to be useful in the management of other large vessel vasculitides.

Optic neuropathy: puls/minus

A 26-year-old Asian woman presented with bilateral disk swelling, retinal exudates and infarcts. Evaluation found the underlying cause of the hypertensive optic neuropathy to be renal artery stenosis due to Takayasu's arteritis.

Anterior uveitis in a child with Takayasu's arteritis

Takayasu's arteritis is a rare idiopathic arteriopathy that produces narrowing and eventually closure of affected blood vessels. Ocular symptoms typically occur late in the disease process in those individuals who have severe involvement of the aortic arch and the carotid arteries. Visual loss typically occurs as a result of either systemic hypertension or concomitant ocular hypo-perfusion. We describe an unusual case of Takayasu's arteritis presenting in a child who complained of painful blurred vision. In this individual, no carotid artery disease was identified on vascular imaging and no evidence of impairment of ocular perfusion was demonstrable. Vision loss in this instance was due to anterior uveitis and cystoid maculopathy. These are atypical and rarely described features of Takayasu's arteritis. The patient responded well to anti-inflammatory treatment and his symptoms resolved. The clinical significance of these findings are discussed and the relevant literature reviewed.

Imagerie des pathologies vasculaires spécifiques

The diagnosis of vascularitis should be proposed when a concentric and regular thickening of the wall of the aorta or one of its branches is observed or when there is late enhancement of the arterial wall, on sites which are usually free from atheromatous lesions and in a young patient. The radiologist must be aware of the associated clinical signs: oral and genital ulcerative lesions in the Behçet syndrome; finger necrosis in a young male smoker in Buerger disease; hip and shoulder arthropathy and headache in a 70 Year old female and Horton disease; pulseless upper limbs and inflammatory syndrome in a young adult for the Takayasu arteritis. The diagnosis of popliteal entrapment or adventitial cyst should be proposed in young patients without atheromatous lesions.

Comment, quand et pourquoi réaliser une imagerie de l’aorte thoracique chez l’adulte ?

CT, MRI and transesophageal echocardiography have become the standard of reference for evaluation of the thoracic aorta. Angiography is mainly performed as a presurgical procedure. Congenital pathologies observed during adulthood include coarctation, patent ductus arteriosus, and aberrant retroesophageal subclavian arteries. Imaging plays a major role for diagnosis and management of patients with acute aortic syndromes: intramural hematoma, dissection, penetrating ulcer and nondissecting aneurysms. Cross sectional imaging of the thoracic aortic wall allows evaluation of inflammatory diseases of the aorta or aortitis.

Takayasu arteritis of subclavian artery in a Caucasian

Takayasu arteritis, an inflammatory and obliterative disease of medium and large arteries, is classified as a giant cell arteritis. It has a predilection for the aortic arch, its main branches, and coronary and pulmonary arteries. The early symptoms of Takayasu arteritis may be mainly systemic and may resemble polymyalgia rheumatica. The etiology is unknown but autoimmunity has been suggested to play a role. Diagnosis is based on symptoms, physical findings, and imaging, because tissue diagnosis is rarely feasible. Unlike atherosclerotic vascular disease, Takayasu arteritis affects primarily, but not exclusively, young women. Contrary to earlier reports, it is not limited to the women of Japanese origin but is present worldwide. The current report is of a Caucasian woman who presented with nonspecific complaints of upper back pain, weakness, malaise, and fatigue. Her physical examination revealed absent left radial pulse and a blood pressure differential, later confirmed by radiological imaging studies to be due to left subclavian artery stenosis consistent with Takayasu arteritis. The presentation and management of the patient is described, and Takayasu arteritis is succinctly reviewed.

Renal revascularization in Takayasu arteritis–induced renal artery stenosis

PURPOSE

This study was undertaken to define the long-term effects of renal revascularization on blood pressure, and renal and cardiac function in patients with Takayasu arteritis-induced renal artery stenosis (TARAS).

METHODS

Twenty-seven patients (25 women; mean age, 27 years) with TARAS underwent intervention. Primary, primary assisted, and secondary patency rates were determined, and the late effects on blood pressure, renal and cardiac function, and survival were analyzed.

RESULTS

All patients had hypertension (mean blood pressure, 167/99 mm Hg; 2.5 antihypertensive medications per patient). Mean estimated glomerular filtration rate in patients not receiving hemodialysis was 76 mL/min, and in five patients serum creatinine concentration was greater than 1.5 mg/dL. Three patients were hemodialysis-dependent, and two had intractable congestive heart failure. Forty interventions were performed, including 32 aortorenal bypass procedures, two repeat implantations, four nephrectomies, and two transluminal angioplasty procedures. Postoperative morbidity was 19%. There were no deaths. During follow-up (mean, 68 months), three graft stenoses, all due to intimal hyperplasia, and three graft occlusions occurred. Two of three graft stenoses were successfully revised. At 1, 3, and 5 years of follow-up, primary patency was 87%, 79%, and 79%, respectively; primary assisted patency was 93%, 89%, 89%, respectively; and secondary patency was 93%, 89%, and 89%, respectively. Intervention resulted in a decrease in blood pressure to a mean of 132/79 mm Hg (P<.0001), and the need for antihypertensive medications was reduced to one per patient (P<.01). Mean glomerular filtration rate increased to 88 mL/min (P<.005), and two patients no longer required hemodialysis. Congestive heart failure resolved in both patients, and did not recur. There were three deaths during follow-up, with 5-year and 10-year actuarial survival of 96% and 80%, respectively.

CONCLUSIONS

Renal revascularization to treat TARAS is durable, has a salutary effect on blood pressure, and enhances long-term renal and cardiac function. This response establishes renal revascularization as a successful and durable intervention for TARAS, and a benchmark to which other therapies should be compared.

Occlusion de branche veineuse rétinienne révélatrice d’une maladie de Takayasu

We report a case of branch retinal vein occlusion in a 28-year-old woman that revealed Takayasu's arteritis. Somatic examination showed humeral blood pressure asymmetry and an abdominal murmur; a biological inflammatory syndrome was noted. Abdominal aortography showed marked stenosis of the superior mesenteric artery. Three of the six diagnostic criteria of Takayasu's arteritis were present in our patient, sufficing to make the diagnosis. This is the first case reported of branch retinal vein occlusion revealing Takayasu's arteritis. It is to be added to the List of atypical initial manifestations of Takayasu's arteritis such as anterior ischemic optic neuropathy. Branch retinal vein occlusion is a rare enough occurrence in a 28-year-old patient to warrant further clinical investigation.

The role of 18F-FDG PET in characterising disease activity in Takayasu arteritis

Takayasu arteritis (TA) is a rare, sporadic and chronic inflammatory arteritis, which predominantly affects the aorta and its branches. Diagnosis can be difficult and there are limitations to the current diagnostic work-up. By detecting areas of active glucose metabolism present in active vasculitis, imaging with fluorine-18 fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) could potentially have a role in the management of TA. Our aim was to assess this role by reviewing 28 (18)F-FDG PET scans performed on 18 patients suspected of having TA. All patients had full clinical and laboratory assessment, cross-sectional imaging and angiography, and 16/18 satisfied the American College of Rheumatologists' criteria for TA. (18)F-FDG PET achieved a sensitivity of 92%, a specificity of 100%, and negative and positive predictive values of 85% and 100% respectively in the initial assessment of active vasculitis in TA. We conclude that (18)F-FDG PET can be used to diagnose early disease, to detect active disease (even within chronic changes) and to monitor the effectiveness of treatment.

Anti-annexin V antibodies in Takayasu's arteritis: prevalence and relationship with disease activity

Annexin V has an important role in the regulation of apoptosis and antibodies directed against it have been shown to lead to apoptosis of vascular endothelial cells. To evaluate the role of anti-annexin V antibodies (AA5A) in Takayasu's arteritis (TA), we investigated these antibodies in the sera of 66 TA patients, 50 healthy controls and in the follow-up sera of 12 active TA patients by enzyme-linked immunosorbent assay. The AA5A-positive patients were analysed further for the presence of anti-endothelial cell antibodies (AECA) and anticardiolipin antibodies (ACLA) to determine the relationship of AA5A with these autoantibodies. AA5A were observed in 36% (24/66) of the patients versus 6% (3/50) of the controls (P<0.001) and in 53% (19/36) of patients with active TA versus 17% (5/30) of those with inactive disease (P<0.01). Levels of AA5A were also observed to be significantly higher in patients with TA compared to controls (0.557 +/- 0.362 versus 0.259 +/- 0.069; P<0.0001) and in patients with active disease compared to those with inactive disease (0.700 +/- 0.403 versus 0.385 +/- 0.205; P<0.0001). In the follow-up study, 6/12 patients who became inactive during follow-up also showed normalization of AA5A levels. AECA and ACLA were detected in 54% (13/24) and 12% (3/24) of the AA5A-positive patients, respectively. Our results show that a significant proportion of TA patients have AA5A, which exhibit an association with AECA and because they have a correlation with disease activity thus appear to be involved in the disease pathogenesis.

Matrix metalloproteinases as novel disease markers in Takayasu arteritis

BACKGROUND

Takayasu arteritis (TA) is a chronic vasculitis that primarily affects large elastic arteries. Monitoring of disease activity is crucial because the disease tends to progress despite treatment with glucocorticoid and/or immunosuppressive agents. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have generally been used as disease activity markers, but these are nonspecific inflammatory markers and lack the sensitivity and specificity to accurately monitor the disease status. Given the histological findings characterized by destruction of elastic fibers, we hypothesized that matrix metalloproteinases (MMPs) could be useful as markers of disease activity in TA.

METHODS AND RESULTS

A consecutive series of 25 patients with TA were enrolled in this study. According to the National Institutes of Health criteria of disease activity, 11 were in an active phase and the remaining 14 were in remission. Circulating levels of MMP-2, MMP-3, and MMP-9 were determined by ELISA in all patients with TA and controls. MMP-2 levels were higher in patients with TA than in controls, but no correlation was found between serum MMP-2 and disease activity score. In contrast, MMP-3 and MMP-9 levels in patients with active disease were higher than in patients in remission and controls, and a positive correlation was demonstrated between circulating levels of MMP-3 or MMP-9 and disease activity score. The high levels of MMP-3 and MMP-9 improved when patients underwent remission.

CONCLUSIONS

The present results indicate that MMP-2 can be helpful in diagnosing TA and that MMP-3 and MMP-9 can be used as activity markers for TA.

Imaging diagnosis of subclavian steal syndrome secondary to Takayasu arteritis affecting a left-side subclavian artery

Takayasu arteritis (TA) is a rare form of large-vessel, chronic, occlusive vasculitis. It involves mainly aorta and its main branches, causing stenosis and/or obstruction. Its frequency has been estimated at 2.9 cases per 1 million people. Epidemiologically, it is found principally in young female patients and is more prevalent in Asia and Latin America. When there is severe stenosis or occlusion in subclavian artery, the phenomenon of subclavian steal syndrome (SSS) occurs, which usually causes symptoms of the vertebrobasilar territory because blood supply to the arm is sustained by reversal of flow in ipsilateral vertebral artery. We describe a case of SSS thought to be due to TA in a Mexican woman. Doppler ultrasound of neck vessels showed retrograde flow in left vertebral artery during systole. Digital subtraction angiography confirmed 30% stenosis of left subclavian artery with filling of left vertebral artery in retrograde direction. In presenting this case, we carried out a brief review of TA, main features in imaging diagnosis of SSS, and the infrequently reported association of TA with SSS.

Hypertension and Elevated ESR as Diagnostic Features of Takayasu Arteritis in Children

Takayasu arteritis (TA) is an inflammatory disease of the aorta and its branches. Delay in diagnosis is a common problem for adults and children. Although early manifestations are nonspecific (i.e., malaise, fever, anorexia, weight loss, myalgia, arthralgia/arthritis, elevated acute phase reactants), the clinical features that lead to diagnosis often appear suddenly and are related to vascular involvement. Hypertension, which is rare in children, and elevated ESR are found in most patients with TA. The authors hypothesized that these features, then, could be used as way to raise the clinical suspicion of TA. A total of 190 young patients with TA were retrospectively analyzed from local records and the literature to find the signs and symptoms associated with the disease that could be used to educate caregivers about when to suspect TA and to provide a screening tool for the disease. Hypertension and elevated ESR are found in most patients with TA. For this local study group, the sensitivity of this combination was 67%. Including the literature sources for which patient-specific information was available, the overall sensitivity was 65%. Thus, the combination of hypertension and elevated ESR in pediatric patients should merit further screening for TA, particularly in those with systemic complaints. Physical examination should focus on pulse abnormalities. Further evaluation should involve extensive imaging of the vascular system.

Takayasu arteritis presenting as a pulmonary-renal syndrome

Takayasu arteritis is an uncommon disease with a variety of presentations. We report a case of Takayasu arteritis with a presentation of a pulmonary-renal syndrome in a 22-year-old woman. She presented in acute respiratory failure with hemoptysis and acute renal failure; interestingly, however, the renal biopsy was normal. Magnetic resonance angiography (MRA) showed significant narrowing in the distal abdominal aorta with bilateral renal and common iliac artery occlusions. Thoracic and abdominal angiogram confirmed MRA findings of type IV Takayasu arteritis. Percutaneous transluminal angioplasty of the left renal artery normalized kidney function. The initial presentation of Takayasu arteritis as a pulmonary-renal syndrome with severe acute renal failure and diffuse pulmonary hemorrhage is unusual; to our knowledge, this has not been described previously in the literature. We provide a clinical review of Takayasu arteritis and a discussion of systemic manifestations pertinent to the case.

Granulomatous vasculitis

Granulomatous vasculitis is a subset of systemic necrotizing vasculitis and has granulomatous inflammation as the main histopathologic feature. Etiopathogenesis remains poorly understood, although recent advances suggest an important role for certain pro-inflammatory cytokines, such as tumor necrosis factor-alpha. They are a heterogeneous group of clinical disorders with protean manifestations. Serologic abnormalities are present, and the presence of granular cytoplasmic staining-antineutrophil cytoplasmic antibodies is most important and is particularly useful for the diagnosis of active Wegener's granulomatosis. Corticosteroids and cyclophosphamide remain very useful in the treatment of most of these disorders.

Takayasu's arteritis: management of left main stem stenosis

Takayasu arteritis is a chronic vasculitis involving the aorta and its main branches, the pulmonary arteries, and the coronary tree, and needs to be considered in a young patient with angina, in particular when pulses are absent. This case illustrates the limitations of exercise testing in diagnosing the extent of coronary artery disease and the risks associated with coronary angiography in patients with inflammatory disease in the left main stem coronary artery. It also highlights the novel use of non-invasive scanning with positron emission tomography using 18-fluorodeoxyglucose in assessing remission from this disease. Revascularisation was performed with percutaneous transluminal coronary angioplasty and stenting as an emergency procedure, but treatment of the restenosis with directional atherectomy was based on a review of the available literature. The lymphocytic alveolitis seen in this patient has not been previously described in Takayasu's disease.

Malignant hypertension as a presenting symptom of Takayasu arteritis

We present an unusual case of malignant hypertension in a 20-year-old white woman. One week before hospitalization, she experienced occasional abdominal pain and claudication of both legs; otherwise, she had no remarkable medical history, including no history of high blood pressure. The origin of the patient's hypertension was renovascular, and the vascular injury was due to vasculitis of the large arteries. The combination of a difference in blood pressure between the patient's arms, angiographic findings, elevated erythrocyte sedimentation rate, and lack of markers for specific vasculitis led to the diagnosis of Takayasu arteritis. Surgical intervention was successful.