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

Imaging modalities used in diagnosis and follow-up of patients with Takayasu’s arteritis

Background/aim

Takayasu’s arteritis (TA) is a rare, large-vessel vasculitis of unknown etiology, affecting aortic arch, and its main branches. Noninvasive imaging methods are frequently used in diagnosis and follow-up in Takayasu’s arteritis. Studies investigating optimal timing of follow up imaging are rare. This study is aimed to investigate the radiologic changes in vascular involvements of Takayasu’s arteritis patients one year after diagnosis.

Materials and methods

Database of our Vasculitis Center was analyzed retrospectively and 97 patients were included into the study. Demographic, clinical, radiological, and therapeutic findings of patients were recorded. Patients with follow-up imaging after approximately one year of diagnosis were recruited into further analysis. Radiological changes and the effect of different immunosuppressive agents on vascular involvements were investigated.

Results

Mean age and disease duration of patients were 43.0 and 9.0 years. The most commonly used imaging methods/modalities for the diagnosis of TA were computer tomography-angiography (CT-Ang) (58.8%), magnetic resonance-angiography (MR-Ang) (29.9%), and doppler ultrasonography (11.3%). Subclavian and common carotid arteries were the most frequently involved vessels. Fifty-three patients underwent follow-up imaging after one year of diagnosis and, in 64% of patients, same imaging method had been used. MR-Ang (62.3%) and CT-Ang (35.9%) were the most preferred follow-up imaging studies. Sixty-eight percent of patients had stable vascular involvement, 28% had progression, and 4% had regression. No difference was found in radiological changes regarding patients with usage of different immunosuppressive agents (P = 0.634). There was no association between the change in serum acute phase reactants and radiological disease activity.

Conclusion

The most commonly used imaging modality for the diagnosis of TA was CT-Ang, whereas MR-Ang was the most preferred for follow-up. Almost 30% of TA patients in our Vasculitis Center had progression at around one year concordant with previous literature. A follow-up imaging at around one year of treatment seems feasible in management of TA.

The Immunopathology of Giant Cell Arteritis Across Disease Spectra

Giant cell arteritis (GCA) is a granulomatous systemic vasculitis of large- and medium-sized arteries that affects the elderly. In recent years, advances in diagnostic imaging have revealed a greater degree of large vessel involvement than previously recognized, distinguishing classical cranial- from large vessel (LV)- GCA. GCA often co-occurs with the poorly understood inflammatory arthritis/bursitis condition polymyalgia rheumatica (PMR) and has overlapping features with other non-infectious granulomatous vasculitides that affect the aorta, namely Takayasu Arteritis (TAK) and the more recently described clinically isolated aortitis (CIA). Here, we review the literature focused on the immunopathology of GCA on the background of the three settings in which comparisons are informative: LV and cranial variants of GCA; PMR and GCA; the three granulomatous vasculitides (GCA, TAK, and CIA). We discuss overlapping and unique features between these conditions across clinical presentation, epidemiology, imaging, and conventional histology. We propose a model of GCA where abnormally activated circulating cells, especially monocytes and CD4+ T cells, enter arteries after an unknown stimulus and cooperate to destroy it and review the evidence for how this mechanistically occurs in active disease and improves with treatment.

Serum complement 3 is a potential biomarker for assessing disease activity in Takayasu arteritis

BACKGROUND

Takayasu arteritis (TA) is a rare disease, lacking convenient and feasible biomarkers to identify disease activity. We aimed to evaluate the value of complements in distinguishing active TA.

METHODS

Consecutive patients were enrolled from the prospective East China TA cohort from April 2008 to June 2019. Patients were divided into two groups according to their baseline Kerr score. The value of complements and other biomarkers in identifying disease activity were analysed with cluster analysis, ROC curves, and combined tests. An independent group of patients from July 2019 to December 2019 were employed to validate the results.

RESULTS

Of the enrolled 519 patients, 406 (72.2%) cases were identified as active disease. Higher erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-6 (IL-6), and complement 3 (C3) levels were observed in the active group. Elevated C3 (≥ 1.085 g/L) had a high value to identify active TA with a sensitivity of 69.9%, specificity of 66.7%, and AUC of 0.715. Combining the CRP (≥ 10.65 g/L; sensitivity, 50.7%; specificity, 82.4%) and C3, the sensitivity could be improved to 85.1% in parallel test and the specificity could be improved to 94.1% in serial test. Validation was further performed to confirm the value of C3 for disease activity assessment. The accuracy of the parallel test of CRP and C3 in external validation with independent 53 TA cases was 72.73% with the AUC of 0.721.

CONCLUSION

Elevated C3 could effectively evaluate the disease activity of TA, and C3 combining with CRP could further improve the disease activity evaluation.

Clinical features of large vessel vasculitis (LVV): Elderly-onset versus young-onset

OBJECTIVES

We compared large vessel vasculitis (LVV) clinical features between age groups.

METHODS

We retrospectively examined clinical features and therapies in 41 LVV patients at our hospital from January 2010 to March 2020. We compared two patient groups, elderly (≥50 years) and young (<50 years).

RESULTS

Of all patients, 29 were elderly and 12 were young. In the younger group, upper extremity symptoms (p <.05), bruits (p <.01), and cardiovascular complications (p <.01) were more common. Of the elderly group, 7 (24%) met classification criteria for giant cell arteritis while none of the younger group met these criteria; however, 10 (83%) of the younger group and 3 (10%) of the elderly group met the ACR classification criteria for Takayasu arteritis (p <.01). In the elderly group, 16 patients (66%) met no criteria (p <.01). There were no significant differences in laboratory findings but imaging showed a significantly higher incidence of head and neck artery lesions in the younger group (p <.05). The younger group was more likely to receive additional tocilizumab (p <.01) and cardiovascular complications were more likely to occur in younger patients (p < .01).

CONCLUSION

LVV clinical features differed between elderly- and young-age-onset groups.

Comprehensive analysis of immunoglobulin and clinical variables identifies functional linkages and diagnostic indicators associated with Behcet's disease patients receiving immunomodulatory treatment

BACKGROUND

Behcet's disease (BD) is a relapsing systemic vascular autoimmune/inflammatory disease. Despite much effort to investigate BD, there are virtually no unique laboratory markers identified to help in the diagnosis of BD, and the pathogenesis is largely unknown. The aim of this work is to explore interactions between different clinical variables by correlation analysis to determine associations between the functional linkages of different paired variables and potential diagnostic biomarkers of BD.

METHODS

We measured the immunoglobulin proteome (IgG, IgG1-4, IgA, IgA1-2) and 29 clinical variables in 66 healthy controls and 63 patients with BD. We performed a comprehensive clinical variable linkage analysis and defined the physiological, pathological and pharmacological linkages based on the correlations of all variables in healthy controls and BD patients without and with immunomodulatory therapy. We further calculated relative changes between variables derived from comprehensive linkage analysis for better indications in the clinic. The potential indicators were validated in a validation set with 76 patients with BD, 30 healthy controls, 18 patients with Takayasu arteritis and 18 patients with ANCA-associated vasculitis.

RESULTS

In this study, the variables identified were found to act in synergy rather than alone in BD patients under physiological, pathological and pharmacological conditions. Immunity and inflammation can be suppressed by corticosteroids and immunosuppressants, and integrative analysis of granulocytes, platelets and related variables is likely to provide a more comprehensive understanding of disease activity, thrombotic potential and ultimately potential tissue damage. We determined that total protein/mean corpuscular hemoglobin and total protein/mean corpuscular hemoglobin levels, total protein/mean corpuscular volume, and plateletcrit/monocyte counts were significantly increased in BD compared with controls (P < 0.05, in both the discovery and validation sets), which helped in distinguishing BD patients from healthy and vasculitis controls. Chronic anemia in BD combined with increased total protein contributed to higher levels of these biomarkers, and the interactions between platelets and monocytes may be linked to vascular involvement.

CONCLUSIONS

All these results demonstrate the utility of our approach in elucidating the pathogenesis and in identifying novel biomarkers for autoimmune diseases in the future.

Pulseless and blindness - An ophthalmologist's role in diagnosing Takayasu arteritis: Case series and brief review of literature

PURPOSE

To study the initial presenting symptoms of Takayasu arteritis in unsuspecting patients.

METHODS

The underlying systemic condition was suspected in five subjects at a tertiary eye care center based on their ocular features. Similar reports in the literature were collated and analyzed for the common presenting features of undiagnosed Takayasu arteritis.

RESULTS

The most common presenting ophthalmic symptoms were vision loss (86.8%), ocular pain (21.1%), eye redness (18.4%), and photophobia (5.3%). There were no reports of glaucoma at presentation. Pupillary abnormalities (42.1%), microaneurysms in retinal mid-periphery (42.1%) and venous engorgement (28.9%) were the most common presenting signs. Despite systemic symptoms such as headache, dizziness, fatigue, weakness, arm claudication, fever, anorexia, weight loss, and syncope in 76.3% of cases, the patients in this series had never sought medical care before developing ocular symptoms.

CONCLUSION

Takayasu arteritis may remain latent until the ophthalmic complications compel the patient to seek medical attention. Hence, ophthalmologists need to be aware of the seemingly innocuous presentations of the disease.

Coexistence of Takayasu's Arteritis in Patients with Inflammatory Bowel Diseases

Background

Takayasu's arteritis (TA) and inflammatory bowel disease (IBD) are chronic inflammatory granulomatous disorders that have rarely been concomitantly reported in case reports and small case series.

Objective

We report a series of seven cases of TA and IBD association in two referral centers with a comprehensive review of literature.

Methods

We analyzed retrospectively the electronic medical charts of TA-IBD patients at the University Hospital of São Paulo, Brazil, and at the Sheba Medical Center at Tel Aviv University, Israel.

Results

Overall, five patients had Crohn's disease (DC) and two had ulcerative colitis (UC), and they were mostly female and non-Asian. All patients developed IBD first and, subsequently, TA. Two underwent colectomy and one ileocecectomy due to IBD activity, while three required cardiovascular surgery due to TA activity. Most patients are currently in clinical remission of both diseases with conventional drug treatment.

Conclusion

Although the coexistence of TA and IBD is uncommon, both seem to be strongly associated through pathophysiological pathways.

Detection of mural inflammation with low b-value diffusion-weighted imaging in patients with active Takayasu Arteritis

OBJECTIVES

To evaluate the performance of low b-value diffusion-weighted imaging (DWI) for detection of inflamed vessels in active Takayasu arteritis (TA).

METHODS

Forty patients with active TA involving the thoracic aorta and its super-aortic branches underwent low b-value (50 s/mm²) DWI, T2-weighted imaging (T2WI), and delayed enhancement T1-weighted imaging (DEI). Corresponding images on these 3 sequences at the same diseased level were evaluated qualitatively and quantitatively using Friedman and Kruskal-Wallis test, and the agreement between them in detection of inflamed vessels was assessed using Cochran's Q test.

RESULTS

The overall image quality of DEI, DWI, and T2WI was scored 7.97 ± 1.15, 7.32 ± 1.73, and 6.51 ± 1.69 respectively. The score of DEI and DWI was higher than that of T2WI (p < 0.001). The quality of blood suppression was rated higher in DWI than T2WI and DEI (p < 0.001). Both the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the diseased vessel walls measured on DEI and DWI were significantly higher than those on T2WI (p < 0.001). However, there was no significant difference in SNR and CNR between DEI and DWI (p = 0.283 and 0.063). In detection of mural inflammation, significant advantage was observed when comparing the findings from DEI/DWI to those from T2WI (p < 0.001). But no significant difference was found between the findings of DWI and DEI (p > 0.99).

CONCLUSIONS

Low b-value DWI may be used as a promising alternative to DEI for detecting inflamed vessels in active TA.

KEY POINTS

• Currently, the most widely used imaging modality in detection of mural inflammation is contrast-enhanced MRI. • Low b-value DWI is shown comparable to contrast-enhanced MRI and superior to T2WI in identifying mural inflammation in patients with active Takayasu arteritis. • Low b-value DWI is a fast and unenhanced MRI technique which may potentially replace contrast-enhanced MRI in identifying disease activity of Takayasu arteritis.

Identification of Novel Serological Autoantibodies in Takayasu Arteritis Patients Using HuProt Arrays

To identify novel autoantibodies of Takayasu arteritis (TAK) using HuProt array-based approach, a two-phase approach was adopted. In Phase I, serum samples collected from 40 TAK patients, 15 autoimmune disease patients, and 20 healthy subjects were screened to identify TAK-specific autoantibodies using human protein (HuProt) arrays. In phase II, the identified candidate autoantibodies were validated with TAK-focused arrays using an additional cohort comprised of 109 TAK patients, 110 autoimmune disease patients, and 96 healthy subjects. Subsequently, the TAK-specific autoantibodies validated in phase II were further confirmed using western blot analysis. We identified and validated eight autoantibodies as potential TAK-specific diagnostic biomarkers, including anti-SPATA7, -QDPR, -SLC25A2, -PRH2, -DIXDC1, -IL17RB, -ZFAND4, and -NOLC1 antibodies, with AUC of 0.803, 0.801, 0.780, 0.696, 0.695, 0.678, 0.635, and 0.613, respectively. SPATA7 could distinguish TAK from healthy and disease controls with 73.4% sensitivity at 85.4% specificity, while QDPR showed 71.6% sensitivity at 86.4% specificity. SLC25A22 showed the highest sensitivity of 80.7%, but at lower specificity of 67.0%. In addition, PRH2, IL17RB, and NOLC1 showed good specificities of 88.3%, 85.9%, and 86.9%, respectively, but at lower sensitivities (<50%). Finally, DIXDC1 and ZFAND4 showed moderate performance as compared with the other autoantibodies. Using a decision tree model, we could reach a specificity of 94.2% with AUC of 0.843, a significantly improved performance as compared with that by each individual biomarker. The performances of three autoantibodies, namely anti-SPATA7, -QDPR, and -PRH2, were successfully confirmed with western blot analysis. Using this two-phase strategy, we identified and validated eight novel autoantibodies as TAK-specific biomarker candidates, three of which could be readily adopted in a clinical setting.

Major Aortic Reconstruction with the Replacement of Supra-Aortic Branches: Successful Surgical Treatment of Takayasu Arteritis Initially Presented as Congestive Heart Failure

Takayasu arteritis (TA) is a rare, large vessel vasculitis that affects aorta, its major branches, and occasionally pulmonary arteries. Patients with TA can present with constitutional features and/or various symptoms and signs caused by morphological changes in the blood vessels affected by the inflammatory process. Corticosteroids (CS) and immunosuppressives (IS) are the first line treatment for active TA. Open surgery remains a treatment of choice for TA patients with moderate-to-severe aortic regurgitation (AR) and ascending aortic aneurysm (AAA). We present a 26-year-old female diagnosed with an advanced stage of TA, initially presented as congestive heart failure. Due to a progressive course of the disease (AR 3+, AAA 5.5 cm), surgery of the Aortic valve and root (Bentall procedure), with total arch reconstruction and replacement of supra-aortic branches was performed. The patient has had an uneventful recovery during the postoperative course with no complications at one year follow-up. Normal left ventricle (LV) diameter, LV ejection fraction 67%, and a trace of AR were seen on the last echocardiography.

High expression of pro-inflammatory cytokine genes IL-1β and IL-1R2 upon TLR4 activation in Takayasu arteritis

Toll-like receptors (TLR) 4 and its endogenous ligands are highly expressed in aorta. In the present study, we have explored the effect of TLR-4 activation by pro-inflammatory and angiogenic factors in PBMCs of patients with Takayasu Arteritis (TA). In the screening cohort, PBMCs of TA (n = 6) and healthy controls (n = 6) were stimulated with LPS and cultured. mRNA expression of 84 genes were quantitated by RT2 Profiler™ PCR Array kit in PBMCs. Validation set of additional PBMCs from TA (n = 7) and healthy controls [HC) (n = 7) were then stimulated with LPS to study expression of selected genes with delta Ct > 0.1 in the screening cohort. Significant gene expressions were correlated with Indian Takayasu arteritis activity scores (ITAS 2010). Increased expression of CCL2 was observed only in unstimulated PBMCs of patients with TA [median relative difference (RD) of 2.37] as compared to HC (RD 1.37, p < 0.03) in validation cohort, while stimulation with TLR4 ligand led to increased mRNA expression of IL-1β (RD 7.9, p < 0.028) and IL-1R2 (RD 0.08 p < 0.013) genes as compared to that of HC [RD of 5.32 for IL-1β and 0.01 for IL-1R2, respectively] in validation cohort. TLR4 activation also led to significantly higher expression of HPSE, TIMP1 and low expression of VEGFB, S1PR1, SERPINF1, ANGPLT4, ANGPT2, TIE1 and NOS3 genes in the screening cohort. But expression of VEGFB was not significant in validation cohort. The significant gene expressions, however, did not correlate with ITAS [ITAS2010 and ITAS-A (CRP)]. TLR4 activation leads to increased expression of IL-1β and IL-1R2 genes in PBMCs of patients with TA.

Takayasu Arteritis Causing Aortitis and Aortic Regurgitation: A Totally Tubular Case Report

•

Echocardiography is the first-line test to diagnose the presence and cause of AR.

•

Acute aortic syndromes should be excluded in patients with AR and a thickened aortic root.

•

Multimodal imaging with cardiac CT and MRI complement TTE and TEE to diagnose secondary causes of AR.

•

Aortitis is a potentially life-threatening disease, and is a rare cause of AR.

Childhood-onset versus adult-onset Takayasu arteritis: A study of 141 patients from Turkey

AIM

To compare childhood-onset (c-TAK) versus adult-onset Takayasu arteritis (a-TAK) patients for vascular involvement, disease activity, damage, and treatment.

METHODS

Patient charts from two tertiary-care centers of a pediatric and adult rheumatology clinic were reviewed. Adult patients diagnosed before the age of 18 years were included in the childhood-onset group. The activity was assessed with the physician's global assessment (PGA) and Indian Takayasu Clinical Activity Score (ITAS). The damage was evaluated with Takayasu Arteritis Damage Score (TADS) and Vasculitis Damage Index (VDI).

RESULTS

Twenty-four c-TAK (follow-up duration: 53 months) and 117 a-TAK patients (follow-up duration: 68 months) were analyzed. Aorta involvement was more prevalent (79% vs. 33%), and the median PGA score was higher in the c-TAK group (9 vs. 7), whereas the mean Indian Takayasu Arteritis Score was similar (14 vs. 13) among both groups. Median VDI score was lower for c-TAK patients (4 vs. 5), whereas TADS was similar for children and adults (8 vs. 8). Higher incidence of glucocorticoid related side-effects, a longer time to diagnosis and upper extremity claudication seemed to account for higher VDI scores in adults.

CONCLUSION

Aorta involvement was more common among children with TAK, whereas upper extremities were relatively spared. Biologic agents were used more commonly among children which may be explained by higher rates of aortic involvement. However, c-TAK patients did not have greater cumulative damage.

Takayasu Arteritis: a Systematic Review and Meta-Analysis of Test Accuracy and Benefits and Harms of Common Treatments

Objective

Takayasu’s arteritis (TAK) is a granulomatous large‐vessel vasculitis primarily affecting the aorta and its proximal branches. TAK can be a difficult disease to diagnose and manage given the rarity of the disease as well as current limitations in biomarkers, imperfect imaging modalities, and few randomized controlled trials.

Methods

In developing the American College of Rheumatology/Vasculitis Foundation guideline for the management of TAK, we performed an extensive systematic literature review to guide our recommendations. We included RCTs first. When RCTs were not available, we included observational studies that reported on patient‐important outcomes for the intervention and comparison. When studies with comparative data were not available, we included case series that present patient‐important outcomes for either the intervention or the comparison.

Results

Three hundred forty‐seven articles were included for full review to answer 27 population, intervention, comparison, and outcome questions related to TAK. Ten studies were evaluated that addressed the use of glucocorticoids (GCs), non‐GC nonbiologic therapies, as well as biologics in treating TAK. A total of 33 studies, including 8 comparative studies, were included to determine the test accuracy of commonly available diagnostic tests for TAK.

Conclusion

This comprehensive systematic review synthesizes and evaluates the benefits and harms of different treatment options and the accuracy of commonly used tests for the management of TAK.

Medium- and Large-Vessel Vasculitis

Systemic vasculitides are multisystem blood vessel disorders, which are defined by the size of the vessel predominantly affected, namely small, medium, or large vessels. The term "large vessel" relates to the aorta and its major branches; "medium vessel" refers to the main visceral arteries and veins and their initial branches. The most common causes of large-vessel vasculitis are giant cell arteritis and Takayasu arteritis, and those of medium-vessel arteritis are polyarteritis nodosa and Kawasaki disease. However, there is some overlap, and arteries of any size can potentially be involved in any of the 3 main categories of dominant vessel involvement. In addition to multisystem vasculitides, other forms of vasculitis have been defined, including single-organ vasculitis (eg, isolated aortitis). Prompt identification of vasculitides is important because they are associated with an increased risk of mortality. Left undiagnosed or mismanaged, these conditions may result in serious adverse outcomes that might otherwise have been avoided or minimized. The ethnic and regional differences in the incidence, prevalence, and clinical characteristics of patients with vasculitis should be recognized. Because the clinical presentation of vasculitis is highly variable, the cardiovascular clinician must have a high index of suspicion to establish a reliable and prompt diagnosis. This article reviews the pathophysiology, epidemiology, diagnostic strategies, and management of vasculitis.

Increased modifiable cardiovascular risk factors in patients with Takayasu arteritis: a multicenter cross-sectional study

BACKGROUND

Modifiable cardiovascular risk factors (MCRFs), such as those related to aerobic capacity, muscle strength, physical activity, and body composition, have been poorly studied in Takayasu arteritis (TAK). Therefore, the aim of the study was to investigate MCRFs and their relationships with disease status and comorbidities among patients with TAK.

METHODS

A multicenter cross-sectional study was conducted between 2019 and 2020, in which 20 adult women with TAK were compared with 16 healthy controls matched by gender, age, and body mass index. The following parameters were analyzed: aerobic capacity by cardiopulmonary test; muscle function by timed-stands test, timed up-and-go test, and handgrip test; muscle strength by one-repetition maximum test and handgrip test; body composition by densitometry; physical activity and metabolic equivalent by IPAQ, quality of life by HAQ and SF-36; disease activity by ITAS2010 and NIH score; and presence of comorbidities.

RESULTS

Patients with TAK had a mean age of 41.5 (38.0-46.3) years, disease duration of 16.0 (9.5-20.0) years, and a mean BMI of 27.7±4.5 kg/m². Three out of the 20 patients with TAK had active disease. Regarding comorbidities, 16 patients had systemic arterial hypertension, 11 had dyslipidemia, and two had type 2 diabetes mellitus, while the control group had no comorbidities. TAK had a significant reduction in aerobic capacity (absolute and relative VO₂ peak), muscle strength in the lower limbs, increased visceral adipose tissue, waist-to-hip ratio, reduced walking capacity, decreased weekly metabolic equivalent, and quality of life (P< 0.05) as compared to controls. However, there were no correlations between these MCRFs parameters and disease activity.

CONCLUSIONS

TAK show impairment in MCRFs; therefore, strategies able to improve MCRF should be considered in this disease.

Renovascular hypertension in children

Paediatric hypertension, defined as systolic blood pressure > 95th percentile for age, sex and height is often incidentally diagnosed. Renovascular hypertension (RVH) is responsible for 5-25% of hypertension in children. Renal artery stenosis and middle aortic syndrome can both can be associated with various conditions such as fibromuscular dysplasia, Williams syndrome & Neurofibromatosis type 1. This paper discusses the approaches to diagnosis and interventional management and outcomes of renovascular hypertension in children. Angiography is considered the gold standard in establishing the diagnosis of renovascular disease in children. Angioplasty is beneficial in the majority of patients and generally repeated angioplasty is considered more appropriate than stenting. Surgical options should first be considered before placing a stent unless there is an emergent requirement. Given the established safety and success of endovascular intervention, at most institutions it remains the preferred treatment option.

Symptomatic aortitis at giant cell arteritis diagnosis: a prognostic factor of aortic event

Background

Giant cell arteritis (GCA) is frequently associated with aortic involvement that is likely to cause life-threatening structural complications (aneurysm, dissection). Few studies have investigated the occurrence of these complications, and no predictive factor has been identified so far. The aim of this study was to investigate factors associated with the risk of aortic complications in a cohort of GCA aortitis.

Methods

Data of all patients managed with aortitis (CT or 18 FDG PET) at the diagnosis of GCA in five hospitals from May 1998 and April 2019 were retrospectively collected. Clinical features were compared according to the presence of aortitis symptoms. The predictive factors of occurrence or aggravation of aortic structural abnormalities were investigated.

Results

One hundred and seventy-one patients with GCA aortitis were included; 55 patients (32%) had symptoms of aortitis (dorsal/lumbar/abdominal pain, aortic insufficiency) at diagnosis. The median follow-up was 38 months. Aortic complications occurred after a median time of 32 months. There were 19 new aortic aneurysms or complications of aneurysm and 5 dissections. Survival without aortic complication was significantly different between the symptomatic and non-symptomatic groups (Log rank, p = 0.0003). In multivariate analysis the presence of aortitis symptoms at diagnosis (HR 6.64 [1.95, 22.6] p = 0.002) and GCA relapse (HR 3.62 [1.2, 10.9] p = 0.02) were factors associated with the occurrence of aortic complications.

Conclusion

In this study, the presence of aortitis symptoms at the diagnosis of GCA aortitis and GCA relapse were independent predictive factors of occurrence of aortic complications during follow-up.

Identification of susceptibility loci for Takayasu arteritis through a large multi-ancestral genome-wide association study

Takayasu arteritis is a rare inflammatory disease of large arteries. We performed a genetic study in Takayasu arteritis comprising 6,670 individuals (1,226 affected individuals) from five different populations. We discovered HLA risk factors and four non-HLA susceptibility loci in VPS8, SVEP1, CFL2, and chr13q21 and reinforced IL12B, PTK2B, and chr21q22 as robust susceptibility loci shared across ancestries. Functional analysis proposed plausible underlying disease mechanisms and pinpointed ETS2 as a potential causal gene for chr21q22 association. We also identified >60 candidate loci with suggestive association (p < 5 × 10^-5) and devised a genetic risk score for Takayasu arteritis. Takayasu arteritis was compared to hundreds of other traits, revealing the closest genetic relatedness to inflammatory bowel disease. Epigenetic patterns within risk loci suggest roles for monocytes and B cells in Takayasu arteritis. This work enhances understanding of the genetic basis and pathophysiology of Takayasu arteritis and provides clues for potential new therapeutic targets.

Treatment of middle aortic syndrome with thoraco-abdominal aortic bypass grafting assisted by endoscope in adult

Middle aortic syndrome (MAS) is a rare disease characterized by distal thoracic aorta or abdominal aorta coarctation, and thoraco-abdominal aortic bypass grafting is an effective treatment for this condition. However, significant trauma is associated with the conventional surgical approach. We report a 26-year-old woman with MAS who presented with hypertension and needed thoraco-abdominal bypass grafting. In this operation, we adopted the endoscopic technique to improve the conventional surgical approach (reduce the incision). This case report shows that it is safe and feasible to use an endoscopic technique to reduce the trauma during this kind of operation, and provides a reference for similar treatments.

Neurologic complications of diseases of the aorta

Neurologic complications of diseases of the aorta are common, as the brain and spinal cord function is highly dependent on the aorta and its branches for blood supply. Any disease impacting the aorta may have significant impact on the ability to deliver oxygenated blood to the central nervous system, resulting in ischemia-and if prolonged-cerebral and spinal infarct. The breadth of pathology affecting the aorta is diverse and neurologic complications can vary dramatically based on the location, severity, and underlying etiology. This chapter outlines the major pathology of the aorta while highlighting the associated neurologic complications. This chapter covers the entire spectrum of neurologic complications associated with aortic disease by beginning with a detailed overview of the spinal cord vascular anatomy followed by a discussion of the most common aortic pathologies affecting the nervous system, including aortic aneurysm, aortic dissection, aortic atherosclerosis, inflammatory and infectious aortopathies, congenital abnormalities, and aortic surgery.

Non-specific aortoarteritis (NSAA) in children: a prospective observational study

OBJECTIVE

Prospective data on clinical profile, natural history and outcomes of NSAA (non-specific aortoarteritis) in children is limited. We initiated this prospective study to evaluate the short-term and medium-term outcomes of NSAA in children.

DESIGN

Prospective observational study.

SETTING

Tertiary care hospital in India.

PATIENTS

We included 28 consecutive children (<15 years) with a diagnosis of NSAA.

MAIN OUTCOME MEASURES

Clinical profile, symptoms, left ventricular ejection fraction (LVEF), the pattern of vessel involvement, complications and markers of disease activity were assessed at the time of diagnosis. All the patients underwent treatment and interventions as per the current guidelines and were followed up for a mean duration of 13.5±6.7 months for disease activity and outcomes.

RESULTS

The mean age of the cohort was 10±2.9 years (14 boys). Twenty (71%) patients had hypertension. Half of the children presented with acute decompensated heart failure (ADHF). Only 21 patients (75%) met Sharma et al modified Ishikawa criteria for the diagnosis. The children with active disease (36%) were managed with immunosuppressive drugs. Percutaneous and surgical interventions were performed in 26 (93%) children. New York Heart Association functional class, LVEF and control of hypertension improved in most children on follow-up. Four children developed vascular restenosis requiring reinterventions. There was no death during mid-term follow-up.

CONCLUSIONS

Children with NSAA, unlike adults seldom present with classical features of the disease. ADHF and ventricular dysfunction are strikingly common in children. Appropriate immunosuppressive therapy for active disease and timely intervention improves clinical outcomes over a medium term follow-up. Future studies assessing long-term outcome are needed.

Radiologic Approach for Pulmonary Vasculitis

혈관염은 혈관벽의 염증을 특징으로 하는 드문 전신 질환으로 간혹 미만성 폐출혈이나 급성 사구체신염으로 생명을 위협하기도 한다. 원인을 알 수 없는 일차성 혈관염도 있지만 자가면역 질환이나 약물, 감염, 종양 등 수많은 원인들에 의해 발생하는 이차성 혈관염도 있으며 분류가 복잡하고 명확한 진단검사가 없어 진단에 어려움이 있다. 또한 다양하고 비특이적인 증상과 징후 및 검사 소견을 보여 혈관염의 진단에는 임상양상, 영상 검사, 자가항체 검사, 병리 소견 등 여러 가지 결과를 종합하는 것이 필수적이다. 이 종설에서는 혈관염의 분류와 진단에 중요한 증상 및 징후, 특징적으로 폐를 침범하는 대표적인 폐혈관염의 영상 소견과 감별 진단, 그리고 새로운 혈관염 분류를 위한 국제적 연구인 Diagnostic and Classification Criteria in Vasculitis에 대해 소개하고자 한다.

A Brazilian Cohort of Patients With Immuno-Mediated Chronic Inflammatory Diseases Infected by SARS-CoV-2 (ReumaCoV-Brasil Registry): Protocol for a Prospective, Observational Study

BACKGROUND

Patients with immune-mediated rheumatic diseases (IMRD) are at increased risk of infections, including significant morbidity and high mortality. Considering the potential for unfavorable outcomes of SARS-CoV-2 infection in patients with IMRD, several questions were raised regarding the impact of COVID-19 at the start of the pandemic.

OBJECTIVE

This paper presents the protocol of a study that aims to prospectively evaluate patients with IMRD and a confirmed COVID-19 diagnosis (using criteria provided by the Brazilian Ministry of Health).

METHODS

The study comprised a prospective, observational cohort (patients with IMRD and COVID-19) and a comparison group (patients with only IMRD), with a follow-up time of 6 months to evaluate differences in health outcomes. The primary outcomes will be changes in IMRD disease activity after SARS-CoV-2 infection at 4 time points: (1) at baseline, (2) within 4-6 weeks after infection, (3) at 3 months after the second assessment (±15 days), and (4) at 6 months (±15 days). The secondary outcomes will be the progression rate to moderate or severe forms of COVID-19, need for intensive care unit admission and mechanical ventilation, death, and therapeutic changes related to IMRD. Two outcomes-pulmonary and thromboembolic events in patients with both IMRD and SARS-CoV-2 infection-are of particular interest and will be monitored with close attention (clinical, laboratory, and function tests as well as imaging).

RESULTS

Recruitment opened in May 2020, with 1300 participants recruited from 43 sites as of November 2020. Patient recruitment will conclude by the end of December 2020, with follow-up occurring until April 2021. Data analysis is scheduled to start after all inclusion data have been collected, with an aim to publish a peer-reviewed paper in December 2020.

CONCLUSIONS

We believe this study will provide clinically relevant data on the general impact of COVID-19 on patients with IMRD.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials RBR-33YTQC; http://www.ensaiosclinicos.gov.br/rg/RBR-33ytqc/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24357.

Association between acute phase reactants, interleukin-6, tumor necrosis factor-α, and disease activity in Takayasu's arteritis patients

Background

To investigate the association between blood biomarkers and disease activity of Takayasu’s arteritis (TAK) in a follow-up cohort.

Methods

Disease activity was assessed by clinical manifestations and repeated vascular Doppler examinations. The association between erythrocyte sedimentation rate (ESR), serum levels of high-sensitive C-reactive protein (hsCRP), interleukin-6(IL-6), and tumor necrosis factor-α (TNFα) and disease activity were analyzed by logistic regression and survival analysis. Kaplan-Meier method was used to estimate the cumulative remission rate curve, log-rank tests for group comparison, and Cox regression for estimating hazard ratios of these parameters for disease activity.

Results

428 patients were included. 188 patients were in active disease, and 240 patients were in inactive disease at baseline. Elevation of ESR, hsCRP, and IL-6 were associated with active disease at baseline and during follow-up. Cox regression and Kaplan-Meier analysis showed that lower possibility and longer time to remission were associated with elevated ESR (hazard ratio [HR] = 0.32, 80 vs 33 weeks, p < 0.001), hsCRP (HR = 0.45, 70 vs 31 weeks, p < 0.001), and IL-6 (HR = 0.54, 66 vs 34 weeks, p < 0.01) in patients with active disease at baseline, while higher risk and shorter time for relapse were associated with elevated ESR (HR = 2.1, 59 vs 111 weeks, p < 0.001), hsCRP (HR = 2.1, 79 vs 113 weeks, p < 0.001), IL-6 (HR = 2.5, 64 vs 117 weeks, p < 0.001), and TNFα (HR = 2.7, 65 vs 114 weeks, p < 0.001) in patients with inactive disease at baseline.

Conclusions

Elevated ESR, CRP, and IL-6 are associated with active disease, lower possibility, and longer time to achieve disease remission. Elevation of any among ESR, CRP, IL-6, and TNFα is associated with high risk and short time for relapse during follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-020-02365-y.

Patterns of Arterial Disease in Takayasu Arteritis and Giant Cell Arteritis

OBJECTIVE

To identify and validate, using computer-driven methods, patterns of arterial disease in Takayasu arteritis (TAK) and giant cell arteritis (GCA).

METHODS

Patients with TAK or GCA were studied from the Diagnostic and Classification Criteria for Vasculitis (DCVAS) cohort and a combined North American cohort. Case inclusion required evidence of large-vessel involvement, defined as stenosis, occlusion, or aneurysm by angiography/ultrasonography, or increased ¹⁸ F-fluorodeoxyglucose (FDG) uptake by positron emission tomography (PET) in at least 1 of 11 specified arterial territories. K-means cluster analysis identified groups of patients based on the pattern of arterial involvement. Cluster groups were identified in the DCVAS cohort and independently validated in the North American cohort.

RESULTS

A total of 1,068 patients were included (DCVAS cohort: TAK = 461, GCA = 217; North American cohort: TAK = 225, GCA = 165). Six distinct clusters of patients were identified in DCVAS and validated in the North American cohort. Patients with TAK were more likely to have disease in the abdominal vasculature, bilateral disease of the subclavian and carotid arteries, or focal disease limited to the left subclavian artery than GCA (P < 0.01). Patients with GCA were more likely to have diffuse disease, involvement of bilateral axillary/subclavian arteries, or minimal disease without a definable pattern than TAK (P < 0.01). Patients with TAK were more likely to have damage by angiography, and patients with GCA were more likely to have arterial FDG uptake by PET without associated vascular damage.

CONCLUSION

Arterial patterns of disease highlight both shared and divergent vascular patterns between TAK and GCA and should be incorporated into classification criteria for large-vessel vasculitis.

A rare presentation of Takayasu’s arteritis- unilateral finger clubbing – case report

Background

Takayasu’s arteritis (TA) is a granulomatous, large vessel vasculitis with a preponderance for young women. The inflammation results in disruption of the arterial endothelium causing stenosis, endoluminal thrombosis and aneurismal dilatation. Early disease presentation is with nonspecific general symptoms, and in such instances, the diagnosis can be missed. Unilateral clubbing is a manifestation of myriad of diseases, but is not a common sign of TA. In medical literature, only three such cases have been reported.

Case presentation

We present a 24-year-old female who presented with multiple constitutional symptoms such as arthralgia, malaise, poor appetite and two episodes of syncope over 3 months’ duration. On examination, unilateral finger clubbing was observed in the right hand, with very low volume radial, ulnar and brachial artery pulses on the ipsilateral side. Her blood pressure measured on the unaffected arm, was normal. Inflammatory markers were elevated and magnetic resonance angiogram (MRA) confirmed TA.

Conclusion

Although rare, unilateral clubbing may be a manifestation of TA. Therefore, detection of unilateral clubbing should raise a strong clinical suspicion of TA and prompt early diagnosis and initiation of treatment.

Effectiveness and safety of methotrexate versus leflunomide in 12-month treatment for Takayasu arteritis

Aims:

The study investigates the effectiveness and safety of methotrexate (MTX) versus leflunomide (LEF) in 12-month treatment of Takayasu arteritis (TAK).

Methods:

This was a cohort study. Patients diagnosed with TAK between 1 January 2013 and 1 January 2019 were enrolled from First Hospital of China Medical University and Zhongshan Hospital of Fudan University. Patients had active disease and were treated with glucocorticoid combined with LEF or MTX. Treatment response, imaging assessment and side-effects were evaluated during 12-month follow-up.

Results:

In total, 68 patients were enrolled (40 cases treated with LEF and 28 treated with MTX). At baseline, age, sex, disease duration and disease activity index showed no significant differences between groups. Prevalence of complete remission (CR) at 6 months was significantly higher in the LEF group than that in the MTX group (LEF versus MTX: 72.50% versus 53.57%, p = 0.04), though the CR prevalence at 9 months and 12 months showed no significant differences between groups. At 9 months, the prevalence of treatment resistance was much lower in the LEF group compared with MTX group (5.41% versus 11.54%, p = 0.03). Furthermore, prevalence of disease relapse in the LEF group was lower than that in MTX group at 12 months (7.24% versus 16.67%, p = 0.03). Patients with high baseline C-reactive protein levels (⩾15 mg/L) carried a higher risk of treatment resistance (OR = 1.36, 95% CI 1.07–13.41, p = 0.06) and disease relapse (HR = 2.51, 95% CI 1.36–12.98, p = 0.04).

Conclusion:

LEF might provide a quicker treatment response with lower prevalence of disease relapse compared with that elicited in MTX during 12 months follow-up for TAK.

Takayasu's Arteritis from the Patients' Perspectives: Measuring the Pulse to the Patient-Reported Outcomes

BACKGROUND

Patients with Takayasu's arteritis (TA) experience important changes in lifestyle, quality of life, and functional status due to ischemic symptoms or treatment toxicity.

PURPOSE

To describe the clinical characteristics and the patient-reported outcomes (PROs), such as quality of life, disability, fatigue, and perception/impact of the disease in Mexican patients with TA.

METHODS

Cross-sectional study including patients with established diagnosis of TA recruited at a tertiary care center. Demographics, comorbidities, clinical characteristics, laboratory, imaging, and treatment were retrieved. Disease activity (the Indian Takayasu Clinical Activity Score (ITAS) 2010), damage (Vasculitis Damage Index (VDI)), quality of life (Short Form 36 (SF-36)), disability (Health Assessment Questionnaire Disability Index (HAQ-DI)), fatigue (Multidimensional Fatigue Inventory-20), and patient's disease perceptions were assessed.

RESULTS

Fifteen women were included, with a median age of 41 years (interquartile range (IQR) 30-45) and disease duration of 108 months (IQR 55-197). Median ITAS 2010 and VDI scores were 0 (IQR 0-2) and 3 points (IQR 2-6), respectively. Mean SF-36 score was 71.38 ± 13.39, with mean physical and mental component summaries of 66.52 ± 13.37 and 76.24 ± 14.89, respectively. HAQ-DI mean score was 0.48 ± 0.62, being grip the most affected domain. Among fatigue subscales, the higher scores were present in the physical fatigue (16.3 ± 5.8). Correlations between the HAQ-DI and the VDI score (r = 0.64, P = 0.03); between the general fatigue, score, and disease duration (r = -0.71, P = 0.01); and between the SF-36 total score and the HAQ-DI (r = -0.87, P = 0.0004) were found.

CONCLUSIONS

It is important to identify disease-specific outcomes of interest to the patients to develop tools that assess them with a holistic approach.

Beyond Giant Cell Arteritis and Takayasu's Arteritis: Secondary Large Vessel Vasculitis and Vasculitis Mimickers

PURPOSE OF REVIEW

To provide an overview of mimickers of large vessel vasculitis (LVV), by the main presenting manifestation, i.e., systemic, vascular, and cranial manifestations.

RECENT FINDINGS

The main differential diagnoses in patients with giant cell arteritis (GCA) and Takayasu arteritis (TAK) presenting with systemic manifestations (i.e., fever, anorexia, weight loss, night sweats, arthralgia/myalgia, and/or increased inflammatory indexes) are neoplastic, infectious, or other inflammatory conditions. In patients with vascular manifestations (such as peripheral ischemia, vascular stenoses, or aneurysms), atherosclerosis and non-inflammatory vascular diseases should be excluded. In those presenting with predominant cranial symptoms (i.e., temporal headache, jaw claudication, scalp tenderness, transient or permanent vision loss), other causes of headache, cerebrovascular accidents, optic neuropathy, and neuromuscular syndromes need to be considered. The diagnosis of LVV maybe challenging, especially when patients present with atypical or incomplete clinical forms. In these cases, a multidisciplinary approach is strongly recommended.

Factors associated with event-free survival in Chinese patients with Takayasu's arteritis

OBJECTIVES

To investigate long-term outcomes of Takayasu's arteritis (TA) and explore the predictive factors associated with poor prognosis.

METHODS

We performed a retrospective study on consecutive TA patients admitted to the Nanjing Drum Tower Hospital during the period from July 2010 to March 2019. Potential factors contributing to adverse outcomes, including death, vascular complications, and vascular stenosis aggravation were assessed by Cox regression analysis.

RESULTS

Seventy-one individuals were enrolled, in which 90.1% were female. The mean onset age was 29.44 ± 11.75 years, and mean follow-up time was 3.42 ± 2.38 years. Adverse outcomes were observed in twenty-five (35.2%) patients, and the 1-, 5-, and 8-year event-free survival was 94.2%, 61.8%, and 29.8% respectively. Univariable Cox regression revealed that pulmonary hypertension (PH) (HR 4.13), high total cholesterol levels (HR 4.49), high LDL cholesterol levels (HR 5.14), and low-dose cyclophosphamide (CTX) treatment (HR 0.53) were associated with adverse outcomes. Among them, only CTX treatment remained significant in multivariable Cox regression analysis (HR 0.62). Interestingly, compared to those ineffective to CTX, the responders had higher immunoglobulin A levels (p < 0.05) but lower CRP levels (p < 0.05).

CONCLUSIONS

Even with vigorous therapy, a large proportion of TA patients may present adverse outcomes along with the development of disease. Low-dose CTX treatment is helpful for a better prognosis. Key Points • The prognosis of Takayasu's arteritis is still poor. • Application of low-dose cyclophosphamide in high-risk patients helps to improve the outcome. • Abnormal lipid profiles may contribute to the development of this disease, which also deserves attention.

Pregnancy Morbidities in Korean Patients with Takayasu Arteritis: A Monocentric Pilot Study

We investigated pregnancy morbidities in Korean patients with Takayasu arteritis (TA) in a single tertiary hospital as a pilot study. We retrospectively reviewed the medical records of 12 pregnancies in seven patients with TA. All patients were diagnosed with TA based on the 1990 American College of Rheumatology classification criteria. The medical records of patients were well-documented, allowing review of clinical data including pregnancy morbidities. The angiographic and Ishikawa classifications at diagnosis and TA activity at delivery were assessed. Of the 12 pregnancies, two pregnancies ended in spontaneous abortion (16.7%), and one pregnancy (8.3%) had therapeutic abortion at 9 weeks due to maternal morbidity. Among the remaining nine pregnancies, only one child was delivered via normal spontaneous vaginal delivery, and the remaining eight were delivered by Caesarean section. Two out of nine (22.2%) neonates were born with low birth weight, and one of them was born at 30 weeks of gestation. The most common maternal complication was hypertension affecting 7/12 (58.3%) pregnancies. Preeclampsia occurred in one pregnancy, and gestational diabetes mellitus (GDM) occurred in two pregnancies. At delivery, disease activity of TA was stable in all pregnancies, and glucocorticoids were administered in nine pregnancies. Live birth rate of pregnant Korean patients with TA was 75%. Future studies are needed to reduce pregnancy-related complications.

The utility of PET/CT in large vessel vasculitis

18F-FDG PET/CT occupies a growing role in the diagnosis of large vessel vasculitis (LVV), illustrating enhanced uptake in the lining of large vessels. A retrospective single center study was conducted of patients who underwent 18F-FDG PET/CT scans between 2009 and 2019 at Sheba Medical Center, Israel. The imaging results were analyzed for evidence of LVV. We reviewed the PET/CT scans of 126 patients and identified 57 studies that either showed evidence of active LVV or that had been performed in patients previously treated for systemic vasculitis. In 6 patients with fevers of unknown origin and elevated inflammatory markers, PET/CT revealed LVV. Six of 13 patients previously treated for systemic vasculitis demonstrated persistent large vessel uptake. LVV was identified in 8 patients with other autoimmune diseases, and in 4 diagnosed with infectious aortitis. In 26 patients who underwent malignancy surveillance, PET/CT revealed more localized large vessel wall inflammation. Our results illustrate that PET/CT may identify large vessel wall inflammation in patients with a suspicion of LVV, and incidentally in patients who undergo malignancy surveillance. PET/CT may also help delineate the presence and extent of vessel inflammation in patients with LVV and in those with other autoimmune diseases.

Clinical characteristics and outcomes of chronic heart failure in adult Takayasu arteritis: A cohort study of 163 patients

BACKGROUND

Chronic heart failure (CHF) is a serious complication and a major cause of mortality in patients with Takayasu arteritis (TA). We aimed to explore the clinical features and long-term outcomes in TA patients with CHF.

METHODS AND RESULTS

Adult TA patients admitted to our hospital between January 2009 to April 2018 were classified as HF and non-HF group. The adverse events were defined as a composite of all-cause mortality and hospitalization for HF. The outcome of the HF-group was further analyzed. A total of 61 HF patients and 102 non-HF patients were identified. In the HF group, the median age at assessment was 41.9 years, and female was predominant (82.0%). The multivariable logistic regression model revealed that pulmonary hypertension, aortic regurgitation, mitral regurgitation, level albumin, and uric acid were independently associated with CHF. After a median follow-up of 1347 days, 25 adverse events occurred in HF patients, and the 5-year event-free rate was 54.7%. The Cox model showed that coronary artery involvement, aortic regurgitation, without interventional treatment were related to adverse events.

CONCLUSIONS

The 5-year event-free rate was not satisfying. Aggressive intervention may decreased the likelihood of adverse events in patients with CHF.

The relationships of serum homocysteine levels and traditional lipid indicators with disease activity and coronary artery involvement in Takayasu arteritis

Serum homocysteine (HCY) levels have been associated with the occurrence of coronary stenosis and disease activity in large-vessel vasculitis. However, whether increases in serum HCY levels and traditional lipid indicators are associated with coronary artery involvement and disease activity in Chinese Han Takayasu arteritis (TA) patients is unknown. This study aims to investigate the clinical and laboratory features of TA by assessing their association with disease activity in TA patients, and to explore the risk factors associated with coronary artery involvement in these patients. Serum HCY levels and traditional lipid indicators were tested in one hundred ninety TA patients and one hundred fifty-four healthy controls. We analyzed the relationships of serum HCY levels and traditional lipid indicators with disease activity and analyzed the risk factors for coronary artery involvement. Twenty-one TA patients were found to have coronary artery stenosis (≥ 50%). TA patients had significantly higher levels of HCY than did healthy controls (p < 0.0001). Serum levels of HCY and low-density lipoprotein cholesterol (LDL-C); the ratios of LDL-C to high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC) to HDL-C, and triglycerides (TG) to HDL-C; and the values of atherogenic index of plasma (AIP) were significantly higher in patients with active TA than in patients with inactive TA and in TA patients with coronary artery involvement than in TA patients without coronary artery involvement. By contrast, the serum levels of HDL-C were significantly lower in patients with active TA than in patients with inactive TA and in TA patients with coronary artery involvement than in TA patients without coronary artery involvement (p < 0.05). In addition, the serum levels of TC and TG were significantly higher in TA patients with coronary artery involvement than those in TA patients without coronary artery involvement. Elevated serum HCY levels increased the risk of coronary artery involvement by 1.3-fold (p = 0.011, odds ratio [OR] = 1.275, 95% confidence interval [CI]: 1.056-1.539), and the cutoff value for serum HCY was 9.55 μmol/L. Elevated serum TG levels increased the risk of coronary artery involvement by 3.5-fold (p < 0.0001, OR = 3.534, 95% CI: 1.907-6.547), and the cutoff value for serum TG was 1.215 mmol/L. The risk of coronary artery involvement was 2.5-fold higher when an elevated TG/HDL-C ratio was present (p < 0.0001, OR = 2.513, 95% CI: 1.567-4.032). This study showed that serum HCY and TG levels and the TG/HDL-C ratio are independent risk factors for coronary artery involvement in TA patients.

Takayasu arteritis: a cohort of Italian patients and recent pathogenetic and therapeutic advances

Takayasu arteritis (TAK) is a rare granulomatous vasculitis of unknown etiology that mainly affects the aorta and its major branches. The aim is to describe the clinical features, diagnostic procedures, pathogenesis, and management of TAK in a longitudinal cohort of patients recruited within a single region of southern Italy. The cohort included 43 patients who were diagnosed with TAK and followed up according to a standard protocol, in a collaboration between four university tertiary referral centers and a regional hospital. Clinical and imaging classification criteria were those established by the American College of Rheumatology. Thirty-five patients (81.4%) were female, and the mean age at disease onset was 32.6 (range 16–54) years. Angiographic assessment of the vascular involvement allowed disease classification in five different types. Clinical features ranged from constitutional symptoms in the early inflammatory stage of the disease to cardiovascular ischemic symptoms in the late, chronic stage. Noninvasive imaging techniques were employed to assess the extent and severity of the arterial wall damage and to monitor the clinical course and response to therapy. Medical treatment, based on pathogenetic insights into the roles of humoral and cell-mediated immune mechanisms, included glucocorticoids mostly combined with steroid-sparing immunosuppressive agents and, in patients with relapsing/refractory disease, biologic drugs. Significant clinical and angiographic differences have been detected in TAK patients from different geographic areas. Patients with life-threatening cardiovascular and neurologic manifestations as well as sight-threatening ophthalmologic signs and symptoms should be promptly diagnosed, properly treated, and closely followed up to avoid potentially severe consequences.

Outcome Measures in Large Vessel Vasculitis: Relationship Between Patient-, Physician-, Imaging-, and Laboratory-Based Assessments

OBJECTIVE

To assess the relationship between measures of disease assessment in patients with large vessel vasculitis.

METHODS

Patients with giant cell arteritis (GCA) or Takayasu arteritis (TAK) were recruited into a prospective, observational cohort. Assessments within the following outcomes were independently recorded: 1) patient-reported outcomes (Multidimensional Fatigue Inventory, patient global assessment of disease activity [PtGA], Short Form 36 health survey [SF-36], Brief Illness Perception Questionnaire), 2) physician global assessment of disease activity (PhGA), 3) laboratory outcomes (C-reactive protein [CRP] level, erythrocyte sedimentation rate [ESR]), and 4) imaging outcomes (PETVAS, a qualitative score of vascular ¹⁸ F-fluorodeoxyglucose-positron emission tomography activity).

RESULTS

Analyses were performed on 112 patients (GCA = 56, TAK = 56), over 296 visits, with a median follow-up of 6 months. Correlation network analysis revealed assessment measures clustered independently by type of outcome. PhGA was centrally linked to all other outcome types, but correlations were modest (ρ = 0.12-0.32; P < 0.05). PETVAS, CRP level, and PtGA were independently associated with clinically active disease. All 4 patient-reported outcomes strongly correlated with each other (ρ = 0.35-0.60; P < 0.0001). Patient-reported outcomes were not correlated with PETVAS, and only PtGA correlated with CRP level (ρ = 0.16; P < 0.01). Patients whose clinical assessment changed from active disease to remission (n = 29) had a corresponding significant decrease in ESR, CRP level, and PETVAS at the remission visit. Patients whose clinical assessment changed from remission to active disease (n = 11) had a corresponding significant increase in CRP level and PtGA at the active visit.

CONCLUSION

Measures of disease assessment in large vessel vasculitis consist of independent, yet complementary, outcomes, supporting the need to develop composite outcome measures or a standard set of measures covering multiple types of outcomes.

Carotid contrast-enhanced ultrasonographic assessment of disease activity in Takayasu arteritis

AIMS

To investigate the usefulness of carotid contrast-enhanced ultrasound (CEUS) in assessment of disease activity in patients with Takayasu arteritis (TA).

METHODS AND RESULTS

After screening 219 CEUS records from 124 consecutive patients followed at our clinic between October 2014 and May 2018, data were analysed from 159 carotid CEUS from 86 patients diagnosed with Type I TA. Patients were categorized based on disease activity according to National Institutes of Health criteria into two groups: active disease group (92 CEUS) and non-active disease group (67 CEUS). The enhanced intensity of carotid artery wall: (i) was higher in active disease group than in non-active disease group (3.09 ± 1.67 dB vs. 1.44 ± 1.29 dB, P < 0.0001, respectively); and (ii) had a high predictive value for TA disease activity with area under the curve (AUC) of 86.3% [95% confidence interval (CI) 79.7-92.9], sensitivity of 88.0%, and specificity of 79.1%. The latter AUC was not significantly affected (P > 0.05) when erythrocyte sedimentation rate, C-reactive protein level, or arterial wall thickness were added to assessment of disease activity in TA.

CONCLUSION

Carotid vascularization by CEUS, as sole inflammatory marker, had a high predictive value for disease activity in Type I TA.

Association of interleukin-18 gene polymorphisms with Takayasu arteritis in a Chinese Han population

Background:

Interleukin-18 (IL18) gene polymorphisms are related to many inflammatory and autoimmune diseases. However, a correlation analysis between IL18 −607C/A and −137G/C gene polymorphisms and Takayasu arteritis (TA) is lacking.

Methods:

This study enrolled 200 patients with TA as the case group and 334 region-, age-, and sex-matched healthy subjects as the control group. We genotyped alleles and genotypes at positions −607 and −137 of the IL18 gene and analyzed the distribution frequencies. Mann-Whitney U test, t test, Chi-squared test and Hardy-Weinberg equilibrium were performed.

Results:

After adjusting for risk factors, the adjusted odds ratios and 95% confidence intervals at position −607C/A were 0.533, 0.391 to 0.880 (P = 0.010); 0.266, 0.586 to 1.002 (P = 0.051); and 0.122, 0.552 to 1.420 (P = 0.613) under the dominant, additive, and recessive models, respectively. For the −137G/C polymorphism, the adjusted odds ratios and 95% confidence intervals were 1.571, 1.068 to 2.311 (P = 0.022); 1.467, 1.086 to 1.980 (P = 0.012); and 1.815, 0.901 to 3.656 (P = 0.095) under the dominant, additive, and recessive models, respectively. Moreover, regardless of the model used, we found no statistical difference in distribution frequency between the active and quiescent states of TA for the −607C/A (P = 0.355, 0.631, and 0.705, respectively) and −137G/C polymorphisms (P = 0.205, 0.385, and 0.208, respectively).

Conclusions:

The IL18 −607C/A gene polymorphism may decrease the risk of TA, and thus is a protective factor, whereas −137G/C may increase the risk of TA, and thus is a risk factor. However, neither polymorphism was related to activity (active vs. quiescent) of TA.

Takayasu Arteritis Presenting as Bilateral Ocular Ischemic Syndrome

A 26-year-old female came in with progressive blurring of vision. She had developed memory loss and complained of headache, significant weight loss, and exertional left calf pain after prolonged walking. Pertinent physical findings included light perception on visual acuity examination, and the brachial and radial pulses of both arms were not appreciable. Thoracic and abdominal aortic imaging by computed tomography with contrast revealed narrowing along the thoracic aorta and its branches. Carotid Doppler showed bilaterally thickened walls in the common carotid arteries, with near total occlusion of the left carotid artery. These findings were consistent with bilateral ocular ischemic syndrome in Takayasu arteritis. She was given methylprednisolone 500 mg intravenously daily for 3 days with noted improvement in vision. She was discharged and showed improvement on prednisone 35 mg/day and aspirin 80 mg/day. On follow-up two weeks post-discharge, she reported being able to see silhouettes of persons and objects.

A case of anti-VEGF therapy application in Takayasu arteries with retinopathy

Purpose

Takayasu arteritis (TA) is a systemic granulomatous large vessel vasculitis that involves mainly the aorta and its primary branches, and occurs most commonly in young females. Ocular manifestations of TA include small vessels dilation, microaneurysm, arteriovenous anastomosis, retinal ischemia and retinopathy. However, no specific and effective treatments for Takayasu retinopathy is applied. This case aimed to demonstrate the role of anti-VEGF (vascular endothelial growth factor) therapy in treating Takayasu retinopathy.

Observations

We herein reported an 18-year-old Asian woman who presented with typical wreath-like arteriovenous anastomosis around the disc in the right eye and vitreous hemorrhage in the left eye. The stenosis and occlusion of bilateral subclavian arteries, carotid arteries and other proximal arteries on angiography confirmed the diagnosis of TA. Meanwhile, elevated ESR and CRP revealed that TA was in the active stage. We applied anti-VEGF therapy in treating Takayasu retinopathy specially to inhibit neovascularization. Additionally, vitreous extraction was conducted in the left eye after the treatment of anti-VEGF therapy.

Conclusions and importance

This is the first report of effective application of anti-VEGF therapy in inhibiting wreath-like arteriovenous anastomosis and improving vitrectomy in TA.

Case Report: Co-existence of sarcoidosis and Takayasu arteritis

Takayasu arteritis is a rare systemic large vessel vasculitis affecting the aorta and its branches. Sarcoidosis, too, is an inflammatory disease. Both entities are granulomatous conditions with a questionable association in their etiopathogenesis. Only a few cases of their coexistence have been reported in the literature. To our knowledge, no such cases have been reported from Nepal. We report a Nepalese woman who presented with non-productive cough, progressive shortness of breath and chest tightness of 3 years duration. She had a history of recurrent bilateral granulomatous uveitis over the previous 3 years. Examination revealed clubbing of digits, absent pulses over the left radial, ulnar and brachial arteries, and a weak pulse over the right arm including the bilateral carotid arteries. Pulmonary function test showed restrictive pattern, a high-resolution computed tomography (HRCT) scan of the chest revealed findings suggestive of pulmonary sarcoidosis. A CT angiogram suggested large vessel vasculitis. Bronchoscopy with biopsy revealed granulomatous inflammation, negative for malignancy and tuberculosis. She was hence, diagnosed with co-existing Takayasu arteritis and sarcoidosis, and treated with Prednisolone 60 mg once daily with dramatic improvement over 4 days and was discharged stable on domiciliary oxygen. She is currently on azathioprine 50 mg, prednisolone 10 mg without the need for supplemental oxygen. This case report highlights the importance of a proper physical examination as a guide to the use of modern technology in making a correct diagnosis. Furthermore, in countries where tuberculosis is endemic, it should always come as the most important differential diagnosis of granulomatous inflammation.

[Dissection of the abdominal aorta revealing Takayasu´s disease: about a case in Guinea]

Takayasu´s disease (TD) is a chronic inflammatory arteriopathy affecting the aorta, its main branches and the pulmonary arteries. It was first described in 1908 by the Japanese ophthalmologist Mikito Takayasu. The study involved a 78-year-old patient with no known history of cardiovascular disease, admitted with abdominal pain, pain in the right lower limb when walking, insomnia. These symptoms had progressed over 1 year. Physical examination showed normal heart rate of 87 beats per minute without pathological noises, with absence of right pedal pulse, blood pressure 120/78 mmhg, free lungs, flexible abdomen, and a beating mass in the right iliac fossa whose auscultation showed continuous murmur. The remainder of the physical examination was normal. Abdominal CT angiography confirmed extensive aortic dissection at the abdominal aorta with synchronous opacification of both channels, thrombotic aneurysm of the primitive iliac arteries measuring 48mmx100mm on the right and 38mm x 90mm on the left, with no visible fissurization. We report a case abdominal aorta dissection associated with thrombus formation in the primary iliac arteries revealing Takayashu´s disease treated in the Department of Cardiology at the Ignace Deen National Hospital. The rate of abdominal aorta dissection in patients with Takayasu´s disease is rare. It is most often diagnosed in the occlusive phase. Prognosis depends on possible complications.