Takayasu arteritis in Korean children: Clinical report of seventy cases

Vasculitis and Kidney Disease

Pediatric vasculitis is a complex group of disorders that commonly presents with multisystem involvement. Renal vasculitis can be isolated to the kidneys or can occur as part of a broader multiorgan vasculitis. Depending on severity, renal vasculitis may present as acute glomerulonephritis (AGN) often associated with hypertension and sometimes with a rapidly deteriorating clinical course. Prompt diagnosis and initiation of therapy are key to preserving kidney function and preventing long-term morbidity and mortality. This review focuses on the clinical presentation, diagnosis, and treatment objectives for common forms of renal vasculitis seen in pediatric patients.

Pediatric Takayasu Arteritis: A Review of the Literature

Takayasu arteritis (TA) is the third most common vasculitis of childhood and is extremely rare. It is mainly characterized by chronic, autoimmune, and granulomatous inflammation of the aorta and its major branches. Women under 40 years of age are mostly affected. It occurs for the first time in childhood in about 30% of affected individuals. Initially, it presents nonspecific constitutional findings. Since there is no specific laboratory finding, diagnosis is challenging. The gold standard imaging method for diagnosis is conventional angiography. Delay in diagnosis can cause devastating consequences. Therefore, in cases presenting with nonspecific findings, with hypertension and high acute phase reactants, the diagnosis should be suspected and confirmed with appropriate imaging method, and treatment should be started immediately. Immunosuppressive agents are the mainstay of the treatment. Biological agents are successful in refractory cases, and endovascular revascularization methods are used in the treatment of complications.

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.

Takayasu arteritis with an initial presentation of chronic monoarthritis mimicking oligoarticular juvenile idiopathic arthritis

Patients with Takayasu arteritis (TA) generally present with non-specific symptoms that, if unrecognized and untreated, may develop vessel stenosis and/or aneurysm. There is limited data regarding chronic monoarthritis as the initial presentation in children with TA. We report a 6-yearold girl diagnosed and treated as oligoarticular juvenile idiopathic arthritis (JIA). She later developed stroke with malignant hypertension and was definitively diagnosed with TA. She additionally developed proteinuria secondary to focal segmental glomerulosclerosis. This is the report of a patient with chronic monoarthritis mimicking oligoarticular JIA which chronic monoarthritis was the presentation of TA. Since JIA is a diagnosis of exclusion, any atypical features of oligoarticular JIA should illuminate the possibility of an alternative diagnosis. Our literature review focused on musculoskeletal presentations of children with TA.

Takayasu Arteritis

Takayasu arteritis is an idiopathic granulomatous vasculitis of the aorta and its main branches and it constitutes one of the more common vasculitides in children. Inflammation and intimal proliferation lead to wall thickening, stenotic or occlusive lesions, and thrombosis, while destruction of the elastica and muscularis layers originates aneurysms and dissection. Carotid artery tenderness, claudication, ocular disturbances, central nervous system abnormalities, and weakening of pulses are the most frequent clinical features. The diagnosis is usually confirmed by the observation of large vessel wall abnormalities: stenosis, aneurysms, occlusion, and evidence of increased collateral circulation in angiography, MRA or CTA imaging. The purpose of this revision is to address the current knowledge on pathogenesis, investigations, classification, outcome measures and management, and to emphasize the need for timely diagnosis, effective therapeutic intervention, and close monitoring of this severe condition.

A 15-Year-Old with Aphasia and Right Hemiparesis

Takayasu arteritis (TA) is the third most common vasculitis in childhood, peaking in the second to third decades of life but affecting patients as young as 6 months of age. It often presents with nonspecific systemic symptoms, although at late stages, it may present with cardiac, renal, or focal neurologic sequelae of vascular compromise. In this case, we describe a 15-year-old patient who presented acutely with stroke. In the absence of more classic rheumatological symptoms and significant laboratory abnormalities on initial testing, the diagnosis of TA was only reached through extensive vascular imaging following consultation with multiple subspecialty teams. This case demonstrates the need to maintain a high index of suspicion for vasculitis in pediatric patients presenting with new onset stroke in the absence of known predisposing factors. Doing so may reduce the time to diagnosis, hasten treatment, and optimize outcomes.

Brazilian multicenter study of 71 patients with juvenile-onset Takayasu's arteritis: clinical and angiographic features

OBJECTIVE

To describe the clinical and angiographic characteristics of Takayasu's arteritis in Brazilian children and adolescents.

METHODS

A retrospective data collection was performed in 71 children and adolescents followed in 10 Brazilian reference centers in Pediatric Rheumatology. The evaluation was carried out in three different time points: from onset of symptoms to diagnosis, from the 6th to 12th month of diagnosis, and in the last visit.

RESULTS

Of 71 selected patients, 51 (71.8%) were girls. The mean age of onset of symptoms and of time to diagnosis was 9.2 (±4.2) years and 1.2 (±1.4) years, respectively. At the end of the study, 20 patients were in a state of disease activity, 39 in remission and 5 had evolved to death. The most common symptoms in baseline assessment, second evaluation, and final evaluation were, respectively: constitutional, musculoskeletal, and neurological symptoms. A decrease in peripheral pulses was the most frequent cardiovascular signal, and an increase in erythrocyte sedimentation rate was the most frequent laboratory finding in all three evaluation periods. The tuberculin test was positive in 41% of those tested. Stenosis was the most frequent angiographic lesion, abdominal artery was the most affected segment, and angiographic type IV the most frequent. Most (90%) participants were treated with glucocorticoids, 85.9% required another immunosuppressive drug, and 29.6% underwent angioplasty.

CONCLUSION

This is the largest study on juvenile-onset Takayasu arteritis, and a high number of patients under the age of 10 years, with predominance of constitutional symptoms early in the disease, was observed.

[Chorea: a rare manifestation of Takayasu's arteritis]

The case of a girl with recurring chorea and a Takayasu's arteritis diagnosis is reported. This clinical manifestation has been reported in only one patient with this vasculitis in the pediatric group.

Developments in large and midsize vasculitis

Childhood vasculitis is a complex and fascinating area in pediatric rheumatology that has experienced an unprecedented surge in research, leading to new knowledge over the past several years. Vasculitis is defined as the presence of inflammatory cell infiltration in blood vessel walls, usually with multisystemic involvement. The most frequent forms of vasculitis in childhood are the small-size vasculitides, of which Henoch-Schoenlein Purpura and other leucocytoclastic vasculitis are the best examples, followed by Kawasaki disease, a midsize vasculitis, and Takayasu arteritis, a large-size vasculitis, both of which are topics in this article.

Heart failure in children in tropical regions

With the ever increasing younger population in tropical countries, the number of children with heart failure is increasing. However, the etiology of heart failure in this region varies considerably from that in the temperate region, with infectious causes leading the list. In this review, we have summarized the important causes of heart failure seen in the pediatric population in tropical regions.

Takayasu Arteritis in the pediatric population: a contemporary United States-based single center cohort

BACKGROUND

Takayasu Arteritis is an idiopathic, chronic, large vessel vasculitis involving the aorta and its primary branches. Few studies have been done in pediatric patients to date with the largest case series of US patients published in 2003 consisting of only 6 patients.

METHODS

A retrospective chart review was performed on all patients seen at Cleveland Clinic Children's up until 2012 who met EULAR/PRINTO/PRES classification criteria for childhood Takayasu Arteritis.

RESULTS

Twenty-one patients with a mean follow up of 2.3 years were studied. Weight loss, fatigue, and anorexia were the most common presenting complaints. 57.1% of patients were hypertensive at first visit. The most common examintation finding was diminished pulses (61.9%), followed by bruits, and then murmurs. Thoracic aorta stenosis was the most common vascular abnormality. Seven of twenty-one patients responded well to methotrexate and prednisone alone. Ten of twenty-one patients required an additional medication for symptom and disease control (infliximab most commonly). About two-thirds of patients required at least one anti-hypertensive medication. Eight of the twenty-one patients required surgical intervention for severe disease refractory to medications (renal artery stenosis being the most common indication). Almost all patients reported symptomatic improvement after surgical intervention. Two of the eight patients required a second surgery for return of symptoms. Disease sequelae included arterial aneurysms, resolved heart failure, and hypertensive emergencies.

CONCLUSION

Our study emphasizes that constitutional symptoms coupled with objective findings of diminished pulses, bruits, and hypertension should raise clinical suspicion for Takayasu Arteritis in pediatric patients. Pharmacologic therapy alone can be successful in controlling disease progression, however surgery was successful in minimizing symptoms when medical therapies failed.

Childhood-onset Takayasu Arteritis — Experience from a Tertiary Care Center in South India

Objective.

To study the clinical profile and outcome of Asian Indian children with childhood-onset Takayasu arteritis (c-TA).

Methods.

Records were studied of patients with c-TA onset prior to age 16. Disease Extent Index-Takayasu (DEI.TAK), Indian Takayasu Arteritis Score 2010, and Takayasu Arteritis Damage Score (TADS) were calculated retrospectively from electronic records. Cumulative incidence of sustained remission was estimated using the Kaplan-Meier curve.

Results.

There were 40 patients with c-TA, with median age of onset of 12.5 years (range 1–16) and median diagnostic delay of 11.3 months (range 1–60). The most common presenting features were hypertension, headache, malaise, and fever. Pulseless disease was observed in 25 cases (62.5%). The majority (n = 28) had active disease with raised inflammatory markers, high baseline median DEI.TAK score of 10 (range 3–24), and high median TADS of 7 (range 1–14). Of the 34 patients followed for 21.5 months (range 3–192), remission was attained in 30. However, cumulative sustained remission was achieved in only 29% of them at 5 years. Median period of sustained remission was 22.5 months (95% CI 17.1–26.8). New areas of vessel involvement were observed in 13 patients (38%). Disease progression was arrested in the majority (n = 22, 66%) through aggressive medical management and endovascular intervention. All 11 patients with an increment in TADS of ≥ 4 during followup had persistently active or relapsing disease. There was a single fatality.

Conclusion.

Despite aggressive immunosuppression, damage progressed in one-third of patients with c-TA in association with persistent inflammation, warranting surveillance with clinical instruments and followup imaging.

Impact of atherosclerosis and age on Doppler sonographic parameters in the diagnosis of renal artery stenosis

OBJECTIVES

The purpose of this study was to investigate the influence of atherosclerosis and age on 4 representative Doppler parameters in the diagnosis of renal artery stenosis.

METHODS

The 4 parameters, renal peak systolic velocity (PSV), renal-aortic ratio, renal-interlobar ratio, and acceleration time, were measured in 208 patients before angiography. The 208 patients were divided into groups according to age and atherosclerosis stratification. The Student t test, 1-way analysis of variance, and the χ(2) test were used to compare all 4 parameters and clinical characteristics. The optimal cutoff values were determined by receiver operating characteristic curves. The diagnostic concordance between atherosclerosis and age strata was evaluated by the Cohen κ coefficient.

RESULTS

Of the 416 renal arteries shown on Doppler sonography, 204 had a diagnosis of renal artery stenosis and 19 as occlusion on angiography. The optimal cutoff values for the renal-aortic ratio and renal-interlobar ratio in the groups aged 46 years or older and younger than 46 years were much different (2.3 versus 1.4 and 5.1 versus 6.5, respectively), whereas those for the renal PSV and acceleration time were close to each other or the same (170 versus 180 cm/s and 51 versus 51 milliseconds). The κ coefficients for the renal PSV, renal-interlobar ratio, acceleration time, and renal-aortic ratio between the atherosclerosis and age strata were 0.93, 0.99, 1.00, and 0.71.

CONCLUSIONS

Atherosclerosis and age show comparable influences on Doppler parameters in the diagnosis of renal artery stenosis. For clinical convenience, cutoff values may be separately established on the basis of a 46-year-old borderline for the renal-aortic ratio and renal-interlobar ratio, although this process is not necessary for the renal PSV and acceleration time.

Familial Takayasu arteritis - a pediatric case and a review of the literature

Takayasu arteritis (TA) is a rare chronic inflammatory disease of the aorta and its major branches. It is seen predominantly in females during the second and third decades of life, although it can occur in childhood. The aetiology of TA remains unknown. To date, familial cases of TA have been considered rare; however, a review of the literature suggests that cases are accumulating. We report a case of two sisters affected by severe TA, and review other reported familial cases.

Clinical characteristics, interdisciplinary treatment and follow-up of 14 children with Takayasu arteritis

BACKGROUND

Pediatric patients with Takayasu arteritis were studied by analyzing clinical presentation, diagnostic images, response to multimodal therapy, and long-term outcome.

METHODS

Fourteen consecutive children and adolescents (mean age: 10 years) were diagnosed with Takayasu arteritis at our institution between 1995 and 2007. They were subjected to clinical and diagnostic studies including color ultrasonography, MRI and angiography, and received interdisciplinary treatment.

RESULTS

The median time lag between the first onset of symptoms and diagnosis was 7.7 weeks. The majority of patients presented with acute severe clinical symptoms and extensive vascular lesions. Hypertension was the most common finding on first presentation (93%), followed by headache (64%), nausea (64%) and palpitation (50%). Ten patients (71%) had reduced or absent carotid, brachial or femoral pulses in one or more locations. C-reactive protein was elevated in 79% of the patients and erythrocyte sedimentation rate in 64%. Cardiovascular imaging showed extensive vasculitis of both sides of the diaphragm in 86%. Complications included renal artery stenosis (n=7), aortic dissection, thoracic aortic aneurysm and infrarenal aneurysm (all n=1). Conservative drug treatment was effective in 50%. Interventional dilatation of stenosis and surgical therapy, including aortic bypass, resection of aneurysms and nephrectomy, were necessary in the remaining patients. Follow-up for 25 months to 12 years showed that all children are well without disease-related mortality.

CONCLUSIONS

Takayasu arteritis is a rare and potentially life-threatening disease in children, likely with a prolonged subclinical course. Rapid diagnosis and interdisciplinary management help to prevent life-threatening complications.

Large vessel vasculitis

Takayasu arteritis is a chronic granulomatous disease of the aorta and its major branches that usually affects women during the second and third decades of life, but it has been reported in young children. This review details the clinical, pathological and radiological features, differential diagnoses and management of the condition, focusing chiefly on the disease in children. The recent definition of Takayasu arteritis is discussed. The condition should be considered in patients with unexplained arterial hypertension or unexplained inflammatory syndromes without signs of localization. Since the disease may be life-threatening and progressive, early recognition is necessary to initiate appropriate therapy. Patients with persistent ischaemic symptoms including hypertension might benefit from revascularization procedures.

Takayasu arteritis in France: a single-center retrospective study of 82 cases comparing white, North African, and black patients

We conducted a single-center retrospective study to compare the characteristics of Takayasu arteritis (TA) among white, North African, and black patients in a French tertiary care center (Hospital Pitié-Salpêtrière, Paris). Eighty-two patients were studied (82.9% female) during a median follow-up of 5.1 years (range, 1 mo to 30 yr). Among these 82 patients, 39 (47.6%) were white, 20 (24.4%) were North African, and 20 (24.4%) were black patients. Median age at diagnosis was 39.3 years (range, 14-70 yr) in white patients vs. 28.4 years (range, 12-54 yr) in North African (p = 0.02), and 28.0 years (range, 13-60 yr) in black patients (p = 0.08). Patients aged >40 years at TA onset were more frequently white than non-white (40.0% vs. 18.6%, p = 0.03). North African patients had more frequent occurrence of ischemic stroke (p = 0.03) and poorer survival (p = 0.01) than white patients. Type V of the Hata classification was the most frequent type among white (38.5%), North African (65.0%), and black patients (40.0%). Corticosteroids were used in 96.1% of patients. Fifty-three percent of white and North African patients, and 44% of black patients required a second line of immunosuppressive treatment (p = 0.60). Vascular surgical procedures were respectively performed in 46.1%, 50.0%, and 55.0% of white, North African, and black patients, p = 0.81. The 5-year and 10-year survival rates were 100% and 95.0%, respectively, in white patients; 67.4% at both 5 years and 10 years in North African patients; and 100% at both 5 years and 10 years in black patients. This study is one of the first direct comparisons of TA profiles among patients of distinct ethnic backgrounds. Our data support the idea that late-onset TA or an overlap between TA and large-vessel giant cell arteritis may be observed in white patients. North African patients have a higher occurrence of ischemic stroke and poorer survival than white patients.

Takayasu arteritis in children

Takayasu arteritis (TA) is a large vessel vasculitis that usually affects young female patients during the second and third decades of life, but has been reported in children as young as 24 months of age. Aim of this report was to describe four children (two girls) with TA, as well as summarizing main published studies. The mean age at presentation of our cases was 11 years (range 8-15). Three patients were Caucasians and one Asian. Arterial hypertension was the commonest mode of presentation followed by systemic symptoms. Other related symptoms were due to ischemia and consisted of abdomen, chest, and limb pain. An abdominal bruit was noted in only one patient. Inflammation markers were always abnormal. Angiography was performed in all cases; left subclavian artery and common carotid artery were more frequently involved. Renal artery stenosis was observed in two patients. One boy was diagnosed as having an associated immune deficiency (Wiskott-Aldrich syndrome). Treatment modalities included prednisone (n = 4), methotrexate (n = 3), and mycophenolate mofetil (MMF) (n = 1). Surgery was required in two patients. Follow-up ranged from 3 to 10 years since diagnosis. In three cases antihypertensive drugs and methotrexate were stopped, and prednisone was reduced to 7.5 mg/day.

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 in children and young indians

Twenty four patients of Takayasu arteritis (TA) aged less than 18 years were studied over a period of 20 years (1978-98). There were 4 males and 20 females with a male:female ratio of 1:5. The mean age of presentation was 14 years and the disease had a mean onset of time 4+/-1.5 months prior to admission to the hospital. Hypertension was the commonest mode of presentation seen in 83% of patients. 16% patients had congestive heart failure. Left ventricular hypertrophy was present in 54% patients. Angiographic findings showed that abdominal aorta was the commonest segment of aorta that was involved (71% cases). Renal artery was involved in 75% cases. Treatment modalities included antihypertensive drugs in 19 patients, antitubercular drugs in 7 patients and steroids in 7 patients. Renal angioplasty was performed in 2 patients with excellent results. On follow up 2 patients died. The causes of mortality were renal failure and heart failure in one patient each. The clinical profile of young patients with TA is similar to that of adults with this disease.

Demographic, clinical, and angiographic data of patients with Takayasu arteritis in Brazil

We collected clinical, demographic, and angiographic data of Takayasu arteritis (TA) patients followed at Rheumatology Division of three Public University Centers (UNIFESP, USP, and UNICAMP) located in São Paulo State, Brazil. Clinical and demographic data were obtained from 73 patients (61 female; 50 white) The mean age at time of diagnosis was 27 y.o. and the mean follow-up time was 5 years. The following clinical features were observed along the evolution of these patients: absent or reduced pulses in upper limbs (85%), arterial bruit (64.5%), claudication of upper members (57%), headache (45%), hypertension (35.5%), dizziness (29%), cardiac bruit (29%), weight loss (27.5%), arthralgia or arthritis (26%), fever (24.5%) and claudication of lower limbs (20.5%). According to new angiographic classification of Takayasu arteritis performed in 28 patients followed at UNTFESP, with routine full aortography, 21% were classified as type I, 4% as type IIa, 4% as type III, 14% as type IV and 57% as type V. No patients had type IIb. Patients with Takayasu arteritis in São Paulo State Brazil showed female predominance and arterial involvement pattern similar to the one observed in Japan, with more than 20% classified as type I with exclusive involvement of the branches from the aortic arch.

Methotrexate use in systemic vasculitis

Although GS and CYC have been important agents in improving the outcome and survival of patients with systemic vasculitis, they carry their own risk of drug-induced morbidity and mortality. It has also become apparent that these medications are not the final answer in disease management because some forms of vasculitis have the potential to relapse or be treatment resistant. For these reasons, the pursuit of effective, less toxic therapeutic alternatives is critical. Initial results from the use of MTX in systemic vasculitis have been encouraging. Although drug-related toxicity and disease relapse have still been found to occur, MTX appears to be a valuable addition in the treatment of vasculitis. Further studies will be necessary to determine the optimal way that this agent may be used to safely and effectively manage vasculitic disease.

Aortitis syndrome in children: clinical observation of 35 cases in Japan

The results of clinical observation of 35 patients with aortitis syndrome (AS) in childhood, obtained by a nationwide survey in Japan, are reported. The male to female ratio was 1:2.5, the estimated age of onset averaged 10.2 years, and the duration from the estimated age of onset to the diagnosis averaged 15 months. In HLA examination A24, Bw52, Cw7 and DR2 were relatively common. Arterial lesions tended to extensively involve the aortic arch and its branches. Fever was the most frequently noted clinical symptom, followed by abdomen, joint and muscle pain. The physical findings in order of frequency were impaired circulation of the upper extremities, cardiac and vascular murmurs, hypertension, impaired cerebral circulation, visual disorder and impaired circulation of the pulmonary artery. The murmurs were found not only over the chest wall but also over the cervical area and abdomen. Pulselessness of the upper extremities occurred in 66% of patients. Percutaneous retrograde aortography and/or intravenous digital subtraction angiography to make the final diagnosis was employed except for three cases. There were not any specific abnormal signs in laboratory data. Steroid hormones were administered in 34 cases, and immunosuppressive agents in 8 cases. Five cases had percutaneous transluminal angioplasty to the right renal artery as an interventional treatment. The high frequency of abdominal pain is considered to be one of the characteristics of AS in childhood. The high frequency of pulselessness of the upper extremities and cardiac and vascular murmurs in this report is considered significant for the diagnosis of AS in childhood.

Percutaneous transluminal angioplasty for renovascular hypertension in children: initial and long-term results

OBJECTIVE

To evaluate the efficacy and safety of percutaneous transluminal renal angioplasty (PTRA) in children.

METHODS

We performed aortography and attempted PTRA in 35 consecutive children (age 5 to 14 years, mean 10.8 +/- 2.5 years) with severe hypertension having > or = 75% renal artery stenosis (RAS).

RESULTS

The stenosis was caused by aortoarteritis in 31 (88.6%) cases and by juvenile idiopathic fibromuscular disease (FMD) in four (11.4%) cases. Twenty-seven (77.1%) patients, including three having RAS of solitary functioning kidney with total occlusion of contralateral renal artery, had bilateral RAS and eight (22.9%) had unilateral RAS. PTRA was technically successful in 54 (91.5%) of 59 stenotic lesions in 31 (88.6%) of 35 patients. Both aortoarteritis and FMD patients had significant decrease in RAS after PTRA. One patient had acute reocclusion of one renal artery after bilateral PTRA, which could be successfully opened by reangioplasty. Postangioplasty angiographic restudy performed in 18 patients at 4 to 72 months (mean 23.1 +/- 27.9 months) after successful angioplasty showed restenosis in 8 (25.8%) of 31 lesions initially dilated and de novo lesions of aorta in two patients. All seven restenotic renal artery lesions attempted and both stenosis of aorta were successfully dilated. Twenty-nine of 31 patients with successful PTRA have been followed up from 4 to 108 months (mean 41.0 +/- 29.3 months). Mean systolic blood pressure decreased from 185.1 +/- 27.4 to 120.6 +/- 19.2 mm Hg and mean diastolic blood pressure decreased from 118.4 +/- 13.2 to 84.6 +/- 10.4 mm Hg after PTRA. Twenty seven (93.1%) of these 29 patients had benefical blood pressure response. Seventeen (58.6%) patients improved, 10 (34.5%) were cured, although 2 (6.9%) patients failed to respond to PTRA. Blood pressure response was better in FMD as compared to aortoarteritis group. Patients with unilateral RAS, discrete stenosis, and post-PTRA stenosis < or = 20% also identified good blood pressure response.

CONCLUSION

Aortoarteritis is the most common cause of renovascular hypertension in South Asian children. PTRA is safe and highly effective and therefore should be the treatment of choice in pediatric renovascular hypertension.

Takayasu arteritis in Thailand: clinical and imaging features

PURPOSE

To present and evaluate the clinical and imaging features of patients with Takyasu arteritis in Thailand.

MATERIALS AND METHODS

Clinical and angiographic findings were studied in 63 patients with Takayasu arteritis collected at Chulalongkorn Hospital Medical School, Bangkok. Imaging features including CT scan in 15 patients, magnetic resonance imaging in 14 patients and magnetic resonance angiography in ten patients were evaluated and compared to angiography.

RESULTS

Among 63 patients there were 43 females and 20 males with the ratio female to male 2.15:1. The most common age groups were in the third and fourth decades of life. The most common clinical findings were hypertension and absence or weakness of pulses. Elevated erythrocyte sedimentation rate was found in 50%. For angiography, the most common vessel affected was the abdominal aorta (20%). The second and third most common sites were renal arteries (18.7%) and the subclavian arteries (14.3%). Coronary artery involvement was found in two out of eight patients. No pulmonary involvement was found in eight cases studied by pulmonary angiography. For classification of angiogram, the most common type of involvement (66.7%) was extensive involvement of the aorta and branches (type V of new classification established from International Conferences on Takayasu arteritis in Tokyo 1994). No patient was found to have only involvement of brachiocephalic branches or ascending aorta and brachiocephalic branches. CT scan showed calcification in the vessel walls (8/15 cases) which helped in diagnosis of the disease. Wall thickness, surrounding tissue, appearance of the vessel and intraluminal thrombus could be well seen. Magnetic resonance imaging added more detail in multiple planes and could demonstrate vascular flow. High detection rate of the lesions (94.8%) was found for the aorta. The study was less sensitive for smaller vessels. Magnetic resonance angiography showed better correlation of the findings of brachiocephalic arteries compared to angiography. Subclavian steal syndrome could be diagnosed. For renal arteries, MR angiography could correctly demonstrate occlusion of renal artery in six out of eight cases. In the other two cases only stenoses of the vessels were found on angiograms. One renal arterial stenosis on MR angiography was confirmed by angiography.

CONCLUSION

Takayasu arteritis could be found in Thailand. Clinical features were almost the same as in reports from other countries. Various forms of arterial involvement were demonstrated by imaging modalities. Angiography remained the best method for detection and diagnosis of Takayasu arteritis in correlation with clinical and laboratory findings. Although CT scan, magnetic resonance imaging and magnetic resonance angiography were limited and less sensitive for detection of the lesions, they were useful as noninvasive modalities showing more details of intraluminal clot, vascular wall and surrounding tissue which could be correlated with pathological findings and pathogenesis of the disease. Our study suggests that MR imaging and MR angiography can be screening and diagnostic techniques for patients with suspected Takayasu arteritis.

Takayasu arteritis: lessons from the American National Institutes of Health experience

Investigators form the National Institutes of Health (NIH), in the United States, have prospectively studied 60 patients with Takayasus's arteritis over a period of 20 years. Unique observations resulted from the requirement that all patients be part of Institutional Review Board-approved standardized protocols that required periodic complete clinical, laboratory and angiographic evaluations, regardless of degree of disease activity. Patients judged to have active disease received protocol defined treatment that always included prednisone, and to which cytotoxic agents were added in the event that relapse followed tapering or withdrawal of corticosteroids. The prospective standard approach applied to this cohort has provided new insights into the presentation, course and treatment-responsiveness of Takayasu's arteritis. This article will focus on the questions raised by this study and implications for patient care.

Current status of Takayasu arteritis in India

The clinical features of 106 patients of Takayasu arteritis (TA) seen over a period of 16 years are documented (65 females and 41 males). The mean age was 27.3 +/- 9.2 years. Hypertension was the commonest mode of presentation (51.3%) and was detected in 82 patients (77.4%) at the time of presentation. Vascular bruits were heard in 72 patients (67.9%) and 13 patients (12.3%) were in congestive heart failure. Aortography was performed in 95 patients. Based on the extent of involvement, Type I (branches of aortic arch) was seen in 7 (6.6%) patients, Type II (aortic arch, its branches and descending thoracic aorta) in 7 (6.6%) patients, Type III (descending thoracic aorta and abdominal aorta) in 4 (3.8%) patients, Type IV (abdominal aorta only) in 29 (27.3%) patients and Type V (aortic arch, descending thoracic aorta and abdominal aorta) in 59 (55.7%) patients. Therapeutic modalities included antihypertensive drug therapy in 81 patients, antitubercular drugs in 8 patients, steroids in 16 patients and cyclophosphamide in one patient. Response to steroids was satisfactory in 5 of these 16 patients while the lesions of vasculitis healed in the patient who was treated with cyclophosphamide. Surgical interventions included nephrectomy and autotransplantation of kidney in 3 patients each and revascularization in 4 patients and angioplasty in 4 patients. In the area of pathogenesis of this disease, a high activity of protein kinase C(PKC), an increased intracellular calcium and inositol 1,4,5 triphosphate in both unstimulated and stimulated T cells of TA was observed. These findings suggest an activation of PKC-calcium pathway in TA.

Unusual presentation of Takayasu arteritis with cardiac involvement and imitation of juvenile arteriosclerosis. A case report

A twenty-five-year-old Caucasian man with Takayasu arteritis, who was formerly diagnosed as suffering from premature arteriosclerosis, is described. Necropsy disclosed involvement of the entire aorta and its major branches, the pulmonary arteries, the coronary arteries, the intramyocardial arteries, and the heart valves, a combination hitherto not described. Literature concerning heart involvement in Takayasu arteritis is reviewed, and the differential diagnosis is discussed.

Indications and drugs for anticoagulation therapy in children

The indications for using anticoagulants in children are reviewed. These include venous thromboembolic disease, thrombosis associated with central venous lines, inherited conditions, arterial thromboembolic disease and umbilical catheterization. The anticoagulants presently available for paediatric use consist of heparin and oral agents including low molecular weight heparin (LMWH). The problems associated with their use in children are examined and potential advantages described. Increasing numbers of children are now requiring anticoagulant therapy and the potential advantages of LMWHs makes it imperative that randomized, controlled trials be carried out in children in prophylactic as well as therapeutic situations.