Maladie de Takayasu

Sudden death due to Takayasu arteritis complication associated with situs inversus totalis: A case discovered at autopsy

Takayasu arteritis is a rare pathology that usually has general and atypical signs that make its diagnosis difficult. These characteristics can delay diagnosis, thus leading to complications and death. We, herein, report an autopsy case of a 25-year-old female patient with a history of multiple consultations for dyspnea. During these consultations, no diagnosis was made. She was found unconscious near her home and shortly after, she was declared dead. Forensic autopsy revealed superficial traumatic lesions. Internal examination revealed complete situs inversus. Multiple bilateral pleural adhesions and bilateral moderate effusion were found. The heart was heavy with thickening of the aortic wall (1.1cm), carotid arteries, and pulmonary trunk, associated with a large aortic valve and evidence of leakage. Histological examination of the aorta and its major branches showed features of panarteritis with segmental involvement. The vascular wall was thick with lymphoplasmacytic infiltrate and giant cells involving mainly the medio-adventitial junction. Disruption of the elastic lamina and reactive fibrosis in the intima were also noted. Diagnosis of large vessel vasculitis and particularly Takayasu arteritis was made. Death was therefore attributed to heart failure due to aortic insufficiency as a complication of Takayasu arteritis.

Autoimmune disease of head and neck, imaging, and clinical review

Autoimmune disease of the head and neck (H&N) could be primary or secondary to systemic diseases, medications, or malignancies. Immune-mediated diseases of the H&N are not common in daily practice of radiologists; the diagnosis is frequently delayed because of the non-specific initial presentation and lack of familiarity with some of the specific imaging and clinical features. In this review, we aim to provide a practical diagnostic approach based on the specific radiological findings for each disease. We hope that our review will help radiologists expand their understanding of the spectrum of the discussed disease entities, help them narrow the differential diagnosis, and avoid unnecessary tissue biopsy when appropriate based on the specific clinical scenarios.

Large-vessel vasculitis diagnosed between 50 and 60 years: Case-control study based on 183 cases and 183 controls aged over 60 years

BACKGROUND

Age at onset of large-vessel vasculitis (LVV) is commonly used to distinguish giant cell arteritis (GCA) and Takayasu arteritis (TA). However, LVV between age 50 and 60 years may be difficult to classify.

METHODS

We conducted a retrospective study including LVV aged between 50 and 60 years at onset (LVV_50-60, cases) and compared them to LVV aged over 60 years (LVV_>60, controls). LVV was defined histologically and/or morphologically. Controls fulfilled ACR 1990 criteria for GCA or presented isolated aortitis.

RESULTS

We included 183 LVV_50-60 and 183 gender-matched LVV_>60. LVV_50-60 had more frequent peripheral limb manifestations (23 vs. 5%), and less frequent cephalic (73 vs. 90%) and ocular signs (17 vs. 27%) than LVV_>60. Compared to LVV_>60, CT angiography and PET/CT scan were more frequently abnormal in LVV_50-60 (74 vs. 38%, and 90 vs. 72%, respectively), with aorta being more frequently involved (78 vs. 47%). By multivariate analysis, absence of cephalic symptoms, presence of peripheral limb ischemia and aorta involvement, and increased CRP level were significantly associated with LVV_50-60 presentation compared to LVV_>60. At last follow-up, compared to LVV_>60, LVV_50-60 received significantly more lines of treatment (2 vs. 1), more frequent biologics (12 vs. 3%), had more surgery (10 vs. 0%), and had higher prednisone dose (8.8 vs. 6.5 mg/d) at last follow-up, CONCLUSION: LVV onset between 50 and 60 years identifies a subset of patients with more frequent aorta and peripheral vascular involvement and more refractory disease compared to patients with LVV onset after 60.

The role of 18F-FDG PET/CT in large-vessel vasculitis: appropriateness of current classification criteria?

Patients with clinical suspicion of large-vessel vasculitis (LVV) may present with nonspecific signs and symptoms and increased inflammatory parameters and may remain without diagnosis after routine diagnostic procedures. Both the nonspecificity of the radiopharmaceutical ¹⁸F-FDG and the synergy of integrating functional and anatomical images with PET/CT offer substantial benefit in the diagnostic work-up of patients with clinical suspicion for LVV. A negative temporal artery biopsy, an ultrasonography without an arterial halo, or a MRI without aortic wall thickening or oedema do not exclude the presence of LVV and should therefore not exclude the use of ¹⁸F-FDG PET/CT when LVV is clinically suspected. This overview further discusses the notion that there is substantial underdiagnosis of LVV. Late diagnosis of LVV may lead to surgery or angioplasty in occlusive forms and is often accompanied by serious aortic complications and a fatal outcome. In contrast to the American College of Rheumatology 1990 criteria for vasculitis, based on late LVV effects like arterial stenosis and/or occlusion, ¹⁸F-FDG PET/CT sheds new light on the classification of giant cell arteritis (GCA) and Takayasu arteritis (TA). The combination of these observations makes the role of ¹⁸F-FDG PET/CT in the assessment of patients suspected for having LVV promising.

[Imaging of pulmonary artery involvement in Takayasu disease]

OBJECTIVES

Illustrate imaging aspects of pulmonary artery involvement in Takayasu's arteritis.

PATIENTS AND METHODS

Retrospective study of six patients among 28 patients with Takayasu arteritis whose disease involved the pulmonary arteries and to review their clinical and computed tomography data.

RESULTS

Mean patient age among those with pulmonary artery involvement was 34 years. All patients exhibited extensive lesions of systemic arteries. The most common computed tomography angiography sign was wall thickening. Dilatation of the pulmonary artery trunk was observed in one-third of cases.

CONCLUSION

Pulmonary arterial involvement in Takayasu's disease is not uncommon. Computed tomography is a reliable imaging technique to establish the diagnosis.

Retroperitoneal fibrosis. Exceptional cause of renal artery thrombosis with secondary hypertension. A case from University Mohamed V, CheikhZaid Hospital, Rabat, March 2013

Retroperitoneal fibrosis is a rare cause of renal artery thrombosis, being the origin of renovascular hypertension, especially in patients less than thirty years old female, without particular medical history. A clinical case we present is a young 24 years old girl with no past history, hospitalized for the discovery of hypertension. She consulted for headache and progressive bilateral back pain, evolving for several months. She also complained for asthenia, accompanied by weight loss in about 7 pounds in 8 months. Clinical examination confirmed a very high blood pressure, bilateral lumbar pain, with a mass located in the left renal lodge. The diagnosis of right renal thrombosis was demonstrated (with dysfunctional right kidney) and a video-laparoscopic nephrectomy was performed. She had satisfactory postoperative clinical course with normalization of blood pressure a few days after, without medical treatment. <Learning objective: The interest is to know that the retroperitoneal fibrosis is a rare cause of renal artery thrombosis. In the search for the cause of renal arterial thrombosis, retroperitoneal fibrosis should not be forgotten; even of patients less than thirty years. The specific pathophysiology is unclear until now, the authors have been controversial. Important thing is to know that when all causes seem to have been discussed without result, retroperitoneal fibrosis can be a possible cause of renal thrombosis.>.

[Large-vessel granulomatous vasculitis during the course of sarcoidosis: Takayasu's arteritis?]

BACKGROUND

Vascular involvement in sarcoidosis is very rare and is characterized by preferential involvement of large vessels similar to that observed in Takayasu's disease. Distinguishing between these two diseases is often difficult and constitutes a diagnostic pitfall. The association between sarcoidosis and Takayasu's arteritis is not coincidental and a common physiopathological factor may exist; it suggests a possible aetiopathogenetic relationship between sarcoidosis and Takayasu's arteritis and casts doubt on whether this form of vasculitis is a disease in its own right or simply a syndrome caused by other diseases.

CASE REPORT

We report the case of a man with a 10-year history of cutaneous and pulmonary sarcoidosis who developed ischaemia of the right upper limb evocative of Takayasu's arteritis. The patient was successfully treated with oral steroids and methotrexate.

DISCUSSION

This case prompts discussion about the relationship between Takayasu's disease and sarcoidosis. Physicians should be aware of the possible occurrence of granulomatous arteritis during the course of sarcoidosis which requires a special work-up.

[Takayasu's arteritis and retroperitoneal fibrosis: a case report]

The authors report a 38-year-old young Moroccan woman with retroperitoneal fibrosis (RPF) associated with Takayasu's disease. The RPF was diagnosed in the presence of an acute renal failure requiring placement of double J catheters while an abdominal CT scan was suggestive of RPF. The diagnosis of Takayasu's disease was suspected three years later when the patient presented with right upper extremity dysesthesia. Aortic angiography showed evidence of typical inflammatory arteritis involvement with bilateral regular and concentric stenosis of axillary arteries and a left, smoothly narrowed primitive carotid artery, and left renal artery partial occlusion. The patient was treated with prednisone (0.5mg/kg per day) with a marked improvement. The association between RPF and Takayasu's disease is very rare, and only five cases have been reported in the literature. These two diseases share similarities in some of the etiologic factors and anatomic localizations.

Review of CT Angiography of Aorta

The most common imaging modality used for diagnosis of aortic disease is CT, followed by transesophageal echocardiography, MRI, and aortography. If multiple imaging is performed, the initial imaging technique most frequently employed is computerized tomography. During the past decade, computed tomographic angiography (CTA) has become a standard non-invasive imaging modality for the depiction of vascular anatomy and pathology. The quality and speed of CTA examinations have increased dramatically as CT technology has evolved from-channel spiral CT systems to multichannel (4-, 8-, 10- and 16-slice) spiral CT system. The quality and speed of CTA is superior to other imaging modalities, and it is also cheaper and less invasive. CTA of the aorta has proven to be superior in diagnostic accuracy to conventional arteriography in several applications.

Refractory rapidly progressive Takayasu's arteritis successfully treated with surgery

We describe a case of a patient with rapidly progressive Takayasu's arteritis (TA) refractory to conventional immunosuppressive therapy in whom bypass surgery was successfully performed. A 38-year-old woman had 2 years history of symptoms of compromised cerebral circulation, severe claudication of upper and lower limbs and stenocardial symptoms. Serial arteriography revealed occlusions of the right subclavian and right common iliac arteries and later on stenosis of the abdominal aorta and complete obliteration of the left subclavian artery. Coronarography did not show coronary stenosis. Completely occluded left subclavian artery resulted in a characteristic subclavian steal syndrome. Therapy with combined immunosuppressants was ineffective, severe ischaemic symptoms related to arterial occlusions progressed and surgical intervention was inevitable. She underwent aorto-bifemoral and 10 months later left carotid-axillary bypass grafting. The ischaemic symptoms were resolved after surgery. At 3 years follow-up, the patient remained asymptomatic with no evidence of restenosis. This case indicates that patients with progressive TA with no improvement while on conventional immunosuppressive therapy could have satisfactory outcome and excellent long-term clinical remission after multiple arterial bypass grafting.