Takayasu's disease: a review

Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains

Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.

Carotid intima-media thickness/diameter ratio and peak systolic velocity as risk factors for neurological severe ischemic events in Takayasu's arteritis

Objective

To characterize Takayasu arteritis (TAK) with supra-aortic involvement and determine the associations between clinical features, carotid ultrasonographic (US) parameters, and neurological severe ischemic events (SIE).

Methods

Patients with supra-aortic involvement including brachiocephalic trunk, bilateral common carotid artery and internal carotid artery, and bilateral subclavian and vertebral artery and baseline carotid US examination were enrolled from the East China Takayasu arteritis cohort. Bilateral carotid diameter, intima-media thickness (IMT), and peak systolic velocity (PSV) were measured by US. Then, IMT/diameter ratio (IDR) was calculated. Risk factors associated with neurological SIE were analyzed by multivariate logistic regression.

Results

Totally, 295 patients were included, of whom 260 (88.14%) were female, and 93 (31.53%) experienced neurological SIE. Involved supra-aortic artery distribution (p=0.04) and number (p<0.01) differed between neurologic and non-neurologic SIE subjects, showing higher prevalence of common carotid and vertebral artery involvement after Bonferroni correction and 56.99% patients having more than four involved arteries in neurological SIE group. The bilateral IDR (p<0.01) differed between patients with and without neurological SIE. The carotid IDR (left: cut-off value ≥0.55, odds ratio [OR] 2.75, 95% confidence interval [CI] 1.24-6.07, p=0.01; right: ≥0.58, OR 2.70, 95% CI 1.21-6.02, p=0.01) and left carotid PSV (≤76.00 cm/s, OR 3.09; 95% CI 1.53-6.27; p<0.01) as well as involved supra-aortic artery number (≥4, OR 2.33, 95% CI 1.15-4.72, p =0.02) were independently associated with neurological SIE.

Conclusion

The carotid IDR and PSV might be performed as valuable markers for recognizing neurological SIE in TAK patients with supra-aortic lesions.

Revascularization Versus Medical Therapy in Takayasu's Arteritis Patients with Coronary Artery Involvement

Introduction

Treatment strategies to improve clinical outcomes in Takayasu's arteritis (TA) with coronary lesions have ranged from pharmacological therapy to invasive procedures, such as coronary angioplasty, stenting, and surgery. However, the therapeutic strategy for this kind of patient is still unclear. This study aimed to investigate the clinical characteristics and influence of revascularization versus medical therapy in TA patients with coronary artery involvement.

Methods

We analyzed the medical records of 806 TA patients between January 2008 and December 2019. Clinical features and treatment were analyzed, and patients were categorized into medical treatment and revascularization. Additionally, patients were sorted as percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) based on the strategy of revascularization.

Results

Ninety cases with coronary lesions induced by TA were enrolled. Among 90 cases, 39 patients adopted conservative treatment, and 51 patients received revascularization (28 subjects with PCI, 23 participants with CABG). The median follow-up time was 63 (45–91) months. There is no significant difference in cardiovascular death between medical treatment and revascularization (2/39, 5.1% vs. 5/51, 9.8%, P = 0.971). The analysis of subgroup indicated that the mortality caused by cardiovascular disease was also similar in the CABG and PCI (2/28, 7.1% vs. 3/23, 13.0%, P = 0.772). However, the proportion of restenosis is much higher in the PCI compared with that of CABG (39.3%, 8.7%, P = 0.022, respectively). Heart failure is an independent predictor of death in these patients.

Conclusions

There is no significant difference in cardiovascular death between medical treatment and revascularization. The analysis of the subgroup indicated that the mortality caused by cardiovascular disease was also similar in the CABG and PCI, but the restenosis is much higher in the PCI compared with that of CABG. Heart failure is an independent predictor of death in these patients.

Takayasu arteritis in paediatrics

Takayasu arteritis is an idiopathic chronic granulomatous panarteritis predominantly affecting the aorta and its main branches. Although idiopathic, genetic contribution to disease susceptibility is being increasingly recognised. Rare in children, Takayasu arteritis is a worldwide disease with significant morbidity and mortality. Its diagnosis is a challenge and requires awareness of the condition as clinical features at presentation are non-specific and assessing disease activity is difficult. In the inflammatory stage, treatment is essential to prevent the insidious course and vascular damage: stenotic, occlusive lesions, aneurysms, and aortic regurgitation. New imaging modalities, such as CT scan, MRI, and 18F-fluorodeoxyglucose positron emission tomography, have expanded the possibilities for non-invasive diagnosis and monitoring; however, digital subtraction arteriography remains the gold standard for the diagnosis of Takayasu arteritis. Steroids are the first-line medical treatment. The combined use of methotrexate, cyclophosphamide, azathioprine, mycophenolate mofetil, and biological agents is common. Revascularisation therapy should be considered in uncontrolled hypertension secondary to renal artery stenosis, symptomatic coronary ischaemia, cerebrovascular disease, severe aortic regurgitation, limb ischaemia, and aneurysms at risk of rupture, using surgical or endovascular procedures and taking into consideration that complications, especially restenosis, are frequent. Disease activity increases the likelihood of complications after revascularisation. Surgical intervention has shown better long-term outcomes, although the endovascular approach is evolving. The aim of this review was to describe key points of the diagnosis, treatment, and follow-up of Takayasu arteritis in childhood.

Abnormalities of the Coronary Arteries in Children: Looking beyond the Origins

Coronary arterial abnormalities are uncommon findings in children that have profound clinical implications. Although anomalies of the coronary origins are well described, there are many other disease processes that affect the coronary arteries. Immune system-mediated diseases (eg, Kawasaki disease, polyarteritis nodosa, and other vasculiditides) can result in coronary arterial aneurysms, strictures, and abnormal tapering of the vessels. Because findings at imaging are an important component of diagnosis in these diseases, the radiologist's understanding of them is essential. Congenital anomalies may present at varying ages, and findings in hemodynamically significant anomalies, such as fistulas, are key for both diagnosis and preoperative planning. Pediatric heart surgery can result in wide-ranging postoperative imaging appearances of the coronary arteries and also predisposes patients to a multitude of complications affecting the heart and coronary arteries. In addition, although rare, accidental trauma can lead to injury of the coronary arteries, and awareness and detection of these conditions are important for diagnosis in the acute setting. Patients with coronary arterial conditions at presentation may range from being asymptomatic to having findings of myocardial infarction. Recognition of the imaging findings is essential to direct appropriate treatment. ^©RSNA, 2017.

Aorto-carotid bypass in patients with Takayasu arteritis

Purpose

Takayasu arteritis is an indication for bypass surgery when this condition results in severe cerebrovascular ischemia due to occlusion of the carotid arteries. We reviewed the patients with Takayasu arteritis who received aorto-carotid bypass due to cerebrovascular ischemia.

Methods

A retrospective review was performed on 19 patients with Takayasu arteritis who underwent aorto-carotid bypass from March 2002 to April 2015.

Results

All patients were female and the mean of their age was 40.6 ± 15.3 years. Eleven patients (57.9%) underwent aorto-uni-carotid bypass and 8 patients (42.1%) underwent aorto-bi-carotid bypass. Five patients (26.3%) whose postoperative blood pressure was not controlled suffered an intracranial hemorrhage within 8 days after bypass surgery. Of the patients with an intracranial hemorrhage, 2 patients (10.5%) expired on 26 days and 7 years after surgery, and 3 patients (15.8%) resolved spontaneously. One patient (5.3%) expired due to an intracranial infarction 9 years after bypass surgery. The intracranial ischemic symptoms resolved after bypass surgery in all of the surviving patients. None of the patients experienced anastomosis site complication postoperatively.

Conclusion

Aorto-carotid bypass is effective for treating Takayasu arteritis with cerebrovascular ischemia, and the results suggest that postoperative blood pressure should be strictly managed to prevent intracranial hemorrhage.

Vascular surgery: the main risk factor for mortality in 146 Takayasu arteritis patients

Takayasu arteritis (TA) is an idiopathic chronic inflammatory disease that affects the aorta and its main branches. According to disease involvement, patients may require surgical treatment mainly due ischemic lesions in association with medical therapy. We evaluated the impact of vascular interventions in a cohort of TA patients. Medical records from 146 TA patients were reviewed. Clinical features, medical, and surgical treatment were revised and disease activity was determined by clinical, laboratorial, and imaging parameters. Clinical parameters associated with mortality alongside vascular procedures were evaluated and their impact on mortality in our cohort was estimated. Ninety-four vascular interventions were performed in 61 patients (41.8%). A third of them were of endovascular procedures. The overall mortality was 4.1%, all due to early postoperative complications, which resulted in a rate of surgery-related mortality of 9.8%. All deaths occurred in patients with active disease. Clinical parameters known to be associated with mortality (aneurysm, secondary hypertension, aortic insufficiency, and cerebrovascular accident) were not found related with death. Patients whose disease began before age 20 years had an OR 3.54 of undergoing a vascular surgical intervention. The observed impact of vascular procedures on mortality in patients with Takayasu arteritis, especially during disease activity, supports the notion that such interventions should be performed with caution and preferably during periods of remission.

Cause of death in Chinese Takayasu arteritis patients

To analyze the causes of death and the related risk factors for in-patients with Takayasu arteritis (TAK) admitted to a referral center of China during 1983 to 2014.The medical charts of 12 deceased TAK patients (10 women, 2 men) were reviewed by two senior rheumatologists. The demographic data, clinical manifestations, angiographic presentations, and the direct causes of death were analyzed retrospectively. Medical records of 40 TAK patients (32 women, 8 men) were selected as controls by age and sex matching method from 81 patients who were sampled isometrically from 810 successively admitted TAK in-patients of the same center during the same period. In addition to the comparison of clinical manifestations between the two groups, binary logistic regression was conducted to explore the related risk factors of mortality of TAK.Twelve patients died at the median age of 33.5 (ranging from 13 to 68 years old). The median survival time was 102.5(ranging from 6 to 567) months. The direct causes of death were heart failure in 5 (5/12, 41.7%), hemorrhage in 2 (2/12, 16.7%), pulmonary infection in 2 (2/12, 16.7%), sudden death in 1 (1/12, 8.3%), postoperative complication in 1 (1/12, 8.3%), and end-stage malignancy in 1 (1/12, 8.3%). Ischemia (4/12, 33.3%) and hemorrhage (4/12, 33.3%) were the two most common presentations in deceased patients. Eight patients had received surgical procedures related to TAK changes. Among them, 2 patients died after surgical procedure, the other 6 patients died later of non-operation-related causes. Compared with the control group (n = 40), patients in the deceased group had longer disease duration (P = 0.017), higher proportion of active disease (P = 0.020), secondary hypertension (P = 0.004), and congestive heart failure (P = 0.017). A model of binary logistic regression had revealed that secondary hypertension (odds ratio [OR] = 9.333, 95% confidence interval [CI]: 1.721 - 50.614, P = 0.010), congestive heart failure (OR = 5.667, 95% CI: 1.248 - 25.734, P = 0.025), and longer disease duration (OR = 1.007, 95% CI: 1.001 - 0.735, P = 0.027) were risk factors for TAK mortality. Active disease (OR = 0.167, 95% CI: 0.038 - 50.614, P = 0.018) was negatively associated with death of TAK.Heart failure is the leading cause of death in TAK patients, followed by ischemia and pulmonary infection. Early deaths occur postoperatively but become rare later after the procedure. Well-control of hypertension, and prevention of congestive heart failure may improve the long-term prognosis.

Kidney involvement in medium- and large-vessel vasculitis

Medium- and large-vessel vasculitides (MVV and LVV, respectively) comprise a heterogeneous group of disorders whose common denominator is the inflammatory involvement of vessels of medium and large size. This disease spectrum includes giant-cell arteritis and Takayasu's arteritis, which typically affect the aorta and its main branches, and Kawasaki's disease and polyarteritis nodosa, which involve medium-sized arteries. Chronic periaortitis, characterized by a perivascular fibro-inflammatory reaction affecting the abdominal aorta and the periaortic tissue, frequently has a systemic distribution, involving other segments of the aorta and its major branches, and could thus be included in this group. Unlike small-vessel vasculitides, MVV and LVV do not cause glomerulonephritis, although glomerular immune-mediated lesions and tubulo-interstitial nephritis occur with varying frequency. However, MVV and LVV can often involve the renal artery and its branches, causing a wide array of lesions that range from renal artery stenosis to intra-renal vasculitis causing renal ischaemia/infarction, microaneurysms and haemorrhage. This review focuses on renal involvement in MVV and LVV and underlines why renal abnormalities in these syndromes should not be overlooked.

Acknowledged signatures of matrix metalloproteinases in Takayasu's arteritis

Takayasu's arteritis (TA) was reported as an eye disease in the year 1905 and later was confirmed as a vasculitis. Since then, the etiology of the disease remains unknown; however, characteristic clinical features suggest multiple causative factors. Recent progress in vascular biology and other disciplines enlightens the pathophysiology of TA and demonstrated induction of various nonspecific inflammatory symptoms and destruction of the arterial wall, which leads to aneurysms and rupture of the affected arteries. Matrix metalloproteinases (MMPs) as an enzyme family have well-established roles in several vascular pathologies including intima formation, atherosclerosiss and aneurysms. MMPs have been proposed to be one of the molecules with a potential of having dual role in the course of TA, first as an active participant in pathophysiology and secondly as a diagnostic biomarker for TA disease. The desire to improve our understanding of the importance of MMPs and their endogenous inhibitors (TIMPs) in TA disease and for the development of therapeutic agents has inspired basic and clinical scientists for over a decade. In the present paper, we summarized the scientific rationale which highlights the signatures of matrix metalloproteinases and their endogenous inhibitors in pathophysiology as well as their being a potential candidate as biomarker for Takayasu's arteritis.

High prevalence of metabolic syndrome in Takayasu arteritis: increased cardiovascular risk and lower adiponectin serum levels

OBJECTIVE

The prevalence of metabolic syndrome (MetS) tends to be high among rheumatic patients, and cardiovascular disease is the leading cause of death in these conditions. We aimed to determine the prevalence of MetS in patients with Takayasu arteritis (TA) and its association with risk factors and adipokine and cytokine levels.

METHODS

A cross-sectional study was conducted in 45 consecutive women with TA and 47 healthy controls matched by age and body mass index.

RESULTS

The prevalence of MetS (International Diabetes Federation/American Heart Association criteria) was higher in TA compared to controls (33.34 vs 8.51%, p = 0.003). Patients with TA had a higher frequency of hypertension (p < 0.001) and dyslipidemia (p = 0.001) and higher levels of insulin (p = 0.021), homeostasis model assessment index (p = 0.024), apolipoprotein E (p = 0.029), resistin (p = 0.018), and C-reactive protein (CRP, p < 0.001) compared to healthy subjects, with similar levels of adiponectin and plasminogen activator inhibitor-1 (PAI-1; p > 0.05). Further analysis of patients with TA with and without MetS revealed a higher frequency of overweight/obesity (66.66 vs 26.66%, p = 0.022), higher Framingham score ≥ 1 (p = 0.032), and lower adiponectin levels (20.37 ± 21.16 vs 38.64 ± 22.62 μg/ml, p = 0.022) in the patients with MetS. No differences were found regarding disease duration, activity, glucocorticoid use, resistin, and PAI-1 levels in the 2 groups of patients with TA (p > 0.05). Patients with and without MetS showed no differences in cytokine levels [interleukin 12 (IL-12, IL-1a, IL-6) and tumor necrosis factor-α]. IL-6 had a positive Pearson correlation with CRP only in TA patients with MetS (r = 0.57; p = 0.050).

CONCLUSION

A high prevalence of MetS was observed in patients with TA and this comorbidity seems to identify a subgroup of overweight/obese patients with high cardiovascular risk without a significant association with disease status. Further longitudinal studies are necessary to observe the effects of controlling this modifiable risk factor in the quality of life and survival of patients with TA.

Coronary artery involvement in pediatric Takayasu's arteritis: Case report and literature review

Takayasu's arteritis (TA) is a form of chronic vasculitis that typically occurs in young adult Asian females, but it can also present in younger patients not fitting this classic profile. In these cases, the sequelae are generally similar to those found in adults. The disease predominantly affects the aorta and its primary branches. However, the coronary arteries are also affected in up to 20% of cases, which may precipitate myocardial infarction. Imaging of the coronary arteries therefore becomes critically important in the evaluation of a patient with possible Takayasu's arteritis. We present a case of a pediatric patient with TA who had no symptoms of angina but who was found to have significant coronary artery involvement on diagnostic imaging. This necessitated tailoring of traditional management.

Takayasu's arteritis: Is it a reversible disease? Case Report and Literature Review

Background:

Takayasu's arteritis (TA) is a rare and potentially devastating condition leading to prolonged morbidity and even death.

Case Description:

We report an 18-year-old female presenting with an acute ischemic stroke treated with intravenous thrombolysis and subsequent endovascular therapy (ET) with excellent results followed by chronic treatment with immunosuppressants after a formal diagnosis of TA. Following immunosupression, improvement was noted in critical stenoses of the extracranial large vessels.

Conclusion:

These observations underscore the importance of early initiation of therapy to halt or even reverse vascular pathology, though frequent follow up is mandatory as relapse is common. In this article we provide brief review of the current literature on TA related to pathophysiology, criterion for diagnosis, therapy, and follow up.

Takayasu arteritis presenting as severe ascending aortic arch dilation and aortic regurgitation in a 10-year-old female

Takayasu arteritis (TA) is a large-vessel arteritis affecting the aorta and its major branches. It is a rare disease in children less than 10 years old, and its diagnosis is frequently delayed, likely because of TA's rarity and nonspecific symptoms early in the disease. Females are affected disproportionately, with a female to male ratio of 8.5 to 1. Recently, the European League against Rheumatism published an international consensus statement for making the diagnosis of childhood TA. Criteria include angiographic abnormalities of the aorta and/or its branches, pulse deficit or claudication, blood pressure discrepancy, bruits, hypertension, and elevated acute phase reactants. We described a 10-year-old female with severe TA of the ascending aorta and who presented with classic signs and symptoms of this rare disease.

The heart of the matter: an atypical presentation of Takayasu arteritis in the Pediatric Emergency Department

Takayasu arteritis (TA) is a rare chronic large-vessel vasculitis of unknown etiology. Although commonly thought of as an adult disease, initial manifestations frequently appear during adolescence. This is a case discussion of an 11-year-old boy with a recent history of fever who presented with shortness of breath, sore throat, chest pain, hypertension, and a new murmur. He had a markedly elevated antistreptolysin O titer, had a prolonged PR interval, and was initially evaluated with acute rheumatic fever. After admission, he had persistent hypertension, proteinuria, and hemoptysis, which prompted a magnetic resonance angiography that revealed aortic enhancement and thickening, and he was evaluated with TA. To our knowledge, this is the first case report in the pediatric literature of TA presenting with heart block. This case highlights the recondite nature of the systemic vasculitides and emphasizes the importance of keeping a broad differential diagnosis when seeing patients who present with common complaints.

Causes and histopathology of ascending aortic disease in children and young adults

BACKGROUND

Ascending aortic diseases (aneurysms, dissections, and stenosis) and associated aortic valve disease are rare but important causes of morbidity and mortality in children and young adults. Certain genetic causes, such as Marfan syndrome and congenital bicuspid aortic valve disease, are well known. However, other rarer genetic and nongenetic causes of aortic disease exist.

METHODS

We performed an extensive literature search to identify known causes of ascending aortic pathology in children and young adults. We catalogued both aortic pathologies and other defining systemic features of these diseases.

RESULTS

We describe 17 predominantly genetic entities that have been associated with thoracic aortic disease in this age group.

CONCLUSIONS

While extensive literature on the common causes of ascending aortic disease exists, there is a need for better histologic documentation of aortic pathology in rarer diseases.

Takayasu's disease presenting as convulsive syncope which had been misinterpreted as epilepsy: a case report

INTRODUCTION

Takayasu's arteritis is a chronic vasculitis mainly involving the aorta and its main branches. The disease has protean clinical manifestation ranging from asymptomatic to catastrophic illness.

CASE PRESENTATION

A 19-year-old woman of Asian origin was referred to our neurology out-patient department for the management of refractory seizures. She reported several episodes of a loss of consciousness with tonic posturing when she assumed an upright position, which was accompanied by constitutional symptoms. A clinical examination showed orthostatic hypotension and an investigation confirmed the diagnosis of Takayasu's disease with presentation as convulsive syncope.

CONCLUSION

Our case highlights the importance of a thorough clinical history and physical examination in order to distinguish events mimicking epileptic seizure. We also describe an unusual presentation of Takayasu's disease with convulsive syncope and systemic constitutional symptoms.

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.

Coexisting Crohn's Disease and Takayasu's Arteritis in Two Patients Treated with Anti-TNF-α Therapies

Crohn's disease (CD) and Takayasu's arteritis (TA) are inflammatory granulomatous autoimmune disorders. Simultaneous occurrence of CD and TA in the same individual is rare. We report two cases treated with biologic agents. Case 1: A 16-year-old male presented with abdominal pain, nausea, vomiting. CT angiogram showed thickening of the terminal ileum, wall thickening and narrowing of multiple large and medium arteries including aorta and left common carotid. Colonoscopy with biopsy of the stenotic ileocecal valve confirmed CD. Resected carotid artery pathology was consistent with TA. Treatment was initially begun with prednisone, then methotrexate was started followed by infliximab. Due to side effects, methotrexate was switched to azathioprine. He remained asymptomatic. Case 2: A 38-year-old male with well-characterized Crohn's ileocolitis for 15 years, who had been treated with prednisone, mesalamine, sulfasalazine, and azathioprine presented with chest, upper back and abdominal pain. CT angiogram showed vasculitis of large and medium arteries, with stenosis of the right renal artery, and wall thickening of the sigmoid colon. He was diagnosed with TA. He underwent treatment with infliximab and adalumimab on different occasions, which were later discontinued due to fever, bacteremia and complications from sepsis. He remained on prednisone and azathioprine. In these two patients with both CD and TA the diagnoses were confirmed by imaging and pathologic findings. Both patients developed vascular complications. Tumor necrosis factor inhibitor therapy was effective in one patient but discontinued in the other due to infection. Further research into the association of CD and TA may provide clues to their etiologies and guide effective interventions.

Update in paediatric vasculitis

Vasculitis refers to a heterogeneous group of disorders that are characterised by inflammatory destruction of blood vessels. Although simple to define, almost nothing about vasculitis is simple. From classification to diagnosis, and from pathogenesis to management, large gaps remain in our understanding. Despite extensive and ongoing research, the fundamental mechanisms underlying the initiation and continuation of systemic vasculitis remain poorly understood. Thus, vasculitis continues to provide tremendous challenges to both clinicians and investigators and remains a rich source of issues for discussion. This review concentrates on recent changes proposed for the classification of paediatric vasculitis and advances in the concepts of aetiopathogenesis. Availability of improved classification criteria for children should prompt planning for multicentre-controlled studies for the treatment of these rare but important diseases.

Progress in pediatric vasculitis

PURPOSE OF REVIEW

To examine recent advances in the pathophysiology and therapy of pediatric vasculitis.

RECENT FINDINGS

The past 2 years have been marked by significant progress in extending novel techniques to the investigation of the two most common pediatric vasculitis syndromes, Henoch-Schonlein purpura and Kawasaki disease. Study of other vasculitides, such as Wegener granulomatosis, Churg-Strauss syndrome, and microscopic polyangiitis, is impeded by the small number of pediatric patients. Nonetheless, national and international registries are beginning to provide the foundation for generation of testable hypotheses regarding pathogenesis and optimal treatment. Thus, recent data from the study of children suggest that disorders in the control of inflammation, such as those that underlie familial Mediterranean fever and other autoinflammatory diseases, may predispose to vasculitis. Improved knowledge of mechanisms of disease, in turn, should pave the way for more targeted, effective, and tolerable therapies for children with systemic vasculitis.

SUMMARY

International collaboration to study rare disorders such as pediatric vasculitis are demonstrating disorders of inflammatory regulation that predispose to these diseases and may point toward new treatment approaches.

Takayasu's arteritis associated with Crohn's disease

Takayasu's arteritis (TA), also known as the "pulseless disease," is a chronic vasculitis of the aorta and aortic branches. TA with Crohn's disease is rare and has not been documented in China before. In this paper we report on a case of Takayasu's arteritis associated with concurrent Crohn's disease. A 17-year-old Chinese male developed upper limb sourness and a sensation of fatigue, and his upper limb pulses were absent. He was diagnosed with TA and underwent an axillary artery bypass with autologous great saphenous vein on the left subclavian artery. After the surgery, he regained the normal blood pressure. This patient also had years of diarrhea and developed an anal canal ulcer, and was diagnosed with inflammatory bowel disease and ulcerative colitis before. Five months after the TA surgery, he was hospitalized for severe stomachache and diarrhea and was finally diagnosed with Crohn's disease. The possible pathophysiological mechanisms responsible for concurrent existence of TA and Crohn's disease may be associated with immune disorders, especially autoimmunity.

Nasal septal perforation in a patient with Takayasu's arteritis; a rare association

Takayasu's arteritis (TA) is a chronic, progressive, granulomatous inflammation of the aorta and its major branches, and is diagnosed often only in the late stage. The late phase of disease is characterized by variety of ischemic symptoms due to stenosis or occlusion of the major arteries. Although major neurological events such as stroke, transient ischemic attacks, and seizures due to either progressive arterial stenosis or hypertension, are reported to occur in one-fifth of the patients, nasal septal perforation has not been previously reported. Herein we present a young woman with TA who was hospitalized with left hemiparesis due to occlusion of stented carotid artery. Her clinical course was also complicated with nasal septal perforation. This case suggested that nasal septal perforation could be a rare complication of TA and might be considered as a part of the clinical spectrum of the disease.