IMAGES
Takayasu Arteritis Presenting as New-Onset Hypertension Jennifer A. Fillaus, DO,* Jennifer Oliveto, MD,Þ Annika Cutinha, MD,þ Amy Cannella, MD,þ and Troy J. Plumb, MD*
A
31-year-old woman was referred for evaluation of newonset hypertension. She presented to her primary care provider with a blood pressure of 160/120 mm Hg. She was taking nifedipine XL, and she was referred for further evaluation. She reported headaches, upper-extremity fatigue and pain, exertional dyspnea, and edema. Her arm pain was aggravated by
repetitive motion. Physical examination revealed pulse rate of 80 beats/min, blood pressure in the right arm of 130/90 mm Hg, blood pressure in the left arm of 138/90 mm Hg, and body mass index of 40.83 kg/m2. She had no bruits, normal heart sounds, and no edema; peripheral pulses were equal bilaterally. Complete blood count, comprehensive metabolic panel, and urinalysis were normal. Her serum aldosterone level was 64 ng/dL (reference range, 4Y31 ng/dL), and plasma renin activity was 4.5 ng/mL/h (reference, G3.3 ng/mL/h). Erythrocyte sedimentation rate was 56 mm/h (reference, 0Y20 mm/h), and C-reactive protein was 0.5 mg/dL (reference, G1.0 mg/dL). Tests were negative for antineutrophil cytoplasmic antibody, myeloperoxidase antibody, and serine protease 3 antibody. Serologies for hepatitis B, hepatitis C, and HIV were all negative. Her antinuclear antibody titer was positive at 1:320 in a homogeneous pattern. DNA double-stranded antibody immunoglobulin G and nuclear antigen panel (ENA) were negative. Because of new-onset hypertension and her symptoms, imaging studies were obtained. Computed tomography angiography of the abdomen (Fig. 1) and magnetic resonance angiography of the chest (Fig. 2A) are shown. A diagnosis of Takayasu arteritis was made based on American College of Rheumatology criteria.1Y3 The patient is being treated with glucocorticoids and has had improvements in her symptoms of upper-extremity fatigue and dyspnea. Her hypertension remains controlled on nifedipine XL 60 mg daily. REFERENCES
FIGURE 1. Computed tomography angiogram of the abdomen. Computed tomography angiogram of the abdomen notable for a small right kidney supplied by collateral vessels (arrow head), occluded right renal and superior mesenteric arteries, and proximal stenosis of the left renal artery (arrow). Color on-line figure available at http://www.jclinrheum.com.
1. Johnston SL, Lock RJ, Gompels MM. Takayasu arteritis: a review. J Clin Pathol. 2002;55:481Y486. 2. Mason JC. Takayasu arteritisVadvances in diagnosis and management. Nat Rev Rheumatol. 2010;6:406Y415. 3. Sharma BK, Jain S, Suri S, et al. Diagnostic criteria for Takayasu arteritis. Int J Cardiol. 1996;54(Suppl):S141Y7.
From the *Division of Nephrology, Department of Internal Medicine, †Department of Radiology, and ‡Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE. The authors declare no conflict of interest. Correspondence: Jennifer A. Fillaus, DO, Division of Nephrology, University of Nebraska Medical Center, Omaha, NE. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 1076-1608/14/2007Y0389 DOI: 10.1097/RHU.0000000000000177
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 7, October 2014
www.jclinrheum.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
389
JCR: Journal of Clinical Rheumatology
Fillaus et al
&
Volume 20, Number 7, October 2014
FIGURE 2. Magnetic resonance angiography/computed tomography of the chest. A, Magnetic resonance angiography of the chest showing narrowing and irregularity of the right subclavian/axillary artery lumen denoted by the arrow. B, Axial image from contrast-enhanced computed tomography scan of the chest corresponding to the bracketed area in A, showing marked, diffuse thickening of the wall of the axillary artery (arrow).
390
www.jclinrheum.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Takayasu Arteritis Presenting as New-Onset Hypertension Jennifer A. Fillaus, DO,* Jennifer Oliveto, MD,Þ Annika Cutinha, MD,þ Amy Cannella, MD,þ and Troy J. Plumb, MD*
A
31-year-old woman was referred for evaluation of newonset hypertension. She presented to her primary care provider with a blood pressure of 160/120 mm Hg. She was taking nifedipine XL, and she was referred for further evaluation. She reported headaches, upper-extremity fatigue and pain, exertional dyspnea, and edema. Her arm pain was aggravated by
repetitive motion. Physical examination revealed pulse rate of 80 beats/min, blood pressure in the right arm of 130/90 mm Hg, blood pressure in the left arm of 138/90 mm Hg, and body mass index of 40.83 kg/m2. She had no bruits, normal heart sounds, and no edema; peripheral pulses were equal bilaterally. Complete blood count, comprehensive metabolic panel, and urinalysis were normal. Her serum aldosterone level was 64 ng/dL (reference range, 4Y31 ng/dL), and plasma renin activity was 4.5 ng/mL/h (reference, G3.3 ng/mL/h). Erythrocyte sedimentation rate was 56 mm/h (reference, 0Y20 mm/h), and C-reactive protein was 0.5 mg/dL (reference, G1.0 mg/dL). Tests were negative for antineutrophil cytoplasmic antibody, myeloperoxidase antibody, and serine protease 3 antibody. Serologies for hepatitis B, hepatitis C, and HIV were all negative. Her antinuclear antibody titer was positive at 1:320 in a homogeneous pattern. DNA double-stranded antibody immunoglobulin G and nuclear antigen panel (ENA) were negative. Because of new-onset hypertension and her symptoms, imaging studies were obtained. Computed tomography angiography of the abdomen (Fig. 1) and magnetic resonance angiography of the chest (Fig. 2A) are shown. A diagnosis of Takayasu arteritis was made based on American College of Rheumatology criteria.1Y3 The patient is being treated with glucocorticoids and has had improvements in her symptoms of upper-extremity fatigue and dyspnea. Her hypertension remains controlled on nifedipine XL 60 mg daily. REFERENCES
FIGURE 1. Computed tomography angiogram of the abdomen. Computed tomography angiogram of the abdomen notable for a small right kidney supplied by collateral vessels (arrow head), occluded right renal and superior mesenteric arteries, and proximal stenosis of the left renal artery (arrow). Color on-line figure available at http://www.jclinrheum.com.
1. Johnston SL, Lock RJ, Gompels MM. Takayasu arteritis: a review. J Clin Pathol. 2002;55:481Y486. 2. Mason JC. Takayasu arteritisVadvances in diagnosis and management. Nat Rev Rheumatol. 2010;6:406Y415. 3. Sharma BK, Jain S, Suri S, et al. Diagnostic criteria for Takayasu arteritis. Int J Cardiol. 1996;54(Suppl):S141Y7.
From the *Division of Nephrology, Department of Internal Medicine, †Department of Radiology, and ‡Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE. The authors declare no conflict of interest. Correspondence: Jennifer A. Fillaus, DO, Division of Nephrology, University of Nebraska Medical Center, Omaha, NE. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 1076-1608/14/2007Y0389 DOI: 10.1097/RHU.0000000000000177
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 7, October 2014
www.jclinrheum.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
389
JCR: Journal of Clinical Rheumatology
Fillaus et al
&
Volume 20, Number 7, October 2014
FIGURE 2. Magnetic resonance angiography/computed tomography of the chest. A, Magnetic resonance angiography of the chest showing narrowing and irregularity of the right subclavian/axillary artery lumen denoted by the arrow. B, Axial image from contrast-enhanced computed tomography scan of the chest corresponding to the bracketed area in A, showing marked, diffuse thickening of the wall of the axillary artery (arrow).
390
www.jclinrheum.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
