Takayasu Arteritis Presenting As Congestive Cardiac Failure

Takayasu arteritis is a chronic systemic inflammatory disease that usualy affects the aorta, its primary branches and occasionaly the pulmonary and coronary arteries. The clinical manifestations vary considerably and are typicaly caused by limb or organ ischemia illness and fever. Occasionally, dyspnea and pedal edema can be the sole primary presentation of Takayasu’s arteritis.


Introduction
Takayasu's arteritis (TA) is a chronic idiopathic vasculitis that variably involves the aorta and or its main branches and the coronary and pulmonary arteries in 50-80%. 1 Inflammation results in stenosis, occlusion, or aneurysm formation. 2neurysms may rarely progress to vascular rupture and death. 3The first report of TA was by R Yamamoto in 1830, while the first presentation on TA was in 1905 by Mikito Takayasu at the 12th annual meeting of the Japan Ophthalmology Society, describing a patient with a peculiar optic fundus abnormality, characterized by coronal anastomoses. 4K Ohnishi and T Kagoshima also presented similar cases and noted their patients lacked a palpable radial pulse 4 .The first autopsy on a patient with TA was carried out in 1940 by K Ohta. 5

Case Presentation
A 21 year old male chronic smoker presented to our Emergency department with a history of fever on and off since last six months.He also had breathlessness and chest pain and bilateral pedal edema.Patient was apparently well six months back when he developed fever which was low to moderate in grade, undocumented, continuous.Fever was also associated with breathlessness which was insidious in onset, gradually progressive, aggravated on exertion and relieved on rest.Patient gave history of central , non radiating chest pain,.There was history of bilateral swelling of feet.There was no history of orthopnea or PND.No history suggestive of diabetes mellitus, hypertension, jaundice, bronchial asthma, blood transfusion, surgery or trauma was there.With regards large vessel disease, the most typical features reflect ischaemia, or aneurysm formation in large vessels such as the aorta and its branches."Aortic arch syndrome" is the term given to disease affecting the upper extremities, heart, neck and head.Patients often complain of arm claudication, and brachial and radial pulses are absent.Hence TA was previously called "pulse less disease". 4urgery, angioplasty or stenting 2 is only required in a minority of patients and should be postponed until the inflammatory component of the disease has been controlled if possible.TA is medically managed ,initially as giant cell arteritis (GCA), with high-dose prednisolone, 40-60 mg per day, as soon as the diagnosis is suspected.Patients with the HLA A24-B52-DR2 haplotype may require larger doses of corticosteroids for longer periods than patients without this haplotype. 6The most common clinical manifestation of takayasu's arteritis is affection of the aorta and its main branches 7 but the involvement of the pulmonary arteries is also known.Recent studies described pulmonary involvement in 14% to 86% of all cases with takayasu's arteritis. 8,9,10,11linical features of chest pain, dyspnea, cough ,haemoptysis, congestive heart failure suggest involvement of pulmonary arteries. 12Conclusion TA can present in wide variety of ways, many with a typical history of other conditions.The use of steroids is paramount to the acute medical treatment but not curative.Surgery, angioplasty or stenting is only required in a minority of patients.
For a definitive diagnosis the use of modern day imaging such as CT, MRI and angiography is vital.
From this case report we learn the importance of keeping an open mind with differential diagnoses, despite a "typical" presenting history, and the need for confirmatory investigations and therefore appropriate treatment.

Ethical Approval:
This case report was published after getting approval of the Ethics Committee of MMIMSR, Mullana (Ambala), India International Journal of Human and Health Sciences Vol. 03 No. 01 January'19 Page : 37-39On examination systolic blood pressure was 100 mmHg and diastolic 70 mm Hg and he had absent radial pulse on the left side.The rest of his examination was normal.On cardiac examination there was tachycardia.Heart sound both S 1 S 2 were normal and systolic murmur was heard in mitral and tricuspid area.
DOI: http://dx.doi.org/10.31344/ijhhs.v3i1.73 Discussion Non specific symptoms of inflammatory disease such as fever, night sweats, and malaise and weight loss are common early in disease and often precede more specific features.2Arthralgiaand myalgia are common.Some patients develop true arthritis or, less commonly, lupus-like rashes, erythema nodosum or glomerulonephritis.