Article Text
PDF
Statistics from Altmetric.com
Description
A 31-year-old woman reported of left lower limb claudication and low-grade fever for 2 months. Examination showed asymmetry of upper limb blood pressure, carotid bruit, absent left dorsalis pedis and carotidynia. Systemic examination was normal. The patient was non-obese and a non-smoker, with no history of hypertension, diabetes mellitus, hypercholesterolaemia, coronary artery disease, rheumatic heart disease or cerebrovascular disease. Her family history was unremarkable. CT angiogram (figure 1) showed diffuse wall thickening of the ascending aorta and arch of the aorta, and stenosis and dilation of the aortic arch branches, and descending and abdominal aorta. Four of the six diagnostic criteria of Takayasu's arteritis (according to American College of Rheumatology 1990 classification criteria) were present and thus we treated the patient with methotrexate 15 mg weekly and a tapering dose of prednisolone 0.5 mg/kg/day. She presented 4 months later with acute onset decreased left eye vision while still on treatment. She had history of neither drug use nor prior visual disturbances. Her visual acuity in the left eye was finger counting at 3 m while the right eye was 20/20. An ophthalmology consult diagnosed the patient as having branch retinal arterial occlusion, based on fundus findings (figure 2). Her laboratory investigations showed normal fasting sugar and lipid profile, and her antiphospholipid antibodies were negative. She was treated immediately with prednisolone 1 mg/kg/day, tapered over 2 months to a maintenance dose of 5 mg/day, with which she improved (figure 3). Her visual acuity at last follow-up improved to 20/60.
CT angiogram showing diffuse wall thickening, irregularity and dilation of the abdominal aorta.
Fundus examination and fluorescein angiography showing retinal oedema secondary to branch retinal arterial occlusion.
Fundus examination showing healed preretinal haemorrhage and optic atrophy.
Discussion
Takayasu's arteritis (TA) is a large vessel vasculitis. The involvement of small vessels, such as retinal vessels, is very rare. A review of cases, in 2013, by Noel et al,1 described seven cases of branch retinal artery occlusion and two cases of branch retinal vein occlusion reported in the literature. Four cases were inaugural of the disease. Type V TA was present in five of nine patients presenting with retinal vessel involvement, similar to that seen in our case. Immunosuppressive therapy benefited five patients while one showed stabilisation. Our patient improved with immunosuppression.
Learning points
Small retinal arterial involvement is a rare manifestation in Takayasu's arteritis.
It may be an inaugural symptom in Takayasu's arteritis.
Immunosuppression is beneficial.
Footnotes
Twitter Follow Yathish Gattimallanahali at @yathishgc45
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.