HISTORY A 36 year old female admitted with H/o pain in the Rt upper limb & Giddiness while working with the Rt upper limb for the past 6 months. She has.
Post on 26-Mar-2015
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AN INTERESTING CASE OFAORTOARTERITIS
PROF.S.SHIVAKUMAR’S UNIT
Dr.N.LOGANATHANPG IN MEDICINE
HISTORY
A 36 year old female admitted with H/o pain in the Rt upper limb & Giddiness while working with the Rt upper limb for the past 6 months. She has right eye pain also while working with the upper limbs.
No H/o fever, chest pain, dysponea, cough
Bowel & Bladder habits normal
PAST HISTORY: No H/o DM / HT / PT / BA / IHD / Epilepsy
PERSONAL & FAMILY HISTORY:Nil significant
GENERAL EXAMINATION:Conscious, oriented, afebrilePallor +No clubbing / cyanosis / PE /
Jaun / GLA /elev.JVP
VITAL SIGNS - PULSE Arteries Rt Side Lt Side
Superficial temporal + +
CCA +
thrill +, bruit +
+
Thrill + , bruit +
Brachial feeble feeble
Radial feeble feeble
Femoral, PA, DPA, PTA
+ +
Blood Pressure: Limb Rt side Lt side
UL 60/0 70/0
LL 210/0 220/0
•RESPIRATORY RATE & TEMP: Normal
SYSTEMIC EXAMINATION:
CVS : S1, S2 +, Hyperdynamic impulse
EDM + in AA
RS : NVBS +, No added sounds
ABD : Soft , No mass palpable
CNS : NFND
NECK:A 3 * 3 cm sized swelling
palpable in the Lt carotid triangle, expansile impulse on palpation +, soft , smooth surface.
? ANEURYSM OF CAROTID ARTERY
PROVISIONAL DIAGNOSISAORTOARTERITIS / ?Carotid
Aneurysm
INVESTIGATIONSHb % : 10.4 gms
TC : 9500
DC : P72 L26 E2
ESR : 10/25
PCV : 26
Urine R/E: Normal
RBS : 119 mgs
Bl.Urea: 16 mg
S.Crea : 0.6 mg
S.Electrolytes:Na+ : 126 meq/LK+ : 2.8 meq/L
LFT:STB: 0.9 mgSGOT: 19 IU/LSGPT : 18 IU/LSAP : 65 IU/LT.Protein : 7.5 gmsAlbumin : 4.8 gms
ECG : LVHCXR : Aortic knuckle prominent &calcified
Cardiomegaly +
ASO : Neg
CRP : Neg
RF : Neg
ANA : Neg
Mantoux test : Neg
HIV : Neg
VDRL : Neg
Anti- HCV : Neg
HBsAg :Neg
USG ABD: Prominent supra renal aorta ?Aneurysm , SMA prominent.
Echo : AR (mod) No AS TR (mod) MV (normal)
Total Cholesterol: 161 mgsThyroid Function Tests: NormalFundus : Normal
SURGICAL, RHEUMATOLOGICAL, CARDIAC OPINION:
? AortoArteritis
VASCULAR SURGEON OPINION:?Aorto Arteritis / ? Carotid
Aneurysm , Suggested Doppler study
Doppler Study of Vascular System:1.Plaque in Rt CCA causing 59 % stenosis
of CCA.Due to the stenosis there is no detectable diastolic flow in Rt ICA & Rt ECA
2. Diseased LCCA indicated by hyperechoiec and irregular intima , no detectable diastolic flow in Lt CCA indicating occlusion prior to LCCA origin. ? In Arch of Aorta 3. Due to the plaque highly pulsatile flow with nil diastolic flow noted in the Lt carotid bulb, Lt ICA & Lt ECA 4.Lt vertebral artery shows no diastolic flow but normal systolic velocity -? Arterial narrowing in ipsilateral SCA
5.Normal study of Renal arteries, infrarenal aorta , both lower limb arterial system. In these normal flow & velocity noted.
In our case…….There is claudication of upper extremities
Aneurysm of carotid artery
Aortic Regurgitation
Feeble upper extremities pulses
Typical Doppler study of arterial system …..
FINAL DIAGNOSISAORTOARTERITIS/
AORTIC REGURGITATION
AORTOARTERITIS
AA is a pan-arteritis involving all the three layers causing extensive intimal proliferation, inflammation of media & adventitia followed by marked fibrous scarring.
Involves aorta & its major branches, pulmonary artery & its branches
TYPES: TYPE I : Inflammatory process is
localised to arch of aorta & its branches
TYPE II:Lesions involve the thoraco-
abdominal aorta & its branches without the involvement of arch
TYPE III:Combined Type I & Type II
TYPE IV:Pulmonary involvement in addition to
features of Type I ,II or III
TYPE V: Involvement of coronary arteries
COMMON PRESENTATIONS:1.Unequal pulse
2.Hypertension (due to renal artery stenosis)3.Renal failure 4.Heart failure(HT /Valvular lesions)5.AR ( Root dilation / valvular)6..Intermittent claudication7.Aneurysmal AA( high incidence of AR,HT, Elevated ESR)7.Others( CNS,Skin,eye changes)
Clinical Diagnosis of Aorto- Arteritis:I. One Obligatory criteria: < 40 yrs
II. Two major criteria : Lt & Rt mid subclavian artery lesions
III. Nine minor criteria : 1.High ESR
2.CCA tenderness3. hypertension
4.Aortic Regurgitation 5.lesions of (pulmonary artery,Lt mid CCA
, distal BCT, thoracic aorta & abdominal aortaHigh Probability of AA:OC + Two/one Major + >=2 / >=4 minor criteria
American College of Rheumatological criteria:
1. Age of onset of disease < 40 yrs2.claudication of extremities 3. decreased brachial artery pulse 4. BP difference > 10 mmHg bt arms5.bruit over subclavian artery or aorta
6.arteriogram abnormality
3 of these 6 criteria suggests diagnosis of Aorto-Arteritis
TREATMENT
Glucocorticoids
Cytotoxic drugs (cyclophosphamide, azathioprine, methotrexate)
Antihypertensives &decongestive therapy
Percutaneous Transluminal angioplasty
Surgery
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