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.

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