A 14-year-old girl presented with the chief complaints of
low grade, intermittent fever and persistent cough for 4
months. She had calf pain and exertional dyspnea for 1
month. Her heart rate was 114/minute. Lower limb pulses were
not palpable. She had a systolic murmur over the pulmonary
area and a bruit over epigastrium. Blood pressure in her
upper limb (186/118 mm of Hg) was considerably higher than
in lower limb (160/86 mm of Hg). Her blood pressure had
never been recorded previously. She had no family history of
hypertension. The blood counts were normal but ESR was 114
mm/1
st hr. Chest
X-ray showed haziness of middle and lower zones of
bilateral lung fields, with an enlarged cardiac shadow.
Echocardiography suggested mild mitral regurgitation with
tricuspid regurgitation and mild pulmonary arterial
hypertension. Ophthalmoscopy showed bilateral papilledema.
Mantoux induration was 32x28 mm. Sputum was positive for
acid fast bacilli (2+). Magnetic resonance angiography
showed narrowing of abdominal aorta from the point of origin
of renal arteries along with absence of collaterals in left
femoral region (Fig. 1). There was narrowing
of both renal arteries. A diagnosis of tuberculosis in a
patient of Takayasu arteritis was made as per 1990 ACR
(American College of Rheumatology) criteria for Takayasu
arteritis [1].
 |
|
Fig.1. MR angiography
showing narrowing of abdominal aorta and absence of
collaterals in left femoral region.
|
We started treatment for tuberculosis
with isoniazid, rifampicin, ethambutol and pyrazinamide.
Prednisolone, methotrexate and folic acid were added
following consultation with rheumatologist. Amlodipine was
also added. Thereafter because of persistence of
hypertension we added atenolol, spironolactone and prazosin
sequentially. Gradually her fever subsided and blood
pressure stabilized at 132/88 mm Hg. She has been discharged
and is under regular follow up.
Patients with Takayasu arteritis have
increased immune response to Mycobacterium tuberculosis
antigens, in particular to its 65 kDa HSP, suggesting a role
of this organism in the immunopathogenesis of the disease
[2]. There have been a few reported cases of active
tuberculosis with Takayasu arteritis in the pediatric
population. In two of the cases [3,4], patients responded to
treatment with antitubercular drugs and prednisolone. In the
other case [5], a 12-year-old boy was given cyclophosphamide
along with anti- tubercular drugs and prednisolone. He
eventually underwent nephrectomy. Anti-hypertensives were
used in all cases. Treatment of TA is based on the use of
immunosuppressants such as prednisolone and/or methotrexate
to decrease inflammatory activity. Our patient received both
azathioprine and cyclophosphamide. Mycophenolate mofetil and
tacrolimus are also used, especially for
corticosteroid-resistant disease. Hypertension should be
aggressively managed.
Acknowledgments: Ritabrata
Kundu and Priyankar Pal, Institute of Child Health, Kolkata,
West Bengal, India.
References
1. Arend WP, Michel BA, Bloch DA, Hunder
GG, Calabrese LH, Edworthy SM, et al. The American
College of Rheumatology 1990 Criteria for the Classification
of Takayasu Arteritis. Arthritis Rheum. 1990;33:1129-34.
2. Aggarwal A, Chag M, Sinha N, Naik S.
Takayasu’s arteritis: role of Mycobacterium tuberculosis
and its 65 kDa heat shock protein. Int J Cardiol.
1996;55:49-55.
3. Khaled Al-Aghbari, Ahmed Al-Motarreb,
Faiza Askar. Takayasu’s arteritis associated with
tuberculosis in a young Yemeni woman. Heart Views.
2010;11:117–20.
4. Pantell RH, Goodman BW Jr. Takayasu’s
arteritis: the relationship with tuberculosis. Pediatrics.
1981;67:84-8.
5. Duzova A, Türkmen O, Cinar A, Cekirge S, Saatci U,
Ozen S. Takayasu’s arteritis and tuberculosis: a case
report. Clin Rheumatol. 2000;19:486-9.
