A 12-year-old Chinese girl was admitted to our hospital with a history of fatigue and hypertension lasting for about 9 months. She also had blood pressure (right arm) of 160/90 mmHg. Free thyroxine (FT4), free triiodothyronine (FT3), and thyroid stimulating hormone (TSH) were 40.5 pmol/L (ref range 12-22 pmol/L), 12.4 pmol/L (ref range 3.1-6.8 pmol/L), and 0.20 uIU/mL (ref range 0.27-4.2 uIU/mL), respectively. The titer of thyroid peroxidase antibodies (TPOAb) and thyroglobulin antibodies (TgAb) were 68 IU/mL (negative ≤34 IU/mL) and 142 IU/mL (negative ≤115IU/mL), respectively. Thyroid ultrasonography revealed increased thyroid volume, with diffuse hypoechogenicity. ECG revealed sinus tachycardia. A diagnosis of Hashimoto’s thyroiditis was made. With treatment of thiamazole, L-thyroxine and propranolol hydrochloride, her FT4, FT3, TSH were detected at 17.5 pmol/L, 4.2 pmol/L, and 3.5 uIU/mL, respectively. Subsequently, she was given levothyroxine replacement treatment to maintain thyrotropin within range; however, her blood pressure was still high.

The blood pressure was 200/90 mmHg in right upper limb and 130/90 mmHg in the left upper limb. It was 145/90 mmHg in right lower limb and 140/80 mm Hg in the left lower limb. The radial artery pulse volume was low on the left side. Neck examination revealed a tender and mobile enlarged thyroid. Heart sounds were normal and bruits were detected over the left subclavian artery and abdominal aorta. She had grade II hypertensive retinopathy. ESR and CRP were 18 mm/h, and 10.5 mg/dL, respectively. Serum creatinine, electrolytes, transaminases and the urinalysis were in normal limits. Human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus were negative. Antinuclear antibody titer was 1:320 in a speckled pattern (low positive), extractable nuclear antigens (ENA) and C-antineutrophilic cytoplasmic antibodies (ANCA) were in normal range. Child was negative for HLA B27 and rheumatoid factor. Tuberculin test was negative. Thyroid scan indicated diffuse hyperplasia. Chest CT scan was normal, ECG showed sinus tachycardia, and an echocardiogram showed mild aortic regurgitation. Digital subtraction angiography (DSA) revealed occlusion of left axillary artery, narrowing of left subclavian artery and right external iliac artery, and proximal stenosis of the left renal arteries. She was diagnosed with Takayasu arteritis type V according to the American College of Rheumatology (ACR) criteria [1], and updated angiographic classification[2]. Prednisolone and antihypertensive agents were added to the aforementioned treatment.

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. Johnston SL, Lock RJ, Gompels MM. Takayasu arteritis: a review. J Clin Pathol. 2002;55:481-6.

3. Park MC, Lee SW, Park YB, Lee SK. Serum cytokine profiles and their correlations with disease activity in Takayasu’s arteritis. Rheumatology (Oxford). 2006;45:545-8