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Pericarditis as an initial symptom in Takayasu arteritis/Takayasu arteriti'nde baslangic semptomu olarak perikardit.

Takayasu arteritis (TA) is a chronic inflammatory vasculitis with unknown etiology, affecting the large and medium sized arteries with a striking predilection for aorta and its major branches. Because of the non specific initial clinical presentation, the disease remains undiagnosed for a long period of time. Cardiac manifestations in TA are rarely reported in the literature. They determine the disease prognosis. Pericardial effusion was rarely reported in TA, and is exceptionally the first manifestation. We report a case, of TA presented initially with acute pericardial effusion.

A 18- year- old female was admitted to the hospital with chest pain and dyspnea. The 2-dimensional echocardiography showed moderate pericardial effusion measuring 1.1 cm anteriorly and 1.2 cm posteriorly. Laboratory finding showed elevated erythrocyte sedimentation rate (ESR; 120 mm/hr) and C-reactive protein (CRP; 6 mg/dl), hemoglobin 11.2 g/dl and platelet count 413.000/ml. She received non steroidal anti-inflammatory drugs (NSAID)for 2 months under the impression of acute viral pericarditis. Her symptoms did not improve and the echocardiography revealed the persistence of pericardial effusion.

The nature of pericardial fluid was an exudate. Protein counts were 5600 mg/dl. Lactic dehydrogenase was 538 Ul/L and WBC counts was 204/[micro]l, with 15% lymphocytes, 10% neutrophil and 75% others. Gram and AFB stains of pericardial fluid showed no organisms and the cytology was negative for malignancy. Pericardial biopsy revealed neither evidence of tuberculosis nor signs of malignancy. Viral and bacterial serology was negatives (B and C hepatitis, Epstein Barr Virus, Herpes Simplex Virus, tuberculosis).

On physical examination, there were pulse differences and carotid tenderness, with asymmetric blood pressure (110/60 mm Hg in the left arm and 135/80 mm Hg in the right arm) and bilateral systolic subclavian and carotid murmurs. The electrocardiogram showed low voltage in the precordial leads.

Ultrasound Color Doppler of the extra cranial arteries showed an intimal thickening interesting essentially the right subclavian artery.

A computed tomography angiography showed a circumferential intimal thickening interesting the right, subclavian artery, vertebral artery and the primitive carotid artery reducing their diameter (Fig. 1).

The clinical manifestations of our patient including high ESR and the vascular lesions fulfilled the diagnostic criteria of TA. She received oral prednisolone 60 mg per day for 4 weeks. Clinical improvement was noted. Her ESR and CRP became rapidly normalized within 2 weeks following oral prednisolone therapy.

To the best of our knowledge only four cases of TA with pericardial effusion have been reported so far (1-5); they are summarized in the Table 1. This pericardial effusion was the first manifestation in only 2 cases, as reported in our case (2-4).

[FIGURE 1 OMITTED]

In our case, the acute pericardial effusion developed in the absence of other intracardiac abnormalities as an initial manifestation of TA. Other cardiac abnormalities were found in the others cases (1-34) including myocarditis, left ventricular dilation, aortic and mitral valve lesions and endocardial invagination.

TA should be considered as one of causes of acute febrile pericardial effusion in especially young women with enhanced CRP and elevated ESR.

References

(1.) Duelos F, Benchimol D, Lauribe R Benchimol H, Bonnet J, Bricaud H. Cardiac lesions in Takayasu's disease. A case with initial pancarditis and tamponade. Presse Med 1991;20: 847-50.

(2.) Lee CK, Kim DK, Lee SH. Takayasu arteritis presented with acute febrile pericardial effusion. Int J Cardiol 1998; 66:101- 5.

(3.) Narita H, Ohte N, Yoneyama A, Hashimoto T, Akita S, Sakuma N. Takayasu's arteritis accompanied with massive pericardial effusion--a case report. Angiology 1999;50:421-5.

(4.) Fateh-Moghadam S, Huehns S, Schmidt WA, Dietz R, Bocksch W. Pericardial effusion as primary manifestation in Takayasu arteritis. Int J Cardiol 2010;145: e33-5.

(5.) Li JJ, Fang CH, Chen MZ, Chen X. Takayasu's arteritis accompanied with pericarditis: a case report. Cardiology 2004;102:106-7.

Amira Hamzaoui, Randa Salem, Rim Klii, Olfa Harzallah, Olfa Berriche, Mondher Golli, Silvia Mahjoub

From Departments of Internal Medicine and ^Radiology, Fattouma Bourguiba Hospital, Monastir-Tunisia

Address for Correspondence/Yazisma Adresi: Dr. Amira Hamzaoui Department of Internal Medicine, Fattouma Bourguiba Hospital, Monastir-Tunisia

Phone: +90 216 986 16 195 Fax: +90 216 734 60 678 E-mail: hamzaoui.amira@yahoo.fr

Available Online Date/Cevrimici Yayin Tarihi: 18.05.2011 sayfasindan ulasilabilir.

doi: 10.5152/akd.2011.095
Table 1. Cases of pericardial effusion in Takayasu disease reported in
the literature

Author, Year   Sex/age,         Clinical         2-D echocardiography
                years           features

Duclos           F/21       Miscarriage 5th        Left ventricular
(1991) (1)                    month, fever          dilatation and
                                                 hypokinesia, lesions
                                                   of the aortic and
                                                     mitral valves

Lee              F/25     Fever, chill, chest    Posterior pericardial
(1998) (2)                discomfort, dyspnea        effusion; no
                               II, acute             intracardiac
                            pericardial, no          abnormalities
                          pulse difference, no
                           bruit, no carotid
                               tenderness

Narita          F/40        Fever, fatigue,       Massive pericardial
(1999) (3)                 malaise and severe        effusion and
                              chest pain.          bilateral pleural
                                                       effusion,
                                                     cardiomegaly

Moghadam         F/32     Back pain, fatigue,        Cardiomegaly,
(2009) (4)                 malaise, fever and    pericardial effusion,
                                adynamia            a mitral valve
                                                  prolapsed with mild
                                                  regurgitation and a
                                                     supravalvular
                                                   pulmonary artery
                                                       stenosis

Author, Year          MR imaging              Biological
                                            abnormalities

Duclos              large coronary           Elevated CRP
(1991) (1)             aneurysms               and ESR

Lee               Segment of luminal       CRP: 5.7 mg/dl;
(1998) (2)         irregularity and         ESR 144 mm/hr
               dilatation in descending
                     thoracic and
                    abdominal aorta

Narita                    --                CRP: 22 mg/dl,
(1999) (3)                                  ESR: 88 mm/hr

Moghadam         Concentric thickening     CRP: 14.2 mg/dl;
(2009) (4)       of the common carotid      ESR: 125 mm/hr
                arteries with discrete
                   luminal narrowing
                  of the right common
                  carotid artery and
                thickening of the right
                  subclavian artery,
                homogeneous concentric
                thickening of the main
                pulmonary artery and of
               the entire ascending and
                descending aortic wall

CRP--C-reactive protein, ESR--erythrocyte sedimentation rate,
MR--magnetic resonance
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Article Details
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Title Annotation:Letters to the Editor/Editore Mektuplar
Author:Hamzaoui, Amira; Salem, Randa; Klii, Rim; Harzallah, Olfa; Berriche, Olfa; Golli, Mondher; Mahjoub,
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Date:Jun 1, 2011
Words:940
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