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TO
CASE PRESENTATION


A YOUNG LADY WITH HEADACHE
PRESENTER:
Dr. Syed Mohammad Ali Romel
MD ( Cardiology) 3
rd
part

MODERATOR:
Dr. Mohammad Ullah
Asstt. Professor
Dept. of Cardilogy,NICVD.
PARTICULARS OF THE PATIENT

Name : Mrs. X.
Age : 29 years.
Sex : Female.
Religion : Islam.
Marital Status : Married.
Occpation : Service holder.
Address : Gazipur, Dhaka.
Date of examination : 20 March, 2011.
THE PRESENTING COMPLAINT


Headache for 3 years.
HISTORY OF PRESENT ILLNESS

According to the statement of the patient
she was alright 3 years back. Then she has
developed episodic, global headache . It is
associated with neck pain , dizziness and
malaise. It was not associated with history of
fall, loss of consciousness, blurring of vision,
aura, nausea, vomiting. Her headache has
no diurnal or perimenstrual variation, no
trigerring factor.



She has got no history of joint pain, pain in
the limbs on walking or at rest, skin rash.
Colour change of palm and sole on exposure
to cold.
She has no significant weight loss. Her
appetite is good.
She has got no H/O palpitation, chest pain
or breathlessness.
Past History:
She had TB Lymphedinitis 2 years back and
treated for 1 year.
No history of migraine ,DM, HTN, Bronchial
asthma.

Family history: Nothing contributory.

Personal history : Nothing contributory.
Menstrual history :
Normal, she takes OCP intermittently.
Obstetric history :
Married for 5 years. Nulliparus, no history of abortion.
Treatment history:
Amlodipin, Bromazepum.
Socioeconomic history :
Middle class
GENERAL EXAMINATION

Appearance : Good
Biuld : Average
Nutrition : Average
Anaemia :
Jaundice : Absent
Cyanosis :

GENERAL EXAMINATION.
Clubbing :
Koilonychia : Absent
Leoconychia :

Oedema : Absent
Dehydration : Absent
Skin condition : Normal, no xenthelesma, xenthomata.
Neck vein : Not raised with normal wave pattern

Respiratory rate : 15 breaths / min

Joints : Normal

SYSTEMIC EXAMINATION : CVS

Pulse : 84 / min, regular and
normal in character, B
Right hand normal volume
left hand -- Small volume
Right Carotid normal volume, N
bruit present RB
Left Carotid -- Small volume, no bruit. N
There was Radio femoral delay. RFD
Popliteal and ADP in both sides are
present but small volume.
Vessel wall was normal.
Examination Of CVS.

Blood pressure:

Right hand 155 / 90 mm Hg
Left hand -- 90 / 60 mm Hg
Lower limb (B/L) 100 / 70 mm Hg

JVP : Not raised with normal wave pattern

Examination Of CVS.
Precordium :
Normal in shape
Apex beat was in left 5
th
intercostal space,
just medial to the left mid clavicular line,
heaving in character
There is no left parasternal heave
P
2
was not palpable,
There was no thrill.
Examination Of CVS.

Heart sounds :
1
st
and 2
nd
heart sound were
normally audible in all four
auscultatory areas.
There was a systolic murmur in the back
best heard in around 10
th
thoracic vertebra.

Examination of abdomen :
Bilateral renal bruit was present
Other findings were revealed normal.

Fundus : Normal.

Other systems : Normal


SALIENT FEATURE
Mrs. X , 29 years ,married woman, by profession a
service holder, hailing from gazipur, Dhaka,
attended in OPD on 20 March, 2011 with the
complaint of progressive, episodic, dull aching
global headache for 3 years.
It was associated with dizziness, neck pain and
malaise.
It was not associated with fever, nausea, vomiting,
aura, blurring of vision, syncope, convulsion,
weakness of any part of the body, limb claudication,
Raynauds phenomena, skin rash, joint pain.

SALIENT FEATURE


Her pulse was 84 beats/min, regular, normal
character, normovolumic in right upper limb but
small volume in left hand and both lower limbs.
There was no radio-radial delay but radio-femoral
delay was there. Vessel wall was normal. Blood
pressure was 155 / 90 mm Hg in right hand . 90 / 60
mm Hg and 100 / 70 mm Hg in left hand and lower
limb respectively. There was carotid bruit in right
side.




SALIENT FEATURE

Apex beat was in left 5
th
intercostal space 9 cm from
the midline, heaving in character.
There was no thrill, no left parasternal heave, no
palpable P
2
.
1
st
and 2
nd
heart sound were normal in all areas.
There was a systolic murmur in the back best heard
in around 10
th
thoracic vertebra.
Bilateral renal bruit was present.


PROVITIONAL DIAGNOSIS


Takayasus arteritis
DIFFERENTIAL DIAGNOSES
Coarctaion of aorta.
Atherosclerotic Peripheral vascular
disease.
Cervical rib.
Interrupted aortic arch.
D/D Points in favors Points against
Takayasus arteritis Young female, < 40
yrs.
Headache, dizziness,
malaise
Past history of TB
Lymphadenitis.
HTN in right Upper
limb.
Small volume pulse &
BP in left. upper limb
& lower limb.
Right sided carotid
bruit.
Bilateral renal bruit.
No history
suggestive of
disease activity, like-
high fever, wt. loss,
anorexia, skin rash,
joint pain.
No limb claudication.
No history of stoke,
convulsion,
hemiplegia


D/D Points in favors Points against
Coarctation of
aorta
Young age.
Hypertension.
Radio-femoral delay.
Small volume pulse & BP
in left. upper limb
(preductal) & lower limb.
Murmur in back.
No history of lower
limb coldness,
claudication, atrophy.
No visible collateral
vessel in front & back
of the chest.
No upper left
parasternal systolic
murmur.



D/D Points in favors Points against
Atherosclerotic
peripheral
vascular disease
Headache, dizziness.
HTN in right Upper limb.
Small volume pulse & BP
in left. upper limb & lower
limb.
Right sided carotid bruit.
Bilateral renal bruit.

Young female.
Non-diabetic.
No family history of
hypertension, DM,
hyperlipidaemia.
No xenthelesma,
xenthomata.
Vessel wall normal
Cervical rib Neck pain, headache No history of
Raynauds
phenomena.
No neurological
feature, like-
redicular pain,
pareasthesia, hand
muscle wasting.


D/D Points in favors Points against
Interrupted aortic
arch
HTN in right Upper
limb.
Small volume pulse &
BP in left. upper limb
& lower limb.
Right sided carotid
bruit.
Rare disease.
Early onset of
symptom in
childhood.
INVESTIGATIONS
CBC : Hb 12.5 mg/dl
ESR 32 mm in 1
st
hour.
TC of WBC 12000 / mm
3

DC of WBC N : 74%, L : 20%
E : 03%, M : 03%
RBS : 5.4 mmol / L.
Urine R/M/E : Alb : Nil, Sugar : Nil
Pus cell : 3-5 / HPF
RBC : Nil, RBC cast : Absent
INVESTIGATIONS..
S. Creatinine : 0.7 mg/dl
Blood urea : 20 mg/dl

Fasting lipid profile :
S. Cholesterol 136 mg/dl
S. HDL -- 36 mg/dl
S. LDL -- 79 mg/dl
S. Trigliceride -- 90 mg/dl

CRP : Negative
HBsAg : Negative
VDRL : Non reactive

INVESTIGATIONChest X-Ray P/A view
INVESTIGATIONECG
INVESTIGATION..


Duplex study
INVESTIGATION.


CT Angiogram
CONFIRMED DIAGNOSIS


Takayasus arteritis
MANAGEMENT
Explanation and reassurance.
Medical management of Takayasus arteritis
depends on the disease activity and the
complications.
MANAGEMENT.
Medical management:
Treatment of hypertension

Interventions

Surgical management
General measures
Diet modification is necessary to manage hypertension
or renal failure.
Activity limitations depend on the severity of the
disease and complications.
Management organ failure, stroke, complications of
pregnancy, seizures, and intracranial hemorrhage.
ICU admission is indicated for patients with critical
deterioration.
Fetal monitoring is indicated in patients with suspected
complications

Prognosis
Takayasus arteritis is rare, data on mortality and morbidity are limited.

Mortality- 35% in Japan and china but 3% mortality world wide.

NIH study showed that 20% of patients had a monophasic illness- self-
limiting.

Remaining 80% of patients pass through relapse and remitting course.

60%. of these, one half experienced relapse after immunosuppressive
therapy was stopped.

The overall morbidity depends on the severity of the lesions and their
consequences.

FOLLOW UP
Disease activity assessment.

Blood pressure

Early detection and management of complications,
like- stroke, intracranial hemorrhage, seizures,
graft stenosis and/or occlusion, ischemia, organ
failure, complications of hypertension, and fetal
injury.

Diagnostic criteria of Takayasus arteritis
The criteria proposed for the clinical diagnosis of Takayasu's disease (chronic inflammatory
arteriopathy of unknown origin) were based on clinical and angiographic data from 108
Japanese patients: 96 with Takayasu's disease and 12 with another disease of the aorta.
One obligatory criterion -- Age less than or equal to 40 years.
Two major criteria -- Left and right mid subclavian artery lesions.
Nine minor criteria
1. High ESR
2. Common carotid artery tenderness
3. Hypertension
4. Aortic regurgitation or annuloaortic ectasia
5. Lesions of the pulmonary artery
6. Left mid common carotid artery
7. Distal brachiocephalic trunk
8. Thoracic aorta
9. Abdominal aorta.
In addition to the obligatory criterion, the presence of two major criteria or of one major
plus two or more minor criteria, or of four or more minor criteria suggests a high probability
of the presence of Takayasu's disease.
The criteria had a 84% sensitivity .