takayasu arteritis associated with systemic sclerosis

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LETTER Mod Rheumatol (2006) 16:120–121 © Japan College of Rheumatology 2006 DOI 10.1007/s10165-006-0459-5 Gönenç Kocabay · Betül Tiryaki · Ahmet Ekmekçi Murat I . nanç Takayasu arteritis associated with systemic sclerosis Received: January 13, 2006 / Accepted: January 25, 2006 Key words Genetic basis · Systemic sclerosis (SSc) · Takayasu arteritis (TA) Takayasu arteritis (TA), or pulselessness disease, is a necro- tizing and obliterative giant cell arteritis whose etiology is unknown; it involves the aorta and its main branches, and coronary and pulmonary arteries. It is diagnosed by clinical findings and angiographic investigation. 1 Systemic sclerosis (SSc) is a connective tissue disease of unknown etiology. Its vasculopathy is manifested by abnormal collection of col- lagen and extracellular matrix in skin and internal organs, and is caused by immunologic mechanisms. 1 Causes of TA associated with SSc are rarely found. 2 We report the case of a patient with TA who developed SSc 1 year later. This is the third case of Takayasu arteritis associated with systemic sclerosis reported in the literature. A 48-year-old female patient was admitted to our clinic with complaints of malaise and cyanosis on the fingertips, especially in cold environments. One year previously a physical examination for intermittent claudication had shown that she had no pulse on the distal arms. Doppler ultrosonographic investigation showed 85% and 75% nar- rowing of the right and left subclavian arteries, respectively. The narrowing showed that the left and right subclavian arteries were obliterated on the distal side of the vertebral artery bifurcation region (Fig. 1). Angiographic investiga- tion of the lower extremities revealed that visualization was not possible for the right dorsal pedal artery, the 1/3 distal side of left tibial anterior artery, and the left dorsal pedal artery. The patient was diagnosed as having TA. She had a 3-year history of Raynaud phenomenon in her medical record. Physical examination showed that her blood pressure was 150/70 mmHg on right thigh, pulse rate rhythm 74/min, and upper extremity pulses could not be palpated. There was no murmur on the vessels of the neck. There were dermal indurations on the proximal metacar- popharyngeal joints and fingers of both hands. There were no abnormalities on the other systemic organs. Laboratory investigations were as follows: leukocyte 10 500/µl, neutrophil 8100/µl, lymphocyte 1400/µl, erythro- cyte 4000 × 10 3 /µl, hemoglobin 12 g/dl, hematocrit 35%, mean erythrocyte volume 91 fl, thrombocyte 223 000/µl, erythrocyte sedimentation rate 14 mm/h, and CRP 7.2 mg/l; serum biochemical examination showed fasting glucose in- tolerance. Human leukocyte antigen (HLA) tissue typing by Terasaki microphototoxicity method showed HLA-A1, 11; HLA-B*41, 52; HLA-DRB1*08, 10. Her thyroidal hormone profile was normal and HbA1c level 6%. Sero- logic investigation revealed that she had positive nuclear type antinuclear antibody and positive anticentromer antibody in 1/320 dilution, and positive anticardiolipin IgM 14.4 MPLU/ml (normal, <40), anticardiolipin IgG 10.4 MPLU/ml (normal, <11) antibodies. Her chest radio- graphy, echocardiography, and respiratory function tests were normal. The patient was diagnosed as having systemic sclerosis by the findings of sclerodactyly, the presence of Raynaud phenomenon for 3 years, and positive anticentromer antibody. Diagnostic clinical evidence on SSc included the finding of Raynaud phenomenon and the presence of a short period between Raynaud phenomenon and SSc, and symmetrical skin involvement in both forearms, face, and trunk, as well as narrowing of the mouth orifice. The sup- porting serological evidence included nuclear type ANA staining and positive anticentromer antibody. She was given calcium channel blocker in addition to Takayasu arteritis therapy. G. Kocabay 1 (*) · A. Ekmekçi · M. I . nanç Departments of Internal Medicine and Rheumatology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey B. Tiryaki Department of Radiology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey Present address: 1 Ahmet Vefik Pas ¸a Caddesi yas ¸am Apartmanı No 60, Kat 2 Daire 2, Çapa, I . tanbul, Turkey Tel./Fax +90-532-518-0035 e-mail: [email protected]. Mod Rheumatol Downloaded from informahealthcare.com by The University of Manchester on 10/31/14 For personal use only.

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Page 1: Takayasu arteritis associated with systemic sclerosis

LETTER

Mod Rheumatol (2006) 16:120–121 © Japan College of Rheumatology 2006DOI 10.1007/s10165-006-0459-5

Gönenç Kocabay · Betül Tiryaki · Ahmet EkmekçiMurat I

.nanç

Takayasu arteritis associated with systemic sclerosis

Received: January 13, 2006 / Accepted: January 25, 2006

Key words Genetic basis · Systemic sclerosis (SSc) ·Takayasu arteritis (TA)

Takayasu arteritis (TA), or pulselessness disease, is a necro-tizing and obliterative giant cell arteritis whose etiology isunknown; it involves the aorta and its main branches, andcoronary and pulmonary arteries. It is diagnosed by clinicalfindings and angiographic investigation.1 Systemic sclerosis(SSc) is a connective tissue disease of unknown etiology. Itsvasculopathy is manifested by abnormal collection of col-lagen and extracellular matrix in skin and internal organs,and is caused by immunologic mechanisms.1 Causes of TAassociated with SSc are rarely found.2 We report the case ofa patient with TA who developed SSc 1 year later. This isthe third case of Takayasu arteritis associated with systemicsclerosis reported in the literature.

A 48-year-old female patient was admitted to our clinicwith complaints of malaise and cyanosis on the fingertips,especially in cold environments. One year previously aphysical examination for intermittent claudication hadshown that she had no pulse on the distal arms. Dopplerultrosonographic investigation showed 85% and 75% nar-rowing of the right and left subclavian arteries, respectively.The narrowing showed that the left and right subclavianarteries were obliterated on the distal side of the vertebralartery bifurcation region (Fig. 1). Angiographic investiga-

tion of the lower extremities revealed that visualization wasnot possible for the right dorsal pedal artery, the 1/3distal side of left tibial anterior artery, and the left dorsalpedal artery. The patient was diagnosed as having TA.She had a 3-year history of Raynaud phenomenon in hermedical record. Physical examination showed that herblood pressure was 150/70mmHg on right thigh, pulse raterhythm 74/min, and upper extremity pulses could not bepalpated. There was no murmur on the vessels of the neck.There were dermal indurations on the proximal metacar-popharyngeal joints and fingers of both hands. There wereno abnormalities on the other systemic organs.

Laboratory investigations were as follows: leukocyte10500/µl, neutrophil 8100/µl, lymphocyte 1400/µl, erythro-cyte 4000 × 103/µl, hemoglobin 12g/dl, hematocrit 35%,mean erythrocyte volume 91fl, thrombocyte 223000/µl,erythrocyte sedimentation rate 14mm/h, and CRP 7.2mg/l;serum biochemical examination showed fasting glucose in-tolerance. Human leukocyte antigen (HLA) tissue typingby Terasaki microphototoxicity method showed HLA-A1,11; HLA-B*41, 52; HLA-DRB1*08, 10. Her thyroidalhormone profile was normal and HbA1c level 6%. Sero-logic investigation revealed that she had positive nucleartype antinuclear antibody and positive anticentromerantibody in 1/320 dilution, and positive anticardiolipinIgM 14.4MPLU/ml (normal, <40), anticardiolipin IgG10.4MPLU/ml (normal, <11) antibodies. Her chest radio-graphy, echocardiography, and respiratory function testswere normal.

The patient was diagnosed as having systemic sclerosisby the findings of sclerodactyly, the presence of Raynaudphenomenon for 3 years, and positive anticentromerantibody. Diagnostic clinical evidence on SSc included thefinding of Raynaud phenomenon and the presence of ashort period between Raynaud phenomenon and SSc, andsymmetrical skin involvement in both forearms, face, andtrunk, as well as narrowing of the mouth orifice. The sup-porting serological evidence included nuclear type ANAstaining and positive anticentromer antibody. She was givencalcium channel blocker in addition to Takayasu arteritistherapy.

G. Kocabay1 (*) · A. Ekmekçi · M. I.nanç

Departments of Internal Medicine and Rheumatology, IstanbulSchool of Medicine, Istanbul University, Istanbul, Turkey

B. TiryakiDepartment of Radiology, Istanbul School of Medicine, IstanbulUniversity, Istanbul, Turkey

Present address:1Ahmet Vefik Pasa Caddesi yasam Apartmanı No 60, Kat 2 Daire 2,Çapa, I

.tanbul, Turkey

Tel./Fax +90-532-518-0035e-mail: [email protected].

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Page 2: Takayasu arteritis associated with systemic sclerosis

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Takayasu arteritis has been found to be associated withHLA-B3902, B5201, DRB1*1502, DPB1*0901 by HLA-Bgen and class 2 gen (DRB1, DQA1, DQB1, DPB1) typingin Japanese people, HLA-B5 in Indian people, and HLA-

Fig. 1. Narrowing showed that the left and right subclavian arterieswere obliterated on the distal side of the vertebral artery bifurcationregion

B52 and HLA-B15 in Mexican Mestizo people.1–3 Progres-sive systemic sclerosis is associated with HLA antigens B8,DR3 and DR52.4 In addition, it is also associated with HLAantigens A9 and its subgroup Aw24.5 Systemic sclerosisis found to be strongly associated with HLA-DRB1*1104allele in the Greek community.6

References

1. Passiu G, Vacca A, Sana G, Cauli A, Laudadio M, Garau P, et al.Takayasu’s arteritis overlapping with systemic sclerosis. Clin ExpRheumatol 1999;17:363–5.

2. Yago T, Ota S, Nishinarita M. A case of systemic sclerosis compli-cated by Takayasu’s arteritis. Ryumachi 2002;42:605–9.

3. Vargas-Alarcon G, Flores-Dominguez C, Hernandez-Pacheco G,Zuniga J, Gamboa R, Soto ME, et al. Immunogenetics and clinicalaspects of Takayasu’s arteritis patients in a Mexican Mestizo popu-lation. Clin Exp Rheumatol 2001;19:439–43.

4. Hietarinta M, Ilonen J, Lassila O, Hietaharju A. Association ofHLA antigens with anti-Scl-70-antibodies and clinical manifesta-tions of systemic sclerosis (scleroderma). Br J Rheumatol 1994;33:323–6.

5. Clements PJ, Opelz G, Terasaki PI, Mickey MR, Furst D. Associa-tion of HLA antigen a9 with progressive systemic sclerosis (sclero-derma). Tissue Antigens 1978;11:357–61.

6. Vlachoyiannopoulos PG, Dafni UG, Pakas I, Spyropoulou-VlachouM, Stavropoulos-Giokas C, Moutsopoulos HM. Systemic sclero-derma in Greece: low mortality and strong linkage with HLA-DRB1*1104 allele. Ann Rheum Dis 2000;59:359–67.

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