In foreign literature, 90% of renal artery stenosis (RAS) is atherosclerotic and 10% secondary to fibromuscular dysplasia (FMD). However, an important differential for hypertension in the young Asian population is Takayasu's arteritis. We present four young patients who initially presented with hypertension due to RAS. Clinical criteria coupled with non-invasive studies in all four cases led to the diagnosis of Takayasu's arteritis. All four patients had good outcomes.
Four patients (1 male and 3 females) all presented with early-onset hypertension in the third decade of life. Two of the females were pregnant at the time they were seen by the Cardiology service of our institution. Physical examination of the abdomen and peripheral pulses provided clinical clues that suggested the diagnosis of Takayasu's arteritis. All four patients had confirmed significant RAS on CT aortogram studies, thus explaining their elevated blood pressures. None had significant elevations in serum creatinine.
Although two patients were initially misdiagnosed as FMD, and one was initially managed just as preeclampsia, utilizing the Ishikawa and American College of Rheumatology (ACR) criteria led to the proper diagnosis of Takayasu's arteritis. The patients were given varying combinations of anti-hypertensives with or without prednisone to control vasculitic flares/disease activity. The two pregnant inpatients were successfully discharged after their emergency Caesarean sections, and all four are on regular follow-up at the outpatient clinic with controlled blood pressure levels.
This case series highlights that even with the rarity of Takayasu's arteritis, a thorough history and physical examination are crucial in raising our index of suspicion for this disease as a possible cause of RAS and secondary hypertension. This report also emphasizes the complexity of managing pregnant patients with Takayasu's arteritis. Early recognition, a multidisciplinary team, and optimal medical management were the keys to a successful outcome.
Department of Medicine, University of the Philippines - Philippine General Hospital, Philippines