Takayasu arteritis: differential diagnosis in a teenager with severe acute kidney injury - a case report

Abstract

Takayasu arteritis (TA) is a chronic granulomatous inflammatory condition of unknown cause that involves large vessels - particularly the aorta and its branches - such as the carotid, coronary, pulmonary, and renal arteries. The left subclavian artery is the most frequently involved vessel. Stenosis of the renal artery has been reported in 23-31% of the cases and may result in malignant hypertension, ischemic renal disease, decompensated heart failure, and premature death. Involvement of both renal arteries is uncommon. Early onset anuria and acute kidney injury are rare and have been reported only in a few cases in the literature. This report describes the case of a 15-year-old female with constitutional symptoms evolving for a year, combined with headache, nausea, and vomiting, in addition to frequent visits to emergency services and insufficient clinical examination. The patient worsened significantly six months after the onset of symptoms and developed acute pulmonary edema, oliguria, acute kidney injury, and difficult-to-control hypertension, at which point she was admitted for intensive care and hemodialysis. Initial ultrasound examination showed she had normal kidneys and stenosis-free renal arteries. The patient was still anuric after 30 days of hospitalization. A biopsy was performed and revealed her kidneys were normal. Computed tomography angiography scans of the abdominal aorta presented evidence of occlusion of both renal arteries. The patient met the diagnostic criteria for Takayasu arteritis and had a severe complication rarely described in the literature: stenosis of the two renal arteries during the acute stage of ischemic renal disease.

Takayasu arteritis, an atypical presentation as chronic kidney disease

“…8 Prolonged ischemia due to renal artery involvement releases inflammatory markers leading to fibrosis, glomerular hyalinization and progressive kidney atrophy. 9 Our patient presented with young onset hy-pertension with bilateral contracted kidney, due to renal artery involvement.…”

Is prolonged febrile syndrome associated with reactive thrombocytosis a possible association in the diagnosis of Takayasu’s arteritis? A case report

“…21 Renal artery stenosis, present in 23-31% of cases, causes malignant hypertension, heart failure or death. 22 In the literature, a single case was reported as being diagnosed after 3 years from the detection of thrombocytosis associated with general manifestations, which suggests that Takayasu's arteritis should be included in the differential diagnosis of these manifestations. 23 Although it seems premature, the findings from this current case suggest that this is more common, probably not routinely evaluated and that it is also possible to measure fibrin monomers during the inflammatory episodes of Takayasu's arteritis.…”

Takayasu’s Arteritis Presenting as Heart Failure in a 19-Year-Old Female

“…The mechanism of hypertension in TA is not well defined but likely involves mechanical vascular obstruction, neural activation of baroreceptors from aortic arch involvement, and hormonal factors (3) . TA involves the renal arteries, resulting in stenosis in 23% to 31% of cases (7) , which likely leads to activation of the renin-angiotensin-aldosterone-system (RAAS), contributing to severe hypertension.…”