A 29-year-old woman comes to the office due to a 6-month history of numbness and pain in her arms. The pain is worse on the left and is exacerbated by lifting or other activities. Associated symptoms include fatigue, fleeting joint pains, and a 5-kg (11-lb) weight loss. Medical history is unremarkable, and the patient does not use tobacco or illicit drugs. She emigrated from Vietnam 5 years ago and works in a furniture repair shop. Blood pressure is 140/90 mm Hg in the right arm and 90/55 mm Hg in the left; pulse is 78/min and regular. Conjunctival and oral mucosae are moist and without lesions. Cardiopulmonary examination shows clear lung fields and no heart murmurs; however, a bruit is heard in the left supraclavicular fossa, and the left radial and brachial pulses are decreased. Abdominal examination is unremarkable. No skin lesions are present. Complete blood count, electrolytes, urinalysis, and renal function are normal. Erythrocyte sedimentation rate is 80 mm/hr. Which of the following is the most likely diagnosis for this patient?

Question

A 29-year-old woman comes to the office due to a 6-month history of numbness and pain in her arms.  The pain is worse on the left and is exacerbated by lifting or other activities.  Associated symptoms include fatigue, fleeting joint pains, and a 5-kg (11-lb) weight loss.  Medical history is unremarkable, and the patient does not use tobacco or illicit drugs.  She emigrated from Vietnam 5 years ago and works in a furniture repair shop.  Blood pressure is 140/90 mm Hg in the right arm and 90/55 mm Hg in the left; pulse is 78/min and regular.  Conjunctival and oral mucosae are moist and without lesions.  Cardiopulmonary examination shows clear lung fields and no heart murmurs; however, a bruit is heard in the left supraclavicular fossa, and the left radial and brachial pulses are decreased.  Abdominal examination is unremarkable.  No skin lesions are present.  Complete blood count, electrolytes, urinalysis, and renal function are normal.  Erythrocyte sedimentation rate is 80 mm/hr.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_d52b_8a1b_bc81_1fb25643fcbe_MD0003_00 This patient with exertional arm pain (likely claudication), systemic symptoms, and left arm pulse deficits (likely left subclavian stenosis) has typical features of Takayasu arteritis, a chronic large-artery vasculitis that predominantly affects Asian women age <40. It primarily involves the aorta and its branches and is characterized by mononuclear infiltrates and granulomatous inflammation of the vascular media, leading to arterial wall thickening with stenosis, occlusion, or aneurysmal dilation. Initial symptoms are nonspecific (eg, fever, arthralgias, weight loss). As the disease progresses, vascular involvement with arterioocclusive manifestations (eg, claudication) may develop, particularly in the upper extremities. Examination findings include blood pressure discrepancies, pulse deficits, and bruits due to localized arterial stenosis. Patients commonly have elevated inflammatory markers (eg, erythrocyte sedimentation rate [ESR], C-reactive protein). CT or MR angiography, the preferred diagnostic modality, may reveal thickening of large-artery walls and narrowing of the arterial lumen. thickening (Choice A) Coarctation of the aorta proximal to the left subclavian artery can cause pulse deficits and decreased blood pressure in the left upper extremity. However, systemic symptoms (eg, fatigue, arthralgias, weight loss) and elevated inflammatory markers (eg, ESR) would not be expected. (Choice B) Polyarteritis nodosa is a necrotizing vasculitis of medium-sized (eg, renal) arteries that can present with systemic symptoms (eg, fatigue, arthralgias). However, because the kidneys are the most commonly involved organ, renal function and urinalysis are usually abnormal. Large-vessel stenosis (eg, subclavian artery) does not typically occur. (Choice C) Systemic lupus erythematosus (SLE) can cause systemic symptoms, joint pains, and elevated ESR. It classically involves multiple systems, including the skin (eg, rash), mucosa (eg, ulcers), kidneys (eg, nephritis), and/or blood (eg, anemia, leukopenia); it is less likely in this patient who has no skin or mucosal lesions and normal complete blood count, urinalysis, and renal function. In addition, SLE rarely causes large-vessel stenoses. multiple systems (Choice E) Thromboangiitis obliterans (Buerger disease) causes inflammation of the small and medium-sized vessels in the extremities. As the disease progresses proximally, this can manifest as claudication; however, distal involvement (eg, digital ischemia/gangrene) typically occurs first. Thromboangiitis obliterans occurs primarily in heavy smokers. Educational objective: Takayasu arteritis is a large-artery vasculitis most common in women age <40 of Asian descent. It often begins with systemic symptoms (eg, fever, arthralgias, weight loss) and progresses to arterioocclusive symptoms (eg, claudication, blood pressure discrepancies, pulse deficits). References: Update on Takayasu arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/26033561) Diagnostic and classification criteria of Takayasu arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/24461381)

A 29-Year-Old Woman Comes to the Office Due to a 6-Month