title: Combined immunosuppressive therapy including a TNF-alpha blocker induces remission in a difficult to treat patient with Takayasu arteriitis and coronary involvement.
abstract: A 40 year old woman presented with symptoms of a systemic inflammatory disease and obstruction of the left subclavian artery. Takayasu arteriitis (TA) was clinically diagnosed and confirmed by MR angiography and FDG-PET scan showing inflammation of the aortic arch and the left subclavian artery. Immunosuppression with glucocorticoids and methotrexate resulted in immediate clinical improvement and normalization of systemic markers of inflammation. Despite that the patient developed chest pain on exertion suggesting coronary involvement, which was confirmed by dobutamine stress echocardiography. After adding the TNF-alpha blocker infliximab coronary symptoms gradually improved and a clinically stable situation could be achieved for more than 6 months. Coronary angiography and aortography showed an occluded main stem of the left coronary artery, an occluded left subclavian artery, and stenoses of the brachiocephalic trunk and the left common carotid artery. Revascularization of the coronary artery and the aortic arch and its branches was performed. The patient returned to work two months after the operation. Immunosuppressive therapy with infliximab and methotrexate is continued, glucocorticoids were stopped after one year of treatment. This case shows that vascular progress in TA patients may occur even when systemic inflammation is controlled, therefore patients have to be carefully observed for new vascular manifestations. TNF-alpha blockers may be an additional treatment option in otherwise difficult to treat TA patients allowing to perform revascularization after a stable disease state has been achieved.
authors.affiliation: Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Mahlmann
authors.forename: C
authors.initials: C
authors.lastname: Pfluecke
authors.forename: A
authors.initials: A
authors.lastname: Ouda
authors.forename: G
authors.initials: G
authors.lastname: Simonis
authors.forename: N
authors.initials: N
authors.lastname: Weiss
authors.forename: U
authors.initials: U
authors.lastname: Kappert
mesh_terms: D000328:Adult; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology / Q000601:surgery; D004359:Drug Therapy, Combination; D025401:Echocardiography, Stress; D005260:Female; D019788:Fluorodeoxyglucose F18; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D000069285:Infliximab; D018810:Magnetic Resonance Angiography; D008727:Methotrexate / Q000627:therapeutic use; D049268:Positron-Emission Tomography; D011237:Predictive Value of Tests; D019275:Radiopharmaceuticals; D012074:Remission Induction; D013625:Takayasu Arteritis / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D000911:Antibodies, Monoclonal; D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D019275:Radiopharmaceuticals; D014409:Tumor Necrosis Factor-alpha; D019788:Fluorodeoxyglucose F18; D000069285:Infliximab; D008727:Methotrexate