A Curious Case of "Septic Shock".
BACKGROUND
Takayasu arteritis, also known as "pulseless disease," causes proximal occlusion of the lumen of large arteries of the neck and arm, leading to impalpable pulses and "pseudohypotension." This may misdirect the management plan for a patient in the emergency setting if the presence of vascular occlusion is not previously known.


METHODS
We describe a young woman who presented to the emergency department (ED) with fever. On evaluation, she had shock, which was not responsive to a fluid bolus. Bedside Rapid Diagnostic Test was positive for Plasmodium vivax, and a diagnosis of severe vivax malaria was made. She was started on intravenous artesunate and vasopressors in view of her persistent hypotension in the face of a normal central venous pressure. A thorough examination at that time revealed palpable lower limb pulses with feeble upper limb pulses. Vasopressors were tapered while monitoring lower limb blood pressure. Computed tomographic angiogram confirmed the diagnosis of Takayasu arteritis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hypotension and shock are regularly encountered in the ED. Occlusive arterial disease involving upper limbs can mimic refractory shock, leading to potentially harmful and unnecessary interventions. Emergency physicians should be aware of this possibility. A simple routine of quickly checking all peripheral pulses would help them avoid this pitfall.
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Arjun
A
Lakshman
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Charanpreet
C
Singh
Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Manphool
M
Singhal
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Sanjay
S
Jain
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Navneet
N
Sharma
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Savita
S
Kumari
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Subhash
S
Varma
D000328:Adult; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use; D000962:Antimalarials / Q000494:pharmacology / Q000627:therapeutic use; D037621:Artemisinins / Q000494:pharmacology / Q000627:therapeutic use; D000077332:Artesunate; D002443:Ceftriaxone / Q000494:pharmacology / Q000627:therapeutic use; D004338:Drug Combinations; D005260:Female; D006801:Humans; D016780:Malaria, Vivax / Q000150:complications* / Q000503:physiopathology; D009638:Norepinephrine / Q000494:pharmacology / Q000627:therapeutic use; D010966:Plasmodium vivax / Q000472:pathogenicity; D011319:Primaquine / Q000494:pharmacology / Q000627:therapeutic use; D011739:Pyrimethamine / Q000494:pharmacology / Q000627:therapeutic use; D012772:Shock, Septic / Q000209:etiology* / Q000503:physiopathology*; D013413:Sulfadoxine / Q000494:pharmacology / Q000627:therapeutic use; D013625:Takayasu Arteritis / Q000150:complications* / Q000503:physiopathology; D014662:Vasoconstrictor Agents / Q000494:pharmacology / Q000627:therapeutic use; D014667:Vasopressins / Q000494:pharmacology / Q000627:therapeutic use
D000900:Anti-Bacterial Agents; D000962:Antimalarials; D037621:Artemisinins; D004338:Drug Combinations; D014662:Vasoconstrictor Agents; D014667:Vasopressins; C001205:fanasil, pyrimethamine drug combination; D000077332:Artesunate; D002443:Ceftriaxone; D013413:Sulfadoxine; D011319:Primaquine; D009638:Norepinephrine; D011739:Pyrimethamine
Takayasu arteritis; pseudohypotension; pulseless disease; upper limb occlusive arterial disease