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HISTORY

HISTORY. A 36 year old female admitted with H/o pain in the Rt upper limb & Giddiness while working with the Rt upper limb for the past 6 months. She has right eye pain also while working with the upper limbs. No H/o fever, chest pain, dysponea, cough Bowel & Bladder habits normal.

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HISTORY

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  1. HISTORY • A 36 year old female admitted with H/o pain in the Rt upper limb & Giddiness while working with the Rt upper limb for the past 6 months. She has right eye pain also while working with the upper limbs. • No H/o fever, chest pain, dysponea, cough • Bowel & Bladder habits normal

  2. PAST HISTORY: No H/o DM / HT / PT / BA / IHD / Epilepsy • PERSONAL & FAMILY HISTORY: Nil significant • GENERAL EXAMINATION: Conscious, oriented, afebrile Pallor + No clubbing / cyanosis / PE / Jaun / GLA /elev.JVP

  3. VITAL SIGNS - PULSE

  4. Blood Pressure: • RESPIRATORY RATE & TEMP: Normal

  5. SYSTEMIC EXAMINATION: CVS : S1, S2 +, Hyperdynamic impulse EDM + in AA RS : NVBS +, No added sounds ABD : Soft , No mass palpable CNS : NFND

  6. NECK: A 3 * 3 cm sized swelling palpable in the Lt carotid triangle, expansile impulse on palpation +, soft , smooth surface. ? ANEURYSM OF CAROTID ARTERY • PROVISIONAL DIAGNOSIS AORTOARTERITIS / ?Carotid Aneurysm

  7. INVESTIGATIONS • Hb % : 10.4 gms • TC : 9500 • DC : P72 L26 E2 • ESR : 10/25 • PCV : 26 • Urine R/E: Normal • RBS : 119 mgs • Bl.Urea: 16 mg • S.Crea : 0.6 mg

  8. S.Electrolytes: Na+ : 126 meq/L K+ : 2.8 meq/L • LFT: STB: 0.9 mg SGOT: 19 IU/L SGPT : 18 IU/L SAP : 65 IU/L T.Protein : 7.5 gms Albumin : 4.8 gms • ECG : LVH • CXR : Aortic knuckle prominent &calcified Cardiomegaly +

  9. ASO : Neg • CRP : Neg • RF : Neg • ANA : Neg • Mantoux test : Neg • HIV : Neg • VDRL : Neg • Anti- HCV : Neg • HBsAg :Neg

  10. USG ABD: Prominent supra renal aorta ?Aneurysm , SMA prominent. • Echo : AR (mod) No AS TR (mod) MV (normal) • Total Cholesterol: 161 mgs • Thyroid Function Tests: Normal • Fundus : Normal

  11. SURGICAL, RHEUMATOLOGICAL, CARDIAC OPINION: ? AortoArteritis • VASCULAR SURGEON OPINION: ?Aorto Arteritis / ? Carotid Aneurysm , Suggested Doppler study • Doppler Study of Vascular System: 1.Plaque in Rt CCA causing 59 % stenosis of CCA.Due to the stenosis there is no detectable diastolic flow in Rt ICA & Rt ECA

  12. 2. Diseased LCCA indicated by hyperechoiec and irregular intima , no detectable diastolic flow in Lt CCA indicating occlusion prior to LCCA origin. ? In Arch of Aorta 3. Due to the plaque highly pulsatile flow with nil diastolic flow noted in the Lt carotid bulb, Lt ICA & Lt ECA 4.Lt vertebral artery shows no diastolic flow but normal systolic velocity -? Arterial narrowing in ipsilateral SCA

  13. 5.Normal study of Renal arteries, infrarenal aorta , both lower limb arterial system. In these normal flow & velocity noted.

  14. In our case……. • There is claudication of upper extremities • Aneurysm of carotid artery • Aortic Regurgitation • Feeble upper extremities pulses • Typical Doppler study of arterial system …..

  15. FINAL DIAGNOSIS AORTOARTERITIS/ AORTIC REGURGITATION

  16. AORTOARTERITIS • AA is a pan-arteritis involving all the three layers causing extensive intimal proliferation, inflammation of media & adventitia followed by marked fibrous scarring. • Involves aorta & its major branches, pulmonary artery & its branches • TYPES: TYPE I : Inflammatory process is localised to arch of aorta & its branches

  17. TYPE II: Lesions involve the thoraco-abdominal aorta & its branches without the involvement of arch • TYPE III: Combined Type I & Type II • TYPE IV: Pulmonary involvement in addition to features of Type I ,II or III • TYPE V: Involvement of coronary arteries

  18. COMMON PRESENTATIONS: 1.Unequal pulse 2.Hypertension (due to renal artery stenosis) 3.Renal failure 4.Heart failure(HT /Valvular lesions) 5.AR ( Root dilation / valvular) 6..Intermittent claudication 7.Aneurysmal AA( high incidence of AR,HT, Elevated ESR) 7.Others( CNS,Skin,eye changes)

  19. Clinical Diagnosis of Aorto- Arteritis: I. One Obligatory criteria: < 40 yrs II. Two major criteria : Lt & Rt mid subclavian artery lesions III. Nine minor criteria : 1.High ESR 2.CCA tenderness 3. hypertension 4.Aortic Regurgitation 5.lesions of (pulmonary artery,Lt mid CCA , distal BCT, thoracic aorta & abdominal aorta • High Probability of AA: OC + Two/one Major + >=2 / >=4 minor criteria

  20. American College of Rheumatological criteria: 1. Age of onset of disease < 40 yrs 2.claudication of extremities 3. decreased brachial artery pulse 4. BP difference > 10 mmHg bt arms 5.bruit over subclavian artery or aorta 6.arteriogram abnormality 3 of these 6 criteria suggests diagnosis of Aorto-Arteritis

  21. TREATMENT • Glucocorticoids • Cytotoxic drugs (cyclophosphamide, azathioprine, methotrexate) • Antihypertensives &decongestive therapy • Percutaneous Transluminal angioplasty • Surgery

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