Tocilizumab and Renal Artery Stent—Therapeutic Strategy for Takayasu Arteritis

Takayasu vasculitis (TAK) is a form of large vessel vasculitis clinically manifesting as pulseless disease or hypertension. It is more common in South East Asia and Japan, India, and Mexico [1]. It is increasingly being recognized due to increased awareness among medical fraternity and better imaging modalities. Undetected hypertension, pulselessness, and syncope are more common symptoms and presentation during pregnancy is unusual and can lead to bad obstetric outcomes. Recent evidences support the use of tocilizumab for inducing remission in Takayasu arteritis. We report this rare case of vasculitis presenting in pregnancy as malignant hypertension. A 20-year-old pregnant woman (45 days) presented with headache and nausea but no fever. She had a history of intermittent claudication of legs for the past 3 years but not evaluated. During examination, pulses were felt normally and blood pressure (BP) 180/110, no murmurs in cardiac auscultation, but she had abdominal bruit (renal vessels). Other systems were normal. Echocardiogram (ECHO) showed dilated ascending aorta. Doppler of renal vessels showed narrowing of renal arteries. Unfortunately, she had to undergo termination of pregnancy (high BP in spite of antihypertensives). Her computed tomography (CT) angiogram showed features of TAK with type 5 pattern–she had methylprednisolone infusion 500 mg daily for 3 days, followed by injection tocilizumab 400 mg monthly 3 doses. Once remission was achieved, she had recanalization by percutaneous transluminal angioplasty of right renal artery. She is currently maintained on aspirin and telmisartan. Awareness of causes of high BP, inputs by radiologist, cardiologist, and rheumatologist and understanding by the patient and family helped to achieve good outcome albeit the miscarriage.

Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome (MALS) is a condition characterized by pain in the abdominal region attributed to compression of the celiac artery by the median arcuate ligament of the diaphragm during expiration. MALS is also known as celiac artery compression syndrome, celiac axis syndrome, or Dunbar syndrome. Pain may result from the tight pressing on the celiac nerves in the area. The patient usually presents with symptoms such as postprandial epigastric pain, weight loss, and, occasionally, an abdominal bruit. Furthermore, some individuals may experience nausea and vomiting. It may be an etiology of a rare disorder, chronic mesenteric ischemia.

Chronic Abdominal Pain in the Elderly: Ischemic Pain

Elderly patients with chronic abdominal pain are commonly misdiagnosed, most likely due to atypical symptom presentations. Chronic mesenteric ischemia is a rare cause of chronic abdominal pain in the elderly. Symptoms are postprandial abdominal pain, weight loss, and an abdominal bruit. The disease results from atherosclerotic plaques that reduce the bowel’s ability to increase blood flow after meals. Patients often are malnourished. Diagnosis can be made with various imaging modalities, although a computed tomography angiogram is likely needed when the syndrome is suspected. The mainstay of therapy for chronic mesenteric ischemia is surgical intervention. Interventional pain techniques, such as celiac plexus neurolysis or spinal cord stimulation, are promising adjunct treatment options.

Laparoscopic decompression as treatment for median arcuate ligament syndrome

Median arcuate ligament syndrome (MALS) is a rare disorder due to coeliac trunk compression by the median arcuate ligament, resulting in coeliac artery stenosis characterised by chronic, recurrent abdominal pain. Patients with MALS are often middle-aged females presenting with a triad of postprandial epigastric pain, weight loss and abdominal bruit. It is a diagnosis of exclusion and confirmed by computed tomography or magnetic resonance imaging. Laparoscopic or open surgical decompression are the only treatment options in MALS. We present two cases of MALS treated by laparoscopic decompression as well as a literature review on this treatment.