CASE REPORT
We present a case of a 25-year-old black African male who presented to our hospital with a 2-day history of sudden onset right sided weakness and inability to talk. He denied any history of headache, fever, prior trauma or chest pain. Additionally, he had no history of chronic illness, intravenous drug use, cigarette smoking, alcohol use or any personal or family history of hypertension, diabetes or cardiovascular disease. Our patient had been working as a commercial motorcycle rider. General exam revealed a young man who was awake and responsive, not in any respiratory distress with no conjunctival pallor. He had a blood pressure reading of 130/79 mmHg on his right arm and 80/47 mmHg on the left arm revealing an obvious discrepancy between the two arms. Our patient had motor aphasia with right sided cranial nerve 7,9,10,11 and 12 palsy. Motor power of 0/5 on the right upper and lower limb on all muscle groups was noted with normal power on the left. Additionally, we noted hyperreflexia and increased tone on the right limbs with normal global sensation. No cerebellar signs were present. On cardiovascular exam our patient had absent pulses on the left arm, an audible carotid bruit on the left with normal heart sounds without any murmur. A distended bladder with urine retention was present on abdominal exam. Further systemic exam was non-revealing. Working with a diagnosis of a cerebrovascular accident likely due to a large vessel vasculitis, a CT scan of the head was ordered and showed a left sided fronto-temporal hypodensity consistent with an ischemic infarct. (See figure 1.) Carotid doppler ultrasound revealed bilateral carotid artery stenosis with 50% occlusion on the right and complete occlusion on the left. Further, a CT angiogram showed left subclavian artery occlusion and bilateral carotid artery stenosis with complete occlusion on the left. (See figure 2 and 3.) A 2D transthoracic echocardiogram and ECG were normal. His screen for syphilis with VDRL was negative. A CSF GeneXpert and BioFire® meningo-encephalitis panel were negative. Of note, ESR and CRP were high with values of 85mm/hr. and 30.4mg/L respectively. Additionally, lipid profile results returned normal with a negative HIV test by ELISA and antinuclear antibody test. His full hemogram and kidney function tests were normal with a hemoglobin level of 15.4 g/dl. Based on the above clinical findings and tests, a diagnosis of Takayasu Arteritis was made. Management was initiated with aspirin 75mg and our patient pulsed with high dose methyl prednisone at one gram once daily for 3 days. Thereafter a maintenance dose of azathioprine 100mg twice daily, deflazacort 6mg twice daily and physiotherapy was initiated. At 3 months post discharge, he is doing well and has a power of 3/5 on the right lower limb, is able to talk with a slurred speech with no other organ involvement noted.