Combined immunosuppressive therapy including a TNF-α blocker induces remission in a difficult to treat patient with takayasu arteriitis and coronary involvement [Kombinierte immunsuppressive Th erapie einschlieslich eines TNF-α Blockers zur Remissionsinduktion bei einer schwierig zu behandelnden Patientin mit Takayasu Arteriitis mit koronarer Beteiligung]

摘要

A 40 year old woman presented with symptoms of a systemic infl ammatory disease and obstruction of the left subclavian artery. Takayasu arteriitis (TA) was clinically diagnosed and confi rmed by MR angiography and FDG-PET scan showing infl ammation 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 infl ammation. Despite that the patient developed chest pain on exertion suggesting coronary involvement, which was confi rmed by dobutamine stress echocardiography. Aft er adding the TNF-α blocker infl iximab 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. Th e patient returned to work two months aft er the operation. Immunosuppressive therapy with infl iximab and methotrexate is continued, glucocorticoids were stopped aft er one year of treatment. Th is case shows that vascular progress in TA patients may occur even when systemic infl ammation is controlled, therefore patients have to be carefully observed for new vascular manifestions. TNF-α blockers may be an additional treatment option in otherwise diffi cult to treat TA patients allowing to perform revascularization aft er a stable disease state has been achieved.