D104-03 A Rare Case Of Severe Takayasu Arteritis Masked by Resistant Hypotension

Abstract Takayasu arteritis is a rare large vessel vasculitis with not entirely understood pathophysiology targeting primarily young women and associated with hypertension. This case is an uncommon presentation of Takayasu arteritis with pseudo-hypotension. This case underscores the importance of a broad differential diagnosis when approaching objective hypotension in the setting of a largely asymptomatic patient. A twenty-eight-year-old woman presented to the emergency room with chest pain and hypotension 68/19 (MAPs lower than 65 found on upper extremities with blood pressure cuffs) that failed to respond to fluid resuscitation. Vaso pressors were initiated while workup was performed. The history, physical exam, and lab investigations, which included lactic acids and an ACTH stimulation test, were negative. The echocardiogram revealed a 56 mmHg RSVP and moderate pulmonary hypertension with a 60% LV ejection fraction. A CT-PE thorax, while negative for PE, demonstrated hilar lymphadenopathy. The patient’s hypotension resolved spontaneously, and she was discharged with pulmonary hypertension follow-up. Pulmonary hypertension was suspected but here was no evidence of right-sided heart dysfunction that could cause hypotension. In the pulmonary clinic, her pressure was 70/40 or lower on multiple upper extremity reads, prompting her to return to the ER. On second admission, the patient reported upper extremity weakness, dry eyes and mouth raising concern for autoimmune syndrome. The negative prior workup and the lack of symptomatology consistent with shock caused a concern for a mechanical error in blood pressure measurement. Blood pressures were obtained in all extremities revealing lower extremity readings consistent with hypertension (150s systolic). CTA revealed occlusions of the subclavian arteries and labs showed an ESR of 100 and CRP of 68.3, indicating Takayasu arteritis. She was successfully treated with a steroid taper then etanercept weekly injections and azathioprine daily. There are cases of Takayasu causing severe hypotension and cardiogenic shock, but these are exceedingly rare and not typically discussed in review of this pathology, in fact hypertension is one of the many diagnostic criteria. With stenosis of multiple vessels, the large-vessel occlusion can result in low blood pressure readings when drawn from affected limbs, masking normal blood pressures. In our case, there were other subtle pieces of history, physical exam, and imaging that could have resulted in an earlier diagnosis. This illustrates the need for clinicians to investigate other etiologies for severe, asymptomatic hypotension and conduct thorough exams including checking blood pressures in all extremities. This abstract is funded by: none