E168 A complex case of Takayasu arteritis and disseminated tuberculosis managed through multidisciplinary collaboration

Background/Aims Takayasu arteritis (TAK) is a rare large-vessel vasculitis that primarily affects the aorta and its major branches, leading to vessel wall inflammation and stenosis. Tuberculosis (TB) itself can cause aortitis and myocarditis through direct infection or immune-mediated mechanisms, which may mimic or coexist with TAK. The coexistence of disseminated TB with TAK presents a diagnostic and therapeutic challenge, as both conditions contribute to vascular inflammation while requiring contrasting management strategies. We hereby present a case of a young Asian lady who had a complicated case of TAK and disseminated TB successfully managed with IV cyclophosphamide. Methods A 30-year-old woman originally from Pakistan, who moved to the UK in January 2024, presented with a 6-month history of profound malaise and 20 kg weight loss. A CT of the chest, abdomen, and pelvis revealed hypoenhancing liver lesions, calcified mediastinal lymph nodes, and abnormal myocardium. MRA showed regional acute-on-chronic myocardial injury/inflammation and a right renal artery stenosis of likely longstanding origin. PET-CT demonstrated moderate uptake in the left ventricle, pericardium, and descending thoracic/upper abdominal aorta. Lymph node biopsy revealed granulomatous inflammation. The pathology team felt the features were not in keeping with IgG4-related disease or sarcoidosis. Although TB PCR, cultures, and HIV screening were negative, given high clinical suspicion and a past TB exposure, she was commenced on anti-tuberculous therapy. This resulted in normalisation of her elevated ESR and marked clinical improvement. After seven weeks of TB treatment, repeat PET-CT showed resolution of hepatic lesions with only a few small cervical lymph nodes, though vascular and myocardial inflammation persisted. Her BNP subsequently rose to 1,598 pg/mL and troponin to 2,991 ng/L. Echocardiography demonstrated an LVEF of 40% with abnormal myocardium. Given that cardiac tuberculosis is exceedingly rare, the findings were felt unlikely to be explained by TB alone. She also reported a previous episode of severe unexplained febrile illness one year earlier. Repeat echocardiogram and cMRI confirmed mild left ventricular dilatation with systolic impairment. Following multidisciplinary discussions at the Bristol Heart Institute and Barts Health Cardiomyopathy MDTs, a subcutaneous ICD was implanted for primary prevention. Her case was discussed at the Imperial MDT and reached a consensus diagnosis of Takayasu arteritis coexisting with disseminated tuberculosis. She was commenced on high-dose oral steroids with gradual tapering and received six cycles of intravenous cyclophosphamide, followed by methotrexate maintenance. She showed significant clinical and biochemical improvement, with normalisation of cardiac biomarkers and complete resolution of aortitis and myocardial inflammation on repeat PET-CT. Conclusion Our patient’s presentation showed significant overlap between disseminated TB and TAK, making diagnosis and management particularly complex. Careful evaluation through multidisciplinary collaboration was essential to reach the correct diagnosis and to balance the need for immunosuppression while continuing TB treatment.