takayasu 's arteritis ( ta ) is a chronic idiopathic occlusive inflammation of aorta and its major branches predominantly affecting females in over 85% of cases .
the major clinical finding is loss of palpable pulses in the upper limbs and neck .
the unsuspected ischemia of vital regional vascular beds may render these patients at risk for inappropriate management .
this case report describes the management of a trauma patient in whom the diagnosis of ta was established by specific investigations done for the same .
the role of meticulous monitoring and importance of anticipation of such disease for prompt diagnosis and management is emphasized .
a 26-year - old female was brought to the emergency room ( er ) with history of motor vehicle accident . on initial evaluation
her physical examination revealed unrecordable upper limb peripheral pulses and blood pressure , although lower limb pulses were easily palpated .
the radiological investigations revealed multiple left - sided rib fractures with bilateral pleural collections and small lung contusions .
after infusion of two liters of lactated ringer 's solution , her blood pressure ( bp measured in right upper limb ) increased to 80/50 mmhg and heart rate ( hr ) was 140/min .
she also had shaft and inter - trochanteric femur fractures on the right and left side , respectively . focused assessment sonography in trauma ( fast ) was negative and x - ray of the pelvis was normal .
bilateral chest tubes were inserted and the patient was transferred to the intensive care unit ( icu ) with ongoing resuscitation with fluids , blood products and dopamine infusion ( 7 g / kg / min ) .
fluid resuscitation was continued to maintain a central venous pressure ( cvp ) of around 10 mmhg .
invasive arterial blood pressure monitoring was established via the right femoral artery and the bp recorded was 140/90 mmhg .
dopamine infusion was then discontinued and thereafter the patient was subjected to arterial doppler and computed tomography ( ct ) angiography studies to rule out traumatic aortic rupture as a differential diagnosis .
arterial doppler showed low - velocity monophasic flow in bilateral axillary , brachial and ulnar arteries .
the erythrocyte sedimentation rate ( esr ) and c - reactive protein ( crp ) were normal .
electrocardiography ( ecg ) , 2d echocardiography ( 2d echo ) and funduscopy were normal .
thoracic epidural catheter was inserted for pain relief with continuous infusion of 0.125% bupivacaine and fentanyl ( 2 mcg / ml ) .
epidural catheter was removed on 5 day of hospitalization and patient was moved to the ward in a stable condition with advice for regular follow - up and advised to check bp measurements in the lower limb if ever required .
the occlusive thromboaortopathy ( ta ) is a group of diseases in which there is no or feeble pulses in upper half of body .
the natural course of disease often gives rise to four main complications : takayasu 's hypertensive ischemic retinopathy , secondary hypertension , aortic regurgitation and aortic or arterial aneurysm .
most patients with ta present during their child - bearing age , and a high index of suspicion is required to make an early diagnosis .
patient may be entirely asymptomatic and the incidental finding of unequal pulse and blood pressure in upper and lower limb , bruit and hypertension may prompt further evaluation .
stroke , congestive heart failure , and rarely ruptured aneurysm may be the heralding events . hemorrhagic shock is the commonest type of shock in trauma patients .
any hypotensive trauma patient is presumed to be hypovolemic and resuscitative attempts are made with fluid infusion as was with our patient .
there was no contributory past history of symptoms or signs suggestive of ta in our patient .
a cvp of around 10 mmhg suggested a normovolemia status unlike the impression got by the low blood pressure ( as recorded in upper limbs ) .
the presence of tachycardia in our patient could be attributed to pain and anxiety associated with trauma .
there was no fall in hematocrit from the baseline ( perhaps due to hemo - concentration ) .
dopamine infusion was started in our patient in an attempt to maintain perfusion and restore blood pressure but was discontinued when invasive monitoring revealed a normal bp .
normal value of esr and c - reactive protein suggested that the disease was not active at that moment .
our patient was perhaps asymptomatic for the disease and was incidentally diagnosed during workup after trauma .
but ta as a differential diagnosis of exclusion may be considered for a pulseless trauma patient .
normocytic normochromic anemia , hyper - gammaglobulin , and elevated esr may occur , but are not pathognomonic .
medical treatment includes corticosteroids , anticoagulants and symptomatic therapy for which anti - hypertensive agents , digitalis and antibiotics are frequently used .
follow - up in cases of ta includes monitoring for disease activity and its complications like hypertension , organ failure , seizures etc .
long - term complications of corticosteroid use are also to be considered in the follow - up .
anesthesiologists may encounter these patients in operation theater for anesthesia or in icus or emergency units after trauma or after one of its complications like a ruptured aneurysm .
tas may be considered as a differential diagnosis in trauma patients , if examination reveals hypotension or unequal peripheral pulses in upper and lower limb in a young adult , provided hypovolemic shock is excluded .
a thorough detailed physical examination with palpation of all the peripheral pulses as stressed in atls guidelines is reemphasized . following the basic atls guidelines
would assist clinicians in picking up this discrepancy as part of their routine evaluation for all trauma patients .
then , the clinician may suspect an atypical cause for hypotension if a blood pressure cuff on an upper extremity is reading a hypotensive measurement but the patient has strong , 2 + pulses in the lower extremities .
these patients may be issued a special identification card containing the details of the disease and treatment course for future reference .
 hemorrhagic shock is the most common reason to explain the inability to feel pulse in a trauma patient . 
 however , clinicians should always suspect atypical causes for differential pulses in this population and takayasu 's arteritis ( ta ) is one such example . 
 we report a case of aorto - arteritis in a patient who presented with trauma and was later diagnosed with ta . 
 she had blood pressure discrepancy between upper and lower limbs noted upon her initial trauma evaluation . 
INTRODUCTION
CASE HISTORY
DISCUSSION
CONCLUSION