Clinical Recognition of Takayasu Arteritis in General OPD
In a general outpatient setting, suspect Takayasu arteritis in any patient under 40 years old (especially young women) presenting with unexplained constitutional symptoms, limb claudication, blood pressure discrepancies between arms, or diminished pulses—and immediately check four-extremity blood pressures and auscultate for vascular bruits. 1, 2
Key Patient Demographics to Trigger Suspicion
- Age and sex: Most commonly diagnosed in the third decade of life (20s), predominantly affects women 10 times more often than men 1
- Geographic consideration: Indian-type disease affects abdominal aorta/renal arteries, while Japanese-type affects thoracic aorta/great vessels 1, 2
Two-Phase Clinical Presentation Pattern
Acute/Early Phase (Constitutional Symptoms)
Watch for non-specific "B symptoms" that may precede vascular manifestations by months to years: 1, 3
- Weight loss
- Fatigue and malaise
- Night sweats
- Anorexia
- Low-grade fever
Critical pitfall: These constitutional symptoms are easily dismissed or attributed to other conditions, causing diagnostic delays. 4
Chronic/Vascular Phase (Organ-Specific Symptoms)
Once fibrosis and stenosis develop, patients report symptoms referable to affected organs: 1, 2
- Upper extremity claudication (>50% of patients) 1
- Cerebrovascular insufficiency (50% of patients): vision loss, lightheadedness, syncope, stroke 1
- Carotid artery pain (carotidynia) in one-third of patients 1
- Hypertension (especially in Indian-type disease due to renal artery involvement) 1, 2
Essential Physical Examination Findings
Perform these specific maneuvers in every suspected case:
Blood Pressure Assessment
- Measure blood pressure in all four extremities 2
- Blood pressure discrepancy >10 mmHg between arms is a key diagnostic criterion 1, 2
- Document systolic BP variation systematically 1
Pulse Examination
- Diminished or absent peripheral pulses (brachial, radial, femoral, dorsalis pedis) 1, 2
- Check pulses bilaterally and compare symmetry 2
- This finding gave rise to the historical term "pulseless disease" 5
Auscultation
- Vascular bruits over subclavian arteries or aorta 1, 2
- Listen systematically over carotid, subclavian, abdominal aorta, and renal arteries 2
American College of Rheumatology Diagnostic Criteria (1990)
When 3 of 6 criteria are present, sensitivity is 90.5% and specificity is 97.8%: 1
- Age of onset <40 years
- Intermittent claudication (especially upper extremities)
- Diminished brachial artery pulse
- Subclavian artery or aortic bruit
- Systolic blood pressure difference >10 mmHg between arms
- Angiographic evidence of aorta or branch vessel stenosis
Laboratory Testing in OPD
- Inflammatory markers (ESR/CRP) are elevated in approximately 70% during acute phase and 50% in chronic phase 1
- Critical caveat: Normal inflammatory markers do NOT exclude active disease—50% of patients with active disease have normal ESR/CRP 2, 4
- No specific autoantibody exists for Takayasu arteritis 2
Immediate Next Steps When Suspicion is High
- Do not delay treatment while awaiting imaging if clinical suspicion is strong 1, 2
- Refer urgently to expert center due to disease rarity and need for specialized imaging/vascular surgery 1, 2
- Order imaging promptly: MRI/CT angiography or conventional angiography to document extent of arterial involvement 1, 2
- Consider starting high-dose corticosteroids (prednisone 40-60 mg daily) immediately for strongly suspected cases to prevent irreversible vascular damage 1, 2
Common Diagnostic Pitfalls to Avoid
- Don't dismiss young patients with hypertension as having essential hypertension—always check for BP discrepancies and bruits 1, 2
- Don't rely solely on inflammatory markers—they are normal in half of active cases 2, 4
- Don't miss the biphasic presentation—constitutional symptoms may precede vascular symptoms by months to years 1, 3
- Don't forget to examine all four extremities—single-limb BP measurement will miss the diagnosis 2