figure 4.D) CT angiogram sagittal view shows marked wall thickness with enhancement at the left subclavian artery (SCA) (white arrow).
While the vasculitis screen returned negative, the CT angiogram findings suggest large vessel vasculitis, specifically Takayasu arteritis. Management commenced with Prednisone (1mg/kg QD) and methotrexate 10mg per week as induction, alongside metoprolol 100mg QD and Lisinopril 10 mg QD. However, no notable improvement in the patient’s condition was observed after three months. During the follow-up, the patient developed recurrent attacks of fever, myalgia, and frequently had elevated inflammatory markers. This condition was labelled as a flare-up under rheumatologist supervision. Medication changes were implemented, and the patient was kept on prednisone 20 mg QD, leflunomide 20mg QD, colchicine 1mg BD, and adalimumab 40mg subcutaneous Q 2wk for 3 months, leading to clinical and laboratory improvement. After that, scheduled prednisone tapering was initiated until reaching 7.5 mg QD.
The patient’s condition remained stable throughout the follow-up period, with consistent improvement observed in serial ECGs (Figure 5) and normal echocardiograms during monthly visits to our cardiology outpatient clinic.