Takayasu's arteritis associated with cerebrovascular ischemia

A 12-year old Korean girl was presented with neck pain and transiently dimmed vision. One year before presenting, the patient developed fever, malaise and bilateral neck pain followed by right leg claudication. More recently, she experienced dimming of the visual field in both eyes, aggravated when facing upwards. She did not have episodes of imbalance, loss of coordination, diplopia or vertigo. She did not complain of dyspnoea, angina or abdominal angina. Her right arm blood pressure (BP) was 99/54 mmHg but the left arm BP was not checkable. A cardiac examination was normal. Both carotid pulses and the right brachial pulse were weak. The left brachial pulse, right popliteal and right dorsalis pedis pulses were not palpable. Bruit was audible over both carotid arteries and in the supraclavicular, infraclavicular and epigastric area. Neurology disclosed no abnormalities. Basal laboratory examinations revealed a white blood count of 9,700 × 10³/μL, erythrocyte sedimentation rate (ESR) 66 mm/h, high sensitivity C-reactive protein (hsCRP) 1.19 mg/dL, protein/albumin 7.3/3.8 g/dL, creatinine 0.53 mg/dL and pro-brain-type natriuretic peptide (proBNP) 18.3 pg/mL.