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|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 4 | Page : 616-617
Dorsal spine involvement in Takayasu arteritis
Viayasaradhi Mudumba, Kalyan Bommakanti, Lakshmanarao Chittem
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Web Publication||4-Aug-2015|
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mudumba V, Bommakanti K, Chittem L. Dorsal spine involvement in Takayasu arteritis. Neurol India 2015;63:616-7
Takayasu arteritis is a chronic inflammatory occlusive disease affecting great vessels. Herein, we report a case with the involvement of vertebral bodies by Takayasu arteritis, which is very rare.
A 55-year-old lady had critical stenosis of the arch of aorta and right common carotid artery and was diagnosed to be having Takayasu arteritis. She underwent an aorto-carotid bypass 22-years earlier and was relieved of her symptoms. At present, she presented with complains of insidious onset, progressive mid back pain. Her erythrocyte sedimentation rate (ESR) was elevated. Magnetic resonance imaging (MRI) of the dorsal spine revealed well-defined, focal areas of altered signal intensities in the center of D6-D10 vertebral bodies. The end plates were not involved [Figure 1]a-c. Takayasu arteritis has a strong association with tuberculosis.  As tuberculosis is endemic in India, a diagnosis of vertebral tuberculosis was made, and she was started on four drug anti-tuberculous treatment by the attending physician. Even after a 6-month course of anti-tubercular therapy, her back pain continued to worsen. We re-evaluated her. The lesions showed no evidence of enhancement on contrast-enhanced MRI. We could appreciate flow voids anterior to the involved vertebrae probably representing enlarged radicular arteries [Figure 1]d. Computed tomogram of the dorsal spine revealed the lesions to be sclerotic [Figure 2]. The diagnostic work up for metastatis, sarcoidosis, and multiple myeloma proved to be normal. Serum electrophoresis revealed slightly decreased albumin (3.35 gm/dl; normal 3.5-5.2 gm/dl), with an increase in alpha, alpha2, and beta2 globulins without any M spike and was consistent with a chronic inflammatory pattern. Vasculitis workup with cytoplasmic and perinuclear antineutrophil cytoplasmic antibodies was negative. Bone scan with 99m Tc-methylene diphosphonate revealed patchy uptake in the bodies of vertebrae from D6 to D10. The histology comprised of lymphocytic infiltration with scanty giant cells of foreign body type that was suggestive of inflammation [Figure 3]. Stains and cultures were negative for tubercle bacilli. In a known patient of Takayasu's aorto-arteritis, isolated dorsal vertebral body involvement without contrast enhancement, with sparing of intervertebral disc, with raised inflammatory markers, with minimal patchy uptake on bone scan, histological examination revealing non-caseating nonspecific granulomatous inflammation and the presence of dilated radicular arteries in the prevertebral space prompted us to believe that it might be Takayasu aorto-arteritis with involvement of radicular arteries and vertebral bodies. We started her on immunomodulator hydroxychloroquine (6 mg/kg) which resulted in an excellent recovery of her back pain from the Visual Analogue Scale score of 7 to 2. After 6 weeks of therapy, ESR decreased to 20 mm/h and serum electrophoresis pattern returned to normal.
|Figure 1: (a-c) Magnetic resonance imaging (MRI) T1, T2 weighed, and STIR sagittal images of dorsal spine showing vertebral body involvement from D6 to D10. The lesions are hypointense in T1 weighted images and hypointense with a peripheral rim of hyperintensity in T2 weighted images and STIR images; (d) MRI T2 weighted MRI axial image showing enlarged radicular arteries (white arrows), anterior to the vertebral bodies|
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|Figure 2: Non-contrast enhanced computed tomography sagittal and axial views showing the sclerotic lesions in the vertebra|
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|Figure 3: Histopathological specimen showing paratrabecular granulomas (white arrow) comprised of foreign body type of giant cells with surrounding lymphocytes|
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Takayasu arteritis is a chronic inflammatory occlusive arteritis and has a variable presentation depending upon the distribution and severity of arterial stenoses.  There are a few case reports describing the association between bone lesions (in scapula, clavicle, radius, ulna) and Takayasu arteritis. ,, Inflammation and hypoxia have been implicated in the pathology of bone lesions by various authors. Kim et al. have opined that the involvement of bones in patients with Takayasu arteritis is distinct from the arteritis. 
In a known patient of Takayasu disease, involvement of vertebral bodies, hypertrophied, and prominent radicular arteries, and patchy uptake on bone scan prompted us to suspect an association between vertebral lesions and Takayasu arteritis. Patients can be started on immunomodulator drugs like hydroxychloroquine after excluding other lesions.
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Kim JE, Kolh EM, Kim DK. Takayasu′s arteritis presenting with focal periostitis affecting two limbs. Int J Cardiol 1998;67:267-70.
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[Figure 1], [Figure 2], [Figure 3]