Today I’m presenting chest radiographs of a 28-year-old man with severe headache and high blood pressure (201/110 mmHg).
What do you see?
NEW CLINICAL INFORMATION:
Pulses were weaker in the lower extremities.
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Findings: Chest radiographs show a moderate cardiomegaly. There is pulmonary vascular redistribution, with the upper vessels (A, red circles) larger that the lower ones (A, blue circles), indicating an early stage of left cardiac failure.
The information of weak pulses in the lower extremities is important. This finding suggests impeded blood flow in the thoracic aorta, the most common cause being aortic coarctation. The small aortic knob and the lack of rib notching go against it, though.
CT angiogram shows narrowing and complete interruption of the distal thoracic aorta (C-E, circles), with abundant collateral circulation. The mid-aortic syndrome usually happens in children and young adults. The etiologies vary. In this particular case, biopsy confirmed Takayasu arteritis.
An aortic graft was placed to circumvent the obstruction (F-G, arrows).
Final diagnosis: Mid-aortic syndrome secondary to Takayasu arteritis
Congratulations to Ner, who made the correct diagnosis and to Krister A who was the first to suggest aortic obstruction.
Teaching point: in a young person with severe hypertension, distal pulses should be checked. If weak, aortic coarctation should be suspected. If the telltale signs of coarctation are missing, mid-aortic syndrome should be considered.