Acute non-ST segment elevation myocardial infarction as the first manifestation of Takayasu arteritis in a 16-year-old female patient: a case report and literature review

Abstract

Takayasu arteritis (TA) is now recognized worldwide and is a disease that mainly affects the aorta and its main branches. TA rarely involves the small or medium-sized vessels. Certain vascular lesions, such as arterial stenosis, occlusion, and aneurysm are common with TA. However, patients with new-onset TA who present with left main trunk acute non-ST segment elevation myocardial infarction are extremely rare. We report a 16-year-old female patient with non-ST segment elevation myocardial infarction due to severe stenosis of the left main coronary artery that was caused by TA. She was eventually diagnosed with TA and underwent successful coronary artery stenting combined with glucocorticoids and folate reductase inhibitor therapy. Over the 1-year follow-up, she experienced two episodes of chest pain and was admitted to the hospital. During the second hospitalization, coronary angiography (CAG) revealed 90% stenosis of the original left main trunk (LM) stent. Following percutaneous coronary angiography (PTCA), drug-coated balloon (DCB) angioplasty was performed. Fortunately, a clear diagnosis of TA was made, and treatment was initiated with an interleukin-6 (IL-6) receptor inhibitor. Early diagnosis and therapy for TA are emphasized.

Keywords: Acute non-ST segment elevation myocardial infarction; Takayasu arteritis; chest pain; coronary artery angiography; coronary artery stenting; folate reductase inhibitor; immunosuppressive therapy; interleukin-6 receptor inhibitor.

Figure 1.

Electrocardiogram (ECG) obtained during the first hospitalization showing ST-segment elevation in the aVR lead and ST-segment depression in leads I, II, III, aVF, aVL, and V1 to V6.

Figure 2.

Coronary angiography (CAG) during the first hospitalization showing 99% stenosis in the ostium of the left main coronary artery (LMCA) (a). A drug-eluting stent was implanted (b). Intravascular ultrasonography (IVUS) showing no calcification; however, the three-layered structure (intima, tunica media, adventitia) is unclear and concentrically thickened. The area of the external elastic membrane (EEM) of the ostium of the LMCA measures 3.11 mm², and negative remodeling is visible (c). After implantation of the drug-eluting stent, the minimum area in the stent measures 12.56 mm², and the stent is well-adhered to the vessel wall (d).

Figure 3.

Pulmonary computed tomography angiography (PCTA) performed during the first hospitalization showing that the trunk of the left pulmonary artery is slightly narrowed, and the left superior lobe is not visible (a). The lingual artery and apical and posterior segments of the right superior lobe artery are also not visible (b). Pulmonary perfusion/ventilation imaging showed minimal perfusion in the upper lobe of the left lung (c) and the middle and upper lobes of the right lung (d).

Figure 4.

Pulmonary arteriography performed during the first hospitalization showing markedly decreased blood flow through the vessel. The left upper pulmonary artery is occluded, and the left lower pulmonary artery has focal stenosis, with reduced perfusion distally.

Figure 5.

Angiography of the thoracic and abdominal aorta performed during the first hospitalization showing that the lumen of the main trunk and primary branch of the right renal artery are thinner compared with the left (a) and The enhancement degree of most of the right renal parenchyma is lower than that of the left (b).

Figure 6.

Positron emission tomography-computed tomography (PET-CT) performed during the first hospitalization showing no abnormally high metabolism or active inflammation in the large blood vessels, namely, the common carotid artery (CCA; central arrows) (a), subclavian artery (arrow) (b), iliac artery (arrows) (c), and aorta (arrows) (d). There was significantly high metabolism in the cardiomyocytes.

Figure 7.

Coronary angiography (CAG) performed during the second hospitalization showing 99% in-stent restenosis (ISR) in the ostium of the left main coronary artery (LMCA); coronary artery stents are visible (a). Stenosis improved markedly after drug-coated balloon dilatation (b). Intravascular ultrasonography (IVUS) showing that the neointima is visible in the stent, with a thickness of 1.5 mm and area of 7.65 mm² (the difference between the cross-sectional area of the stent and the minimum cross-sectional area of the lumen) (c). After treatment, the cross-sectional area of the lumen improved markedly, and the minimum luminal area was 12.56 mm² (d).

Figure 8.

Positron emission tomography-computed tomography (PET-CT) performed during the third hospitalization showing diffuse hypermetabolism in the walls of the large vessels (arrows in each image), namely, the root of the aorta (a), ascending aorta (b), aortic arch (c), and brachiocephalic trunk (d).