Extremity Pulses Research Articles

Laughter-induced Syncope

Harbingers of serious illness were noted after a 29-year-old white woman delivered her second child via cesarean section. At that time, her blood pressure could be measured only in her legs; diminished upper extremity, brachial, and radial pulses were simultaneously noted. Over the next 2 years, the patient gradually developed progressive global fatigue plus numbness, tingling, and fatigability of her arms, particularly when raising her arms above her head to comb her hair. Increasing exertional dyspnea occurred during periods of physical activity.

Thrombosis in renal artery in a newborn. Presentation a review of a case

This report describes a newborn who presents high pressure values and absence of pulses in inferior extremities in his 4th day of life. Posterior to placement of umbilical arterial catheter, confirming diagnostic of thrombosis in aorta and left renal artery. A gamagraphy with MAG 3 was performed that gave evidence of left renal exclusion and aorta and left renal angioresonance. A management with no fractional heparin and streptokinase during 6 hours was initiated. The compromise in lower extremities was totally recovered, improving presure values in a few days. Following studies of renal function and growth give evidence of left renal artery flow and some function. This report describes an improvement with anticoagulant and thrombolitic treatment of a newborn kidney depite of a prolonged ischemia.

Hypoplasia of the Abdominal Aorta and Hypomelanosis of Ito

A 4-year-old girl with hypomelanosis of Ito (HI) was referred to the cardiologist for an absence of pulses in the lower extremities. Medical history included hydrocephalus treated with ventriculoperitoneal shunt and congenital glaucoma. She always remained asymptomatic. Physical examination showed upper-body hypertrophy and a repeatedly measured systolic pressure difference between the upper and lower extremities of 35 mm …

Acute bilateral renal infarction secondary to cocaine-induced vasospasm

CASE PRESENTATION A 47-year-old African-American male with a history of hypertension for 1 year and cocaine use presented to the emergency department with acute onset of bilateral flank pain, nausea, vomiting, and diarrhea. Physical examination was unremarkable. Laboratory evaluation revealed a white blood count of 15.1 K/μl (normal 4.5-11.5 K/μl) and a serum creatinine of 2.4mg/100ml. A non-contrast CT scan of the abdomen was unremarkable. The patient was treated with morphine (for pain) and i.v. fluids, felt better, and was discharged for out-patient follow-up. The patient saw his primary care physician 2 days later (day 3) and reported persistence of the bilateral flank pain. The patient also reported a transient inability to urinate for 36 h before the visit. An abdominal ultrasound and blood chemistry were obtained. On day 5, he was referred by his physician to the emergency department for a serum creatinine of 9.2 mg/100 ml from day 3. At the time of admission, the patient reported using 5-6g/day of ibuprofen for the previous 4 days and admitted to sniffing cocaine a few hours before the initial onset of flank pain. On physical examination, the patient was a well-built African-American male with a temperature of 99.2 °F, pulse rate of 60/min, blood pressure of 150/85 mm Hg and weight of 85 kg (BMI 27.7 kg/m 2 ). There was no orthostasis, pallor, or skin rash. The heart and lung examinations were unremarkable. The abdomen was soft, with no suprapubic dullness. There was no costovertebral angle tenderness or pitting edema. The extremity pulses were symmetric and equal. Laboratory results are presented in Table 1. Serologic tests for hepatitis B and C viruses, human immunodeficiency virus, antinuclear antibody, and rheumatoid factor were negative. Serum complements, including C3, C4, and CH50, were within the normal range. Hemoglobin electrophoresis, chest X-ray, electrocardiogram, and echocardiogram were unremarkable. Renal ultrasound revealed normal-sized kidneys with mildly increased echogenecity and no hydronephrosis. A 99m Tc-MAG3 (mercaptoacetyltriglycine) radionuclide renogram showed multiple wedge-shaped photopenic areas in both kidneys (Figure 1a). Owing to the absence of a clear explanation for the patient's acute renal failure, renal biopsy was performed 12 days after the onset of symptoms.

Anatomical repair of a congenital aneurysm of the distal abdominal aorta in a newborn

Congenital (primary) neonatal abdominal aortic aneurysm (AAA) is an extremely rare truncular arterial abnormality among numerous congenital vascular malformations. Only seven cases have been reported as congenital origin in newborns. This report presents the case of a male infant in whom a 33-mm congenital AAA was diagnosed prenatally and was successfully treated 10 days after birth without exogenous graft material or aneurysmorrhaphy. Follow-up study at 39 months demonstrated excellent clinical, ultrasound scan, and computed tomography scan findings. Anatomic reconstruction with native vessels is the preferred surgical technique to ensure the child's potential for harmonious growth.

Management of Takayasu Arteritis During Pregnancy

25-year-old woman who was at 24 weeks’gestation presented to our institution with a2-day history of worsening epigastric and midtho-racic back pain. The patient denied chest pain,shortness of breath, palpitations, nausea, andvomiting. Her medical history was significant fora history of 2 spontaneous abortions, hyperten-sion, and anemia. Her only medications wereprenatal vitamins and iron supplements. Onphysical examination, blood pressure (BP) of120⁄70 mm Hg was noted in the right arm and152⁄90 mm Hg in the left arm. Neck examina-tion revealed 1+ bilateral carotid pulsations withloud carotid and subclavicular bruits. There wasno jugular venous distension or thyromegaly.Normal first and second heart sounds were nor-mal intensity with II⁄VI diastolic murmur at theleft upper sternal border. Abdominal examinationrevealed positive bowel sounds, tender epigastri-um with no fundal tenderness, rebound, orguarding. Lower extremities revealed 2+ pittingedema. Right upper extremity (radial and bra-chial) pulses were absent with 1+ left brachialand radial pulses. Initial laboratory valuesincluded mild anemia with hemoglobin of11 g⁄dL. White blood cell and platelet counts,chemistries, liver function tests, urine toxicology,and pancreatic enzymes were within normallimits. Urinalysis revealing a 4+ proteinuria.Erythrocyte sedimentation rate was 41 mm⁄hrand C-reactive protein was 4.4, respectively. Elec-trocardiography results showed normal sinusrhythm at 84 beats per minute with no ST⁄T-wave changes. Chest x-ray showed a mildly ectat-ic thoracic aorta. Fetal heart tracing at baselinewas 140 to 150 seconds with minimal heart ratevariability.The patient was admitted to the obstetrics wardfor preeclampsia and fetal monitoring. Consideringthe vascular and cardiac examination findings, thecardiology service was consulted. Transthoracicechocardiography was performed and revealed nor-mal left and right systolic function with mild tomoderate aortic insuffici ency. No valvular or con-genital abnormalities were identified. A computedtomography (CT) scan of the chest without con-trast revealed circumferen tial wall thickening of thedescending aorta with no dissection. Limited mag-netic resonance imaging (MRI) of the abdomenwithout gadolinium showed irregular wall thicken-ing of the aorta and significant stenoses of theproximal celiac and superior mesenteric arteries.Based on American Society of Rheumatology classi-fication criteria, the patient was diagnosed withTakayasu arteritis and started on intravenous ste-roids. She later underwent duplex ultrasonographyof the neck, which showed absence of flow in theinnominate, common carotid, and right vertebralartery. Flow was maintained in the internal carotidartery through retrograde flow in the external caro-tid artery. The right subclavian artery was occludedwith minimal flow in the right axillary arterythrough collaterals, which was later confirmed byselective angiography after pregnancy.The following morning, the patient complainedof recurrent epigastric abdominal pain and had ele-vatedBP196⁄108 mm Hg measured from the leftarm BP cuff. The patient was started on labetololvia oral and intravenous routes as well as methyl-dopa. These measures only temporarily decreased

A case of lupus nephritis coexisting with podocytic infolding associated with Takayasu’s arteritis

A 61-year-old Japanese woman with both Takayasu's arteritis (TA) and systemic lupus erythematosus (SLE) presented with proteinuria due to glomerulopathy associated with podocytic infolding. She presented with unequal pulses in the upper extremities at 38 years old. TA was diagnosed on the basis of angiographic identification of stenosis in the left subclavian artery. Eight years after onset of TA, SLE was diagnosed on the basis of clinical and laboratory findings, including proteinuria, hematological and immunological abnormalities, high titer of antinuclear antibody, and a positive lupus band test on the skin. A renal biopsy showed lupus nephritis coexisting with podocytic infolding associated with TA, which has rarely been reported. After low-dose prednisolone therapy and immunosuppressive therapy by cyclosporine for 14 years, proteinuria has persisted without deterioration of serum creatinine levels.

A giant aneurysm of a branch of axillary artery

A 61-year-old man presented with a painful mass in the right axilla that had been present for several months. Over the past few weeks, it had grown in size and his level of discomfort had increased dramatically. The patient denied fevers, redness, recent travel, insect bites, or similar symptoms in the past. He denied any history of recent or remote trauma to the right axilla, recent use of crutches, or other possible injury. He had no history of ischemic arm symptoms. On examination, a large pulsatile and tender mass was appreciated without surrounding erythema or induration (A). All extremity pulses were palpable, and there were no ischemic, neurologic, or edematous signs in the arm. An axillary duplex scan demonstrated a mass of 15 cm in its widest diameter and turbulent pulsatile flow within the mass. Arteriography confirmed the presence of a giant aneurysm of right lateral thoracic artery (Cover). Surgical treatment was recommended. The origin of the aneurysmal branch was ligated at its junction with the axillary artery through a deltopectoral-subclavicular approach, and then the aneurysm was excised (B). No sign of infection was encountered during exploration and histopathology of the aneurysmal mural specimen revealed only atherosclerosis (C). The patient was discharged without complication after postoperative 5 days. He remained problem-free at the 1-year follow-up. Degenerative, sometimes termed atherosclerotic, aneurysms of the axillary artery and its branches are rare. Pseudoaneurysms represent the majority of the reported aneurysms in this location, and they almost always occur as a result of trauma or instrumentation. 1,2 True aneurysm of the axillary artery or its branches can cause vascular or neurologic compression complications, thromboembolic events, or rupture, so they should be treated. Although endovascular options could be considered, in this case the large size and associated symptoms required decompression and open surgical treatment was effective.

A case of bilateral brachial plexus palsy due to shoulder braces

We report the case of a 32 year-old man who underwent a laparoscopic-assisted sigmoid colectomy and who developed bilateral upper trunk brachial plexopathy. The complication occurred with intraoperative signs of neurovascular compression. Failure to recognize the significance of a decrease in pulses in the upper extremities, with resulting lack of remedial action, may have been a major factor leading to patient injury.

Ruptured hepatic artery aneurysm: A novel approach to distal control

We describe a unique method for obtaining distal control in a ruptured hepatic artery aneurysm. A 34-year-old man with Ehlers-Danlos syndrome type IV presented with a ruptured left hepatic artery aneurysm. The distal aneurysm was within the parenchyma of the liver. Proximal control was obtained with pledgeted sutures. The distal hepatic artery was difficult to control. Injection of 5 mL of thrombin into the distal left hepatic artery resulted in hemorrhage control. This technique should be considered in select patients in whom distal arterial control is challenging.

Coarctation of the Aorta Associated with Left Subclavian Artery Aneurysm: A Case Report

Aneurysm of the left subclavian artery (LSA) in association with coarctation of the aorta (CoAo) is a rare phenomenon, especially in the younger population. A 19-year-old male patient was admitted for lower extremity varices and diagnosed to have severe CoAo and a 45-mm LSA aneurysm after digital subtraction angiography following detection of nonpalpable lower extremity pulses on physical examination. Corrective surgery was performed from a left posterolateral thoracotomy through the 4th intercostal space, and a discrete ring-like coarctation tissue was observed in the aorta just below the level of the LSA orifice. Complete excision of the coarctation tissue was followed by aortoplasty with a Dacron patch. Additionally, the subclavian aneurysm was completely excised and a 10-mm Dacron tube graft interposition was performed. Prompt diagnosis and surgical treatment in particularly hypertensive patients precludes significant mortality and morbidity following a possible rupture.

Presentation of Congenital Heart Disease in the Neonate and Young Infant

1. Michael Silberbach, MD* 2. David Hannon, MD† 1. *Editorial Board 2. †East Carolina University, Greenville, NC After completing this article, readers should be able to: 1. Describe the general principles of the cardiac examination of the newborn. 2. Name the four presentations of congenital heart disease in the newborn period. 3. Recognize the innocent heart murmurs that occur during infancy. 4. Identify the signs and symptoms of congestive heart failure in infants. 5. Describe the pathophysiology of the more common cyanotic heart defects. Significant congenital heart disease (CHD) may be diagnosed at virtually any age. Some conditions always are discovered in neonates; others rarely are identified during infancy. Prenatal ultrasonography may detect CHD before birth, but it is essential for primary care practitioners to assess any newborn who is suspected of having heart disease at the time of birth. This review considers CHDs that present during the newborn period or early infancy. The profound hemodynamic transitions that occur at the time of birth make the clinical presentation of heart disease a “moving target.” Although echocardiography often reveals the anatomic details of a given lesion, an understanding of underlying pathophysiologic principles can provide the clinician with the tools to anticipate and treat problems as they arise. Visual inspection of the infant may reveal cyanosis, but it is equally important to recognize dysmorphic features. Congenital heart lesions associated with some specific syndromes are summarized in Table 1, and the incidence of most common cardiac malformations is presented in Table 2. Assessment of the precordial activity is as important as cardiac auscultation. Palpation of the intensity and timing of the upper and lower extremity pulses as well as measurement of blood pressure in all four extremities are critical in the assessment of left heart obstructive disease. Auscultation should focus on the heart sounds as well as any murmurs. | Etiologic Syndrome | Frequency of Cardiac Anomalies† | Distinguishing Features | |:----------------------------------------------:| ------------------------------- | ---------------------------------------------------------- | -------------------------------------------------------------------------------------- | | All (%) | Distinctive or Most Common | | Autosomal Dominant | | | | | Adams-Oliver syndrome | 20 | Left-sided obstruction (eg, COA, parachute MVP), TOF | Scalp cutis aplasia, terminal transverse limb defects | | Alagille syndrome | 95 | (P)PS, TOF/TOF with PA, ASD, VSD | Bile duct paucity, chronic cholestasis, butterfly vertebrae, posterior embryotoxon | | Char syndrome | 60 | PDA | Anomalies on fifth finger, supernumerary nipple | | Cornelia de Lange syndrome | 25 | VSD, ASD, PS, TOF | Upper limb deficiency, GI anomalies | | Holt-Oram syndrome | 80 | ASD± other CVM, VSD, TA, TOF, PAPVC, conduction defect | Upper limb malformations | | Neurofibromatosis | 2 | PSV, ASV, COA, HCM | Cafe au lait macules, optic glioma, scoliosis, pseudarthrosis, neurofibromas | | Noonan syndrome | 85 | PSV, ASD, AVSD partial, COA, HCM | Short, webbed neck; pectus deformity; cryptorchidism | | Rubinstein-Taybi syndrome | 35 | PDA, ASD, VSD, left-sided obstruction (eg, COA, HLHS) | Broad thumbs and great toes | | Williams syndrome | 60 | SVAS, PS, other left-sided obstructions (eg, ASV, MS, COA) | Hypercalcemia, hypodontia, hypoplastic nails | | Autosomal Recessive | | | | | Ellis-van Creveld syndrome | 60 | AVSD, common atrium, ASD primum | Short limbs, polydactyly, hypoplastic nails, dental anomalies | | Fryns syndrome | 50 | ASD, VSD, conotruncal | Diaphragmatic hernia, distal digital hypoplasia | | Keutel syndrome | 70 | (P)PS | Short digits, mixed hearing loss, cartilage calcification | | Smith-Lemli-Opitz syndrome | 45 | ASD, VSD, complete AVSD, TAPVC | Two- to three-toe syndactyly, cleft palate, lung anomalies, genital anomalies | | X-linked Recessive | | | | | Simpson-Golabi-Behmel syndrome | 25 | ASD; VSD; rare, variable cardiomyopathy | Macrosomia, cleft palate, supernumerary nipples, hernias, hypospadias, poly/syndactyly | | Suspected Gene Etiology | | | | | Cardio-facio-cutaneous syndrome | 75 | ASD, HCM | Sparse, curly hair; low, rotated ears; hyperkeratosis | | Hall-Hittner syndrome (CHARGE association) | 80 | Conotruncal/arch, assorted CVMs | Coloboma, choanal atresia, genital anomalies, ear anomalies | | Costello syndrome | 60 | MVP, AV, thickening HCM, arrhythmia (atrial tachycardia) | Skin/joint laxity, fine/curly hair, deep palm creases, ulnar deviation, papillomata | | PHACES syndrome | 100 | COA; IAA, A right; double, cervical aortic arch | Posterior fossa malformations, hemangiomas, eye anomalies | | Ritscher-Schinzel syndrome (3C) | 100 | TOF, DORV, AVSD | Posterior fossa malformations, cleft palate, coloboma | * ASD=atrial septal defect, ASV=aortic stenosis, valvar, AV=atrioventricular valve, AVSD=atrioventricular septal defect, COA=coarctation, CVM=cardiovascular malformations, …

Presentation of Congenital Heart Disease in the Neonate and Young Infant

Presentation of Congenital Heart Disease in the Neonate and Young Infant

Taking Care With the Standard of Capacity

Taking Care With the Standard of Capacity

Diffuse acute abdominal pain and palpation of the lower limb pulses: what kind of link?

A 71-year-old woman was referred to our hospital complaining of abrupt onset of diffuse abdominal pain and vomiting. The medical history included arterial hypertension and atrial fibrillation under pharmacological treatment with calcium channel blockers, digoxin, and aspirin. At physical examination, the sensorium was clear, axillary temperature was 36.7°C; arterial blood pressure 140/80 mmHg; pulse 68 bpm, dysrhythmic, no presence of a heart murmur; respiration 18 breaths/min. The chest was clear. Examination of the abdomen revealed diffuse tenderness. The left leg appeared pale and cold, the right lower extremity pulses were normal, but pulses distal to the left femoral artery were absent. On further persistent questioning, the patient reported the presence of pain in the left leg, but she gave no importance to this symptom due to the preponderant abdominal pain. Laboratory data showed a white blood cell count 12 000/mm3 (86% neutrophils); fibrinogen 735 mg/dl; erythrocyte sedimentation rate 60 mm/h; C-reac

Implantation of a Drug-Eluting Stent for the Coronary Artery Stenosis of Takayasu Arteritis

A 35-year-old woman with a history of hypertension presented with shortness of breath and atypical chest discomfort. Although a vascular bruit was not heard at any site of the body, the upper extremity pulses were very faint on both sides. The erythrocyte sedimentation rate (ESR) was 39 mm/h, and measurement of C-reactive protein (CRP) yielded a value of 1.94 mg/dL. Although the ECG was not suggestive of ischemia, an echocardiogram revealed severe hypokinesia of the anterior wall from the middle left ventricle to the apex. Angiography revealed total occlusions of both subclavian arteries (Figure 1A and 1B). Coronary angiography revealed a tight ostial stenosis of the left main coronary artery and right coronary artery (RCA) without any distal disease (Figure 2A and 2B). A clinical diagnosis of Takayasu arteritis was made because the patient had faint pulses with mild claudication of both arms and ostial coronary disease. A percutaneous coronary intervention (PCI) with a paclitaxel-eluting stent (3.5-mm diameter, 12 mm long; TAXUS, Boston Scientific, Natick, Mass; Figure 2C) was performed successfully on the ostial lesion of the …

Gastroc Tear in a Collegiate Basketball Player

HISTORY: A 21-year-old male basketball player presented with calf pain at the end of the basketball season. He had a history of a “torn gastroc” in high school and had a deformity since that time. He complained of a gradual onset of deep achy pain over the left gastrocnemius muscle. The pain was associated with swelling and tightness in his lower leg and general fatigue after long periods of activity. The symptoms were improved with compression and stretching and resolved with rest. Past medical history is significant for left hip chondroblastoma, resected 6 years previously. Review of systems is significant for general malaise without fever or chills; decreased appetite and 12 pound weight loss during training over the previous 3 months. He complained of occasional migraine headaches. He denied chest pain, dyspnea on exertion, but complained of mild intermittent diarrhea. PHYSICAL EXAMINATION: Afebrile, appears gaunt, weight 185. No scleral icterus. Heart rate and rhythm regular. Lungs clear bilaterally. Abdomen: muscular. No organomegaly or masses. Left lower extremity evaluation revealed a normal hip and knee exam. The ankle examination was normal except for slightly decreased dorsiflexion. The left calf appeared mildly deformed and swollen just proximal to the musculotendinous junction. On palpation, there was an approximately 10 cm compressible spongy mass over the distal gastrocnemius in the area of his “gastroc tear”. There was no point tenderness. The gastrocnemius and soleus muscles had slight decreased flexibility. Strength was 4+/5 compared to the right calf. Sensation and reflexes were normal in bilateral knees and ankles. There were 2+ pulses in the bilateral lower extremities. DIFFERENTIAL DIAGNOSIS: Chronic Gastrocnemius/Soleus Tear Recurrence of Chondroblastoma - Mass Popliteal entrapment due to mass Exertional Compartment Syndrome Stress fracture versus pathologic fracture Hemangioma TEST AND RESULTS: X-ray: Bilateral tibia and fibula: No fracture or mass noted. MRI: Large hypervascular enhancing soft tissue mass in the left soleus muscle consistent with hemangioma Biopsy: Sarcoma FINAL WORKING DIAGNOSIS: Alveolar soft-part sarcoma TREATMENT AND OUTCOMES: Oncology consult; non-surgical management with sub-cutaneous interferon. At present the athlete continues to train.

Ineffective Peripheral Tissue Perfusion: Clinical Validation in Patients With Hypertensive Cardiomiopathy

To validate defining characteristics of ineffective peripheral tissue perfusion using vasomotor function assessment. Twenty-four patients with hypertensive cardiomiopathy were evaluated for 18 defining characteristics of ineffective peripheral tissue perfusion and underwent vasomotor function assessment with induction of reactive hyperemia, intra-arterial infusion of acetylcholine, and pulse wave velocity measurement. The Student's t test and Kruskall-Wallis test were used to assess the significance of relationships between defining characteristics and vasomotor function data. Diminished lower extremity pulses were associated with diminished forearm blood flow during acetylcholine infusion; left ventricular overload, intermittent claudication, and diminished skin moisture were associated with elevated pulse wave velocity values. The defining characteristics of ineffective peripheral tissue perfusion were highly associated with vasomotor function data as "gold standards" for that diagnosis. Nurses should be able to accurately assess diminished lower extremity pulses, intermittent claudication, and diminished skin moisture as relevant characteristics of ineffective peripheral tissue perfusion in patients with hypertensive cardiomiopathy.

Takayasu’s arteritis associated with antiphospholipid antibodies

The finding of elevated level of antiphospholipid antibodies (APLAs) in a proportion of Takayasu’s arteritis (TA) patients suggests a contribution of APLAs in vascular injury at least in some of TA patients [1–3]. However, these findings have not been confirmed in other series of TA [4]. The controversy regarding the APLAs in TA is in part due to the small number of reported TA patients with APLAs assayed, and therefore we present a TA patient with increased levels of APLAs and lupus anticoagulant (LAC). In 2001 a 27-year-old woman developed Raynaud’s phenomenon, claudication of both upper extremities and visual disturbances. The complains started during the last 3 months of her the only pregnancy and she delivered a healthy child. She presented at hospital in January 2003 with absence of radial and brachial pulses in both upper extremities and vascular bruits over the right carotid and both subclavian arteries (SCA). Femoral and dorsum pedis pulses were palpable and blood pressure was 160/95 mm Hg on both legs. Color Doppler sonography: occlusion of the left common carotid artery (ACC), internal carotid artery (ACI) and external carotid artery (ACE), concentric thickening of the right ACC, ACI and ACE, stenosis of both SCA. The flow through both verterbral arteries (VA) was normal with a poststenotic spectrum type. Descending aorta and renal arteries were normal. Transcranial Doppler sonography: poststenotic spectra in both middle and posterior cerebral arteries. Angiography (Fig. 1): occlusion of ACC and left SCA, circular narrowing of the right ACC and narrowing of the right SCA to the origin of VA. Collateral circulation with retrograde flow through the left VA to the left SCA. Funduscopy: left, optic disc atrophy; right, diffuse small hemorrhages and extravasations. Erythrocyte sedimentation rate (ESR) was 85 mm/h and C-reactive protein (CRP) level was 19.1 mg/l (normal <5 mg/l). Platlets count was normal. Antinuclear antibody, antiSmith antibody, and anti dsDNA were negative. C3 and C4 levels were normal. Circulating immunocomplex level was 7.3 lg/ml (normal <5). The patient possessed B8 and DR3 HLA alleles Lupus anticoagulant and anticardiolipin antibodies (aCLa) were positive in two subsequent measurements ( IgM aCL 157 and 172 IU/ml, normal <100; IgG aCL 95 and 93 IU/ml; normal <100). Therapy included methylprednisolone (pulses 1 g i.v./ 3 days, 1 mg/kg body weight/day/4 weeks followed by 6 mg/day orally), cyclophosphamide (1 g i.v. every 4 weeks), and methotrexate 10 mg weekly. Ethylbuscomate was given for positive LAC and aCL antibodies although there was no manifest thrombosis. In the course of therapy, a moderate improvement of carotid flow and laboratory test normalization (ESR 6 mm/h, CRP 4 mg/l) occurred. One month latter, at home, the patient suddenly lost consciousness with epileptic attack. She died few hours later, most likely due to ischemic brain insult; autopsy was not performed. In our patient, the diagnosis of TA (type III according to Ishisawa) relied on her clinical data meeting all American College of Rheumatology 1990 criteria [5], J. Morovic-Vergles Department of Clinical Immunology and Rheumatology, University Department of Medicine, School of Medicine, University of Zagreb, Zagreb, Croatia

Cyclosporine - a treatment and a rare complication: Raynaud's phenomenon

Cyclosporine - a treatment and a rare complication: Raynaud's phenomenon