The Ophthalmologist’s Pulse Examination That Identified a Vasculitis!

Today we discussed an impressive diagnostic mystery of a young woman with chronic neck pain and paresthesias who was later found to have a diminished ipsilateral pulse and a SBP of > 60 points in the affected arm compared to the contralateral arm!

The case highlighted a few, highly important points – first – that the pulse examination is paramount in the patient with paresthesias of an extremity.

A broad differential for diminished/absent radial pulse includes atherosclerosis (i.e PAD), embolism, vasculitis (i.e GCA and TA, less commonly Beurger Disease), anatomic (dissection, thoracic outlet obstruction, thrombosed aneurysm) and iatrogenic (i.e post ABG, vasopressors). When you notice unequal pulses in a patient with symptoms relating to that extremity, you must treat this as an emergency!

We then reviewed the distinguishing characteristics of GCA and TA

GCAvsTA.GIF

The key takeaway to remember is that TA is a chronic disease, filled with relapses and therefore these patients must be diligent about their immunosuppression, which in some cases may be lifelong at very low doses.

For those of you who are still here, a historical treat is your reward. At the 12th Annual Meeting of the Japan Ophthalmology Society held in 1908 in Fukuoka, the young Dr. Mikito Takayasu presented a curious case of vascular malformations of the eye. Two of his colleagues, Drs. Katsutomo Onishi and Tsurukichi Kagoshima also presented similar findings, but noted absence of pulses as well. The findings are impressive, but even more impressive is a subspecialist examining the entire body in a patient they were concerned about, a truly admirable – but increasingly uncommon – practice!

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