Tubercular aortitis mimicking Takayasu arteritis: a diagnostic challenge in an endemic region

Abstract

Takayasu arteritis (TA) is a chronic granulomatous large-vessel vasculitis involving the aorta and its major branches, with a possible pathogenic association with Mycobacterium tuberculosis, particularly in endemic regions due to shared immunopathological and epidemiological features. We report three pediatric cases of TA with concurrent or recent tuberculosis infection, all presenting with systemic symptoms, hypertension, and vascular insufficiency; computed tomography (CT) angiography confirmed large-vessel involvement, and inflammatory markers were elevated in all. Tuberculosis screening revealed positive Mantoux tests in each case, with one child having microbiologically confirmed rifampicin-sensitive tuberculosis on cartridge-based nucleic acid amplification test (CBNAAT) from gastric aspirate and two showing granulomatous lymphadenitis suggestive of tubercular etiology. Management included antihypertensives, anti-tubercular therapy, and carefully timed immunosuppression, resulting in clinical improvement and better blood pressure control, although vascular changes persisted. This case series highlights the clinically significant coexistence of TA and tuberculosis in children from endemic regions. The overlapping clinical, radiological, and immunological features pose diagnostic and therapeutic challenges. Screening for tuberculosis should be considered in all patients with suspected or confirmed TA prior to initiating immunosuppressive therapy. Early recognition and a coordinated treatment strategy integrating anti-tubercular therapy with immunosuppression are crucial for optimal patient outcomes.