Coronary aneurysms and coronary arterial bypass graft disease as initial presentation of Takayasu's arteritis, induced by hepatitis B infection

A 51-year-old Indian gentleman, after CABG surgery, developed blood transfusion induced acute hepatitis B infection, which recovered completely with symptomatic treatment. Subsequently, he developed recurrent angina, dyspnoea along with musculoskeletal symptoms with elevated acute phase reactants. A CT angiography showed thickening of bilateral subclavian arteries and left renal artery stenosis. His RIMA graft was totally occluded at the origin and the LIMA graft showed an aneurysm at the anastomotic site with the left anterior descending artery (LAD). FDG-PET scan showed active inflammation of the ascending and descending thoracic aorta. He was diagnosed as Takayasu's arteritis. He responded to steroids and immunosuppressants. One month later he developed acute coronary syndrome and a coronary angiography showed severe left main stenosis with a left main aneurysm and a significant ostial LCx lesion. His LAD had an aneurysm at the anastomotic site with the patent LIMA graft. His RCA also had an aneurysm followed by a total occlusion. His LIMA graft also showed a significant lesion and his RIMA graft was occluded. He underwent angioplasty and stenting with DES to the LAD at the anastomotic site and to the left main-LCx.DiscussionThe case highlights the diverse modes of presentation of Takayasu's arteritis. Our case presented as acute coronary syndrome with multiple coronary aneurysms and bypass graft disease, which was successfully treated with angioplasty and stenting. The case also highlights the importance of viral infections and vaccinations in the pathogenesis of Takayasu's arteritis.