Ischaemic stroke associated with Takayasu arteritis and latent tuberculosis: a diagnostic and therapeutic challenge

A man in his early 40s presented late with right-sided weakness and dysarthria. MRI showed an infarct in the posterior limb of the left internal capsule in the anterior choroidal artery territory. CT angiography of the head and neck showed no large-vessel occlusion, significant cervicocephalic stenosis or dissection. Given his young age, limited vascular risk factors apart from hypertension and systemic vascular clues, further assessment revealed pretreatment CT angiographic evidence of large-vessel arteritis involving the abdominal aorta and branch vessels. Rheumatology favoured Takayasu arteritis after consideration of mimics. The stroke mechanism remained uncertain; hypertensive small-vessel disease was plausible although an inflammatory contribution was considered clinically possible. QuantiFERON-TB Gold was positive and was managed as latent tuberculosis after respiratory/infectious diseases review found no evidence of active tuberculosis. Positron emission tomography (PET)-CT performed after immunosuppression showed thoracic nodal uptake, but subsequent high-resolution computed tomography (HRCT) thorax was unremarkable. Treatment included stroke therapy, corticosteroids, rifampicin and tocilizumab.