Utility and safety of tocilizumab in Takayasu arteritis with severe heart failure and muscle wasting

Abstract

Takayasu arteritis (TA) is a large vessel vasculitis of unknown aetiology characterized by chronic inflammatory changes of the aorta and its major branches. We report the active TA case who had severe heart failure due to acute myocardial infarction and aortic regurgitation. Bentall procedure was successfully performed, but he had severely depressed left ventricular function and muscle wasting together with vascular inflammation. The treatment with tocilizumab, an interleukin-6 receptor monoclonal antibody, in addition to prednisolone and standard heart failure therapy led to prompt remission of TA activity and improvement of left ventricular function and muscle wasting. Taken together with possible involvement of interleukin-6 in the pathogenesis of heart failure and muscle wasting, inhibition of interleukin-6 receptor signalling by tocilizumab may be a safe and reasonable approach in the treatment of active TA with heart failure and muscle wasting.

Keywords: Aortic regurgitation; Heart failure; Interleukin-6; Sarcopenia; Takayasu arteritis; Tocilizumab.

Figure 1

(A) 3D computed tomography angiography showing aortic root dilatation and dilated and stenotic changes of both common carotid arteries and their branches. (B, C) Axial computed tomography images showing wall thickening with enhancement of right (B) and left (B, C) common carotid arteries. (D) Histological findings of surgically resected aortic tissue showing massive infiltration of lymphocytes and giant cells mainly in the media and adventitia with destruction of the media. Images of Elastica von Gieson staining (original magnification ×100) and haematoxylin and eosin staining (inset, original magnification ×400) are shown. (E, F) ¹⁸F‐fluorodeoxyglucose (FDG) positron emission tomography/computed tomography showing strong ¹⁸F‐FDG uptake in the left main coronary artery (E) and its disappearance after the treatment with prednisolone and tocilizumab (F).

Figure 2

Clinical course of this case. Tocilizumab was initially scheduled to administer every 14 days, but it changed to every 7 days because of re‐elevation of C‐reactive protein 16 days after the initial dose of tocilizumab.