Carotidynia – What Lies Beneath The Pulse
Main Author: Syeda Rida E Zehra
Karachi, Pakistan
Liaquat National Hospital and Medical College
Purpose Statement: Introduction
Carotidynia is a rare condition characterized by neck pain in the region of the carotid bifurcation. The cause is unknown but might be related to the ongoing autoimmune process, reaction to a drug, or an unknown inflammatory process. In a young patient with no comorbidities, it should prompt an investigation into underlying diagnosis and the differential must include Large Vessel Vasculitis. Here we report a case of a young female who presented with Carotidynia and was found to have Takayasu Arteritis on appropriate workup and imaging.
Method(s): A 16 year old female, with no significant past medical history presented to our outpatient clinic with complaints of right sided neck swelling ongoing for about 8 months. Swelling was localized to the right side of the neck, gradually increasing in size, and associated with pain which aggravated with neck movements. There was no discharge from the swelling, fever, night sweats, weight loss, difficulty swallowing, change of voice or preceding upper respiratory tract infection reported by the patient. Physical exam revealed a non-compressible, non-erythematous, pulsatile, tender swelling about 3×4 cm in size over right side of her neck extending laterally. The neurological exam was normal. Laboratory investigations revealed erythrocyte sedimentation rate at 85 mm/Hr and CRP at 45 mg/dL. To investigate the neck swelling further, Ultrasound neck with Carotid Artery Doppler was performed which revealed an aneurysmal dilation of the RCCA measuring 1.5×0.6 cm, with dual flow, characteristics on color Doppler imaging resembling Halo Sign. Autoimmune workup including antinuclear antibody (ANA) was negative. CT angiogram of the neck showed ectatic (dilated) right common carotid artery (RCCA) extending from origin to bifurcation with circumferential wall thickening indicative of vasculitis. Extensive imaging including Magnetic Resonance and Angiogram of the brain with Computed Tomography scan of the abdomen were unremarkable. Patient was started on oral corticosteroids according to her weight with concurrent Methotrexate therapy, which resulted in partial response at 4 weeks in terms of her symptoms including pain and swelling. Inflammatory markers showed slight improvement. She was followed up with Cerebral Angiogram after 3 months which showed ~90% focal stenosis of distal RCCA (Fig. 1), ~ 50-70% focal stenosis of proximal RCCA and right subclavian artery. She was thereafter, planned to start on biological therapy with Infliximab, and was also referred to Vascular Interventional Radiology for possible carotid artery stenting.
Result(s): Pulsatile neck swelling diagnosed to be large vessel vasculitis in a young female.
Conclusion(s): Clinicians must be aware to keep Carotidynia in the list of differential diagnoses for lateral neck pain, and should be able to construct age appropriate differential diagnosis for it. Unilateral neck pains should be evaluated meticulously, and not always be put down to muscular etiology. Early recognition of a critical cause of Carotidynia like Large Vessel Vasculitis allows prevention of lethal consequences