Takayasu arteritis presenting with dysphagia and morning stiffness: a diagnostic challenge in a middle-aged woman

BACKGROUND: Takayasu arteritis is a rare, chronic vasculitis affecting large arteries, primarily the aorta and its principal branches. The illness frequently presents with non-specific systemic symptoms, leading to a postponed diagnosis. Dysphagia resulting from aortic involvement is a rare manifestation and may resemble other cardiovascular or gastrointestinal disorders. CASE PRESENTATION: We report a 45-year-old Iranian woman with a one-year history of exertional dyspnoea, intermittent dysphagia for solid food, and diffuse musculoskeletal pain with morning stiffness. Initial evaluation showed elevated inflammatory markers, moderate aortic regurgitation, and aneurysmal dilation of the ascending aorta and aortic arch, and infective endocarditis was initially suspected. After serial negative blood cultures and resolution of a suspicious valvular finding on repeat transoesophageal echocardiography, upper gastrointestinal endoscopy and endoscopic ultrasonography localised her dysphagia to extrinsic oesophageal compression by the dilated thoracic aorta. Computed tomography angiography confirmed a non-dissecting aneurysm of the ascending aorta and arch, and whole-body ¹⁸F-FDG PET demonstrated markedly increased metabolic activity along the thoracic aorta and its supra-aortic branches, consistent with active large-vessel vasculitis. After systematic exclusion of infective and other inflammatory mimics, a clinical diagnosis of Takayasu arteritis was made. CONCLUSION: This case illustrates an uncommon presentation of Takayasu arteritis with dysphagia produced by extrinsic oesophageal compression from thoracic aortic aneurysmal dilatation. Constitutional symptoms, elevated inflammatory markers, and unexplained cardiovascular findings should prompt evaluation for large-vessel vasculitis. Early multimodal imaging and a systematic approach to excluding infective and other inflammatory mimics are essential for accurate diagnosis and timely treatment.