A 69-year-old woman with intermittent claudication and elevated ESR.

Accepted 23 April 1998 A 69-year-old woman was referred to our out-patient clinic because of long-term hypertension and stable chronic renal failure (creatinine 132 ,umol/l), which had been attributed to nephroangiosclerosis. She presented with a one-year history of anorexia, asthenia and loss of 6 kg ofweight. In addition, she complained of intermittent claudication of the left arm and both legs lasting 2 months. This provoked important functional limitation of the three limbs, and impaired ambulation. She did not complain of headache or symptoms suggestive of polymyalgia rheumatica. Her blood pressure was 160/95 mmHg on the right arm and undetectable on the left arm and lower limbs. Both temporal arteries were palpable and not painful. Auscultation of both carotid arteries was normal, without murmurs. Cardiac and pulmonary auscultation were normal. Murmurs were audible on both subclavian arteries. Neither the humeral nor the radial pulse were detectable on the left upper limb. Murmurs were also audible on both femoral arteries, and neither popliteal nor distal pulses were palpable. Her feet were cold although they had no ischaemic lesions. Funduscopic examination was essentially normal. The most relevant laboratory data were: erythrocyte sedimentation rate (ESR) 120 mm/h, C-reactive protein 4.4 mg/dl (normal range <1.5); antinuclear and antineutrophil cytoplasmic antibodies were negative. A digital subtraction angiography (DIVAS) of both upper limbs was performed as part of her intermittent claudication syndrome evaluation (figures 1 and 2). All carotid, vertebral, renal arteries and aorta were normal and there were no atheroma plaques at any level. A DIVAS of the lower limbs showed stenosis of 50-80% in both femoral arteries and complete proximal obliteration of both popliteal arteries (figure 3).