Perivascular carotid inflammation: an unusual case of carotidynia

Clinical and image features: large-vessel vasculitis after granulocyte colony stimulating factor administration

BACKGROUND

Granulocyte colony stimulating factor (G-CSF) is known to cause vasculitis, mainly in the small vessels. Several cases of large-vessel vasculitis (LVV) caused by G-CSF have recently been reported in the literature; we retrospectively suspect that some cases of LVV in our institution were associated with administration of G-CSF.

PURPOSE

To evaluate the clinical and radiological findings in our cases and to compare them with those in previous reports.

MATERIAL AND METHODS

We retrospectively evaluated clinical and radiological findings in four cases of LVV that occurred after administration of G-CSF in our institution. We also reviewed papers on G-CSF-related LVV and compared their findings to ours.

RESULTS

G-CSF-related LVV occurred in patients aged > 50 years and more frequently in women. Most patients developed vasculitis within 15 days after the last administration. While 14/16 patients were symptomatic, the remaining two patients were asymptomatic and diagnosed incidentally. In all cases, laboratory inflammatory markers increased, but there were no autoantibodies that clearly indicated other autoimmune vasculitis. Computed tomography revealed elevated soft tissue density around the affected vessels.

CONCLUSION

LVV is among the potential adverse events of G-CSF administration. We should keep this outcome in mind when we interpret medical images of patients with previous G-CSF treatment history even if they are asymptomatic.

First reported case of ANCA-associated vasculitis induced by oxaliplatin, capecitabine, and trastuzumab

A 68-year-old male, who was undergoing XELOX plus trastuzumab therapy for gastric cancer, developed proteinuria, hematuria, and progressive increase in creatinine after 3 months. Subsequently, the patient also experienced hemoptysis, nasal bleeding. Chest CT examination shown pulmonary hemorrhage. The MRI of the nasopharynx ruled out nasopharyngeal cancer recurrence. The MPO and PR3 were elevated, and renal biopsy confirmed ANCA-related vasculitis, which affected the lungs, kidneys, and nasopharynx. Based on the review of the patient''s medical history and medication, it is believed that ANCA-related vasculitis was caused by XELOX plus trastuzumab chemotherapy, but it is difficult to confirm which specific drug caused it. After stopping XELOX plus trastuzumab chemotherapy, glucocorticoids and cyclophosphamide was given, the patient''s pulmonary hemorrhage and nasal bleeding stopped, and the lung lesions were absorbed. The renal function also improved. The patient later experienced pulmonary infection again, and tNGS indicated Legionella pneumophila and pulmonary tuberculosis infection. Despite anti-infection treatment, steroid dose was rapidly reduced. Ultimately, the patient gave up on treatment and eventually died.

Relapsing TIPIC Syndrome after Administration of an mRNA-Based COVID-19 Vaccine

Reported vascular complications following mRNA-based COVID-19 vaccines are consisting of myocarditis, cerebral venous thrombosis, cerebral vascular thrombosis, and vaccine-induced thrombocytopenia. Here, we describe a case of a 49-year-old woman with left-sided pain above the middle common carotid artery (carotidynia) starting a few days after her second vaccination with an mRNA-based COVID-19 vaccine (Spikevax). Imaging was indicative of transient perivascular inflammation of the carotid artery (TIPIC) syndrome. The diagnostic workup for other immunologically mediated diseases was negative. The inflammation subsided after a course of prednisone and aspirin, and clinical symptoms vanished, but later mildly relapsed in the context of a viral upper respiratory tract infection other than SARS-CoV-2. Carotidynia because of TIPIC syndrome may present as an immunogenic side effect of the newly developed mRNA-based vaccinations against COVID-19. TIPIC syndrome should be considered in new-onset neck pain after vaccination.

Subacute and Recurrent Transient Perivascular Inflammation of the Carotid Artery (TIPIC syndrome) and Supraclavicular Lymphadenopathy Associated with Ipsilateral Intramuscular m-RNA COVID-19 Vaccine

We describe a case of recurrent transient perivascular inflammation of the carotid artery (TIPIC) syndrome and associated supraclavicular lymphadenopathy after ipsilateral intramuscular administration of an mRNA-based COVID-19 vaccine.

Granulocyte colony-stimulating factor- and chemotherapy-induced large-vessel vasculitis: six patient cases and a systematic literature review

OBJECTIVE

Patients receiving chemotherapy are prone to neutropoenic infections, presenting with non-specific symptoms such as a high fever and elevated inflammatory parameters. Large-vessel vasculitis (LVV) may have a similar clinical presentation and should be included in differential diagnostics. A few published case reports and adverse event reports suggest a causal association between LVV and the use of granulocyte colony-stimulating factor (G-CSF) and chemotherapy. Our objective was to evaluate the relationship between LVV, G-CSF and chemotherapy.

METHODS

Between 2016 and 2018, we identified six patients in Finland with probable drug-induced LVV associated with G-CSF and chemotherapy. All six patients had breast cancer. A systematic literature review was performed according to PRISMA guidelines using comprehensive search terms for cancer, chemotherapy, G-CSF and LVV.

RESULTS

The literature search identified 18 similar published case reports, of which most were published after 2014. In all patients combined (n = 24), the time delay from the last drug administration to the LVV symptoms was on average 5 days with G-CSF (range = 1-8 days) and 9 days with chemotherapy (range = 1-21 days). Common symptoms were fever (88%), neck pain (50%) and chest pain (42%). Based on imaging, 17/24 (71%) had vascular inflammation in the thoracic aorta and supra-aortic vessels, but 5/24 (21%) reportedly had inflammation limited to the carotid area.

CONCLUSION

This review suggests that LVV may be a possible serious adverse event associated with G-CSF and chemotherapy. Successful management of drug-induced LVV requires early identification, through diagnostic imaging, and discontinuation of the drug.

Transient perivascular inflammation of the carotid artery; a rare cause of intense neck pain

Carotidynia or Transient Perivascular Inflammation of the Carotid Artery (TIPIC) syndrome is a rare cause of atypical neck pain. Exact aetiopathogenesis of this clinical entity is poorly understood. A 43-year-old female presented with progressively increasing right side neck pain of 3 days duration associated with focal tenderness over the right carotid pulse corresponding to the level of upper border of thyroid cartilage. Her inflammatory markers were not elevated. An ultrasound scan revealed increased echogenicity surrounding the distal common carotid artery, obliteration of the perivascular tissue planes with preserved doppler flow pattern. MRI showed soft tissue thickening around the distal common carotid artery, carotid bulb and proximal external carotid artery on right side of the neck corresponding to sonographic findings with gadolinium enhancement. A diagnosis of TIPIC syndrome was made and she was started on celecoxib. Pain completely subsided within 2 weeks. In conclusion, TIPIC syndrome is a rare differential diagnosis of neck pain. It is caused by a transient perivascular inflammation of the carotid artery. A high degree of suspicion is necessary for the diagnosis. Imaging is the gold standard investigation for the diagnosis of TIPIC syndrome. It is a self-limiting pathology and often responds rapidly to nonsteroidal anti-inflammatory drugs.

Imaging Spectrum of TIPIC Syndrome : Validation of a new Entity with Vessel Wall Imaging

PURPOSE

Acute neck pain can have non-vascular and vascular causes. Some patients present with distinct vascular and perivascular changes on imaging at the site of tenderness. This study aimed to evaluate the imaging findings of transient perivascular inflammation of the carotid artery (TIPIC) syndrome with an emphasis on vessel wall imaging using 3‑Tesla (3-T) high-resolution (HR) magnetic resonance imaging (MRI).

METHODS

Clinical data along with diagnostic and follow-up imaging of patients presenting to these hospitals with acute neck pain/tenderness and at least 1 imaging study using color Doppler ultrasound (CDU) and/or MRI including vessel wall imaging from September 2013 through September 2017 were retrospectively evaluated. A total of 15 patients with no other underlying cause of pain, findings meeting the imaging criteria for TIPIC syndrome and clinical recovery (spontaneous or with treatment) were included in the study.

RESULTS

The mean patient age was 43.2 years. With CDU and precontrast MRI, perivascular inflammation (PVI) of the involved artery segment was evident in all patients. Contrast enhancement of the adventitia and PVI were noted on postcontrast HR vessel wall MRI in all patients. Of the patients five had co-existing plaques at the site of tenderness. Follow-up imaging demonstrated pronounced regression or complete resolution of the findings.

CONCLUSION

Imaging is useful for the establishment of TIPIC syndrome diagnosis and to rule out other conditions. The use of CDU is usually sufficient for diagnosis and follow-up but in clinically doubtful and complicated cases, vessel wall imaging with HR-MRI is very valuable. Thorough knowledge of this entity among radiologists enables a prompt diagnosis, which accelerates the clinical management.

Carotid artery inflammation associated with gemcitabine-based therapy: a special report

Vasculitis is an inflammation that can present as acute or chronic in nature, which causes changes in the walls of blood vessels, including thickening, weakening, narrowing and scarring. Gemcitabine, an antimetabolite chemotherapeutic agent, is generally well tolerated with a favorable side effect profile. However, there is increasing evidence that it is associated with vasculitis, which can affect small and large vessels. In this case report, we report a patient who has experienced fever with severe tenderness over right carotid artery, which occurred on the fifth day after the administration of gemcitabine. The exact mechanism of gemcitabine-induced vasculitis is unknown but cessation of gemcitabine and initiation of anti-inflammatory treatment appears to aid in the resolution of the clinical syndrome.

CT findings in a patient with bilateral metachronous carotidynia

Carotidynia is a self-limiting, idiopathic clinical syndrome characterized by acute unilateral neck pain and tenderness of the carotid artery. We describe a unique case of bilateral carotidynia that occurred metachronously, with each incident resolving without long-term sequelae. Knowledge of this entity is important to properly interpret the imaging findings and to not mistake this finding as an ill-defined tumor, thus avoiding unnecessary biopsy.

Carotidynia after anticancer chemotherapy

Carotidynia is characterised by inflammation limited to the common carotid artery, which has been recognised as a distinct disease entity by advanced vascular imaging. Although most cases of carotidynia are idiopathic, we herein present a case of carotidynia after anticancer chemotherapy. A 64-year-old male patient received docetaxel followed by granulocyte-colony stimulating factor (G-CSF) for the treatment of lung squamous carcinoma. After the treatment, bilateral cervical pain developed. Vascular imaging, including magnetic resonance imaging, computed tomography and ultrasonography, showed characteristics specific for carotidynia. Although there was no strong confirmation using tests such as a challenge test, our observations suggest that docetaxel or G-CSF could be a causative drug triggering carotidynia.