Inflammatory diseases of the aorta: Part 1: Non-infectious aortitis

A rare case of aortitis presenting as chest pain: a case report and literature review

Introduction and importance

Chest pain is a frequent reason patients seek medical attention. The broad spectrum of potential etiologies makes determining the underlying cause of chest pain complex. Among cardiovascular etiologies, aortitis is a rare but life-threatening possibility that should be considered in the differential diagnosis.

Case presentation

A 53-year-old female with a history of smoking presented with progressively worsening chest and epigastric pain over several weeks. She had seen multiple physicians previously for the same symptoms with unremarkable work-ups. Physical examination was notable for severe tenderness upon palpation of her lower abdomen. The electrocardiogram and troponins were unremarkable. Computed tomography of the abdomen revealed aneurysmal dilatation of the abdominal aorta, soft tissue thickening, and surrounding inflammatory stranding, consistent with aortitis. Infectious and autoimmune work-ups were unremarkable. Intravenous steroids were initiated, and her symptoms improved significantly. Her aortitis was attributed to inflammation secondary to chronic smoking.

Clinical discussion

Aortitis is a rare condition with varied clinical presentations. Etiologies of aortitis include infection and non-infectious inflammation. Diagnosis of aortitis requires a thorough clinical assessment and prompt imaging of the aorta, with computed tomography being the preferred imaging modality.

Conclusion

Evaluation for cardiovascular chest pain must extend beyond an electrocardiogram and troponin level. Imaging should be considered in patients with atypical symptoms. Aortitis is a rare but important diagnosis requiring immediate treatment.

The cardiovascular pathologist in the aortic team

Aortic diseases require a multidisciplinary management for diagnosis, treatment and follow-up with better outcomes in referral centers using a team-based approach. The setting up of a multi-disciplinary aortic team for the discussion of complex cases has been already proposed; it is also supported by the ACC/AHA. Surgeons and radiologists, more or less other physicians such as cardiologists, geneticists, rheumatologists/internal medicine specialists and pathologists are involved into such a team. The role of the cardiovascular pathologist is to examine the aortic specimens, to diagnose and classify the aortic lesions. Herein, the role of the pathologist in the aortic team is discussed and the pathobiology of aortic diseases is reviewed for reference by pathologists. The aortic specimens are mainly obtained from emergency or elective surgical procedures on the thoracic aorta, less frequently from organ/tissue (including cardiac or heart valve) donors, post-mortem procedures or abdominal aortic surgery. In the last decade, together with the progress of medical sciences, the histological definitions and classifications of the aortic pathology are undergoing thorough revisions that are addressed to an etiopathogenetic approach because of possible clinico-pathological correlations, therapeutic and prognostic impact. Pathologists may also have an important role in research and teaching. Therefore, histological analyses of the aortic specimens require adequate sample processing and pathologist expertise because histology contributes to definite diagnosis, correct management of patients and even (in genetic diseases) families, but also to research in the challenging field of aortopathies.

Single centre experience of 120 patients with non-infectious aortitis: Clinical features, treatment and complications

BACKGROUND

Aortitis is an important form of vasculitis with significant risk of complications. Very few studies have provided detailed clinical phenotyping across the whole disease spectrum. Our primary aim was to look the clinical features, management strategies and complications associated with non-infectious aortitis.

METHODS

A retrospective review was performed on patients with diagnosis of noninfectious aortitis at the Oxford University hospitals NHS Foundation Trust. Clinicopathologic features were recorded including demographics, presentation, aetiology, laboratory, imaging findings, histopathology, complications, treatment, and outcome.

RESULTS

We report the data on 120 patients (59% females). Systemic inflammatory response syndrome constituted the most common presentation (47.5%). 10.8% were diagnosed following a vascular complication (dissection or aneurysm). All patients (n = 120) had raised inflammatory markers (median ESR 70.0 mm/h and CRP 68.0 mg/L). Isolated aortitis subgroup (15%) had significantly higher likelihood of presenting with vascular complications and challenging to diagnose due to non-specific symptoms. Prednisolone (91.5%) and methotrexate (89.8%) were the most used treatment. 48.3% developed vascular complications during the disease course including ischaemic complications (25%), aortic dilatation and aneurysms (29.2%) and dissection (4.2%). Risk of dissection was higher in the isolated aortitis subgroup at 16.6% compared to all other types of aortitis at 1.96%.

CONCLUSION

Risk of vascular complications is high in non-infectious aortitis patients during disease course, hence early diagnosis and appropriate management is key. DMARDs such as Methotrexate appear to be effective, nonetheless there remain gaps in evidence for longer-term management of relapsing disease. Dissection risk seems much higher for patients with isolated aortitis.

Emergent Magnetic Resonance Angiography for Evaluation of the Thoracoabdominal and Peripheral Vasculature

Thoracoabdominal and peripheral vasculature pathologies include a variety of severe and life threatening conditions that may be encountered in the emergent setting. Computed tomography angiography (CTA) is the first-line modality for imaging of the vasculature in this context, but magnetic resonance angiography (MRA) also plays an important and emerging role in the evaluation of carefully selected patients. Intravenous (IV) iodinated contrast is necessary for CTA, although MRA is most useful in patients who cannot receive IV iodinated contrast for reasons including prior severe allergic-like reaction to iodinated contrast, poor IV access, or severe renal insufficiency. Gadolinium-based contrast agents are administered for MRA when possible, as they generally improve the diagnostic quality and shorten the duration of the exam. In most clinical situations, however, noncontrast MRA is sufficient to obtain a diagnostic evaluation. In this review, we discuss the key strengths and limitations of MRA performed in the emergent setting, highlighting the role of MRA in the diagnosis of acute aortic syndromes, aortitis, aortic aneurysm, pulmonary embolism, and peripheral vascular disease.

Aortitis as a Harbinger of Esophageal Cancer

Aortitis is a rare diagnosis that requires a high index of suspicion due to nonspecific symptoms and its multiplicity of etiologies.

An 80-year-old man, independent in activities of daily living (ADLs), had three consecutive hospitalizations in three months for fever, general malaise, anorexia associated with arthritis of the hands and feet with the inability to walk. Inflammatory markers were increased without a focus of infection identified. Upper digestive endoscopy (UDE), colonoscopy, blood cultures, thoracoabdominal-pelvic CT and transthoracic (TT) echocardiogram were performed without changes, with discharge for consultation after demonstrating apyrexia. At the patient second hospitalization for fever and arthritis, a transesophageal echocardiogram was performed that showed the presence of multiple complex atherosclerotic plaques, with associated thrombi in all segments of the aorta with a suspicious mass of vegetation on the aorta. Thoracic-abdominopelvic CT demonstrated calcified atheromatosis of the entire aorta with para-aortic nodes; MRI showed aortic thickening; and autoimmunity study was negative. Aortitis was the working diagnosis of possible infectious etiology and anticoagulation and antibiotic therapy were started. Fever recurred and a third admission led to a working diagnosis of inflammatory, non-infectious aortitis. The patient responded well to empiric corticosteroids.

The patient followed up in consultation, remained asymptomatic under a low dose of corticosteroids with negative temporal artery biopsy. In the sixth month, he repeated UDE due to dysphagia, which showed the presence of esophageal neoformation with the histological diagnosis of squamous cell carcinoma, maintaining on the CT as alterations in the aorta.

This is an unusual case of aortitis associated with arthritis with improvement after corticosteroids, which interestingly occurred before the progression of esophageal cancer. In hindsight, we think this may have been a large vessel paraneoplastic vasculitis that preceded the detection of esophageal squamous cell carcinoma.

Salmonella aortitis successfully treated with antibiotics without surgery

Aortitis is an inflammation of the aorta that is linked to large vessel vasculitis and other rheumatologic cases. Less often, an infectious etiology of aortitis is diagnosed. Aortitis is associated with high mortality and morbidity and requires a high index of suspicion. Here we present a rare case of aortitis secondary to Salmonella Septicemia treated with six weeks of antibiotics in the hospital without and remained asymptomatic and inflammatory markers normalized at 2 weeks follow up (ESR, CRP, and WBCs).

Role of MRI in the Evaluation of Thoracoabdominal Emergencies

Thoracic and abdominal pathology are common in the emergency setting. Although computed tomography is preferred in many clinical situations, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have emerged as powerful techniques that often play a complementary role to computed tomography or may have a primary role in selected patient populations in which radiation is of specific concern or intravenous iodinated contrast is contraindicated. This review will highlight the role of MRI and MRA in the emergent imaging of thoracoabdominal pathology, specifically covering acute aortic pathology (acute aortic syndrome, aortic aneurysm, and aortitis), pulmonary embolism, gastrointestinal conditions such as appendicitis and Crohn disease, pancreatic and hepatobiliary disease (pancreatitis, choledocholithiasis, cholecystitis, and liver abscess), and genitourinary pathology (urolithiasis and pyelonephritis). In each section, we will highlight the specific role for MRI, discuss basic imaging protocols, and illustrate the MRI features of commonly encountered thoracoabdominal pathology.

Clinically isolated descending thoracic aortitis in a healthy older woman: a diagnostic challenge

A woman travelling to Australia in her early 70s presents to a regional emergency department with chest pain and associated shortness of breath. Her medical history was that of seasonal affective disorder treated with citalopram, and an allergy to ibuprofen. Subsequent CT imaging revealed aortic wall thickening and associated periaortic fluid, and a moderate pleural effusion. This was successfully treated with oral prednisolone, responding within 1 day. Further blood tests revealed a high CD4/CD8 T-cell ratio, which can be seen in autoimmune disease, sarcoidosis and haematological malignancies. Without evidence for other autoimmune processes, the patient was given a provisional diagnosis of descending thoracic aortitis secondary to sarcoidosis, prescribed a weaning regimen of prednisolone, and asked to seek further investigation and management in her home country. This is a case with several learning points; rare disease can cause common presentations/reports, and sometimes empirical therapy is the only therapy.

Lupus Aortitis Successfully Treated with Moderate-dose Glucocorticoids: A Case Report and Review of the Literature

Lupus aortitis is a rare and potentially life-threatening disorder. Previous studies have reported the utility of high-dose systemic glucocorticoids or surgery as the treatment, although there have been no related controlled trials. We herein report a 49-year-old woman with a 35-year history of systemic lupus erythematosus who was diagnosed with aortitis. Her symptoms and laboratory and imaging abnormalities rapidly resolved upon the administration of moderate-dose glucocorticoids. We subsequently performed a literature review of similar cases to identify the appropriate treatment and discuss these cases. A study of further cases will be needed to identify the characteristics of patients who would benefit from moderate-dose glucocorticoid therapy.

Fabrication of aortic bioprosthesis by decellularization, fibrin glue coating and re-endothelization: a cell scaffold approach

Aortic dysfunctions (aneurysm, aortitis) lead to the most serious conditions related to aortic wall with life-threatening complications. The most common modality of management for such conditions is replacement (diseased part) of aorta by a larger diameter stent (reconstructive vascular surgery) which in itself is a big trial. The most natural way is to use a re-endothelized scaffold. Developing a scaffold with biomimetic properties is an experimental aim for most of the scientists and surgeons. We aim to structure a strategy to overcome the well-known problems associated with aorta. In this study, we plan to remold a larger diameter blood vessel such as aorta from xenogeneic origin using different protocols to decellularize and comparing them with normal aorta. The chemicals and enzymes used for bovine aorta decellularization are 1% SDS (group II), 70% ethanol + 0.25% trypsin (group III), 70% ethanol (group IV), and 0.25% trypsin (group V). Group I served as control (without decellularization). Histology and SEM study were conducted for cellular presence/absence in all scaffolds. Later, the scaffolds were coated with the fibrin glue (FG) and endothelial cells were proliferated over them. 3D images were taken showing the remolding of the endothelial cells on FG-coated surfaces. The re-endothelization was confirmed by lectin and vWF^+/+ expression. Graft elasticity and burst pressure were confirmed by biomechanical tensile testing. Further, the absence of host tissue DNA and presence of cellular DNA after re-endothelialization were confirmed by PicoGreen assay. The acceptability for metabolically active cellular proliferation on scaffolds and its non-toxicity were proved by cell viability assay. Current findings accomplish that larger diameter aorta extracellular matrix scaffold (group II) can be fabricated and re-endothelialized to develop non-thrombotic surfaces with improved graft patency with promising results compared to other fabricated scaffold groups.

Aortitis and aortic aneurysm in systemic vasculitis

The term "large-vessel vasculitis" refers to chronic inflammation affecting the elastic arteries, mainly aorta and its major branches. Large-vessel vasculitis affecting the aorta is termed as "aortitis." This leads to diffuse wall thickening, loss of elasticity, stenosis, occlusion, dissection, calcification or aneurysm formation. Vasculitis involving the aorta includes Takayasu arteritis (commonest large-vessel vasculitis in India), giant cell arteritis (GCA), the periaortitis spectrum (including inflammatory abdominal aortic aneurysm), rheumatic diseases and IgG4-related disease. It is important for physicians to be aware of the aortic manifestations of common vasculitis-so that clinically relevant aortic involvement is not missed. Also, it is equally important for surgeons to keep in mind that aortic aneurysms can have an inflammatory aetiology. The primary reason for this is the central role that immunosuppressive therapy plays in the management of inflammatory aortic aneurysms. Surgical or percutaneous interventions, when needed, are most likely to succeed when performed after activity control; perioperative steroids may be beneficial in select cases, and postoperative disease activity control is imperative.

A case of aortitis during cisplatin-based chemotherapy for cervical cancer

A case of aortitis in a patient undergoing adjuvant cisplatin and topotecan chemotherapy for cervical cancer following presentation with pyrexia of unknown origin and raised inflammatory markers is presented. Although many chemotherapy agents are known to cause small vessel vasculitis and there are several reported cases of large vessel vasculitis following gemcitabine chemotherapy, there is only one previously described case of aortitis following cisplatin administration. This case is presented with corresponding CT and ¹⁸F-FDG PET-CT imaging with discussion of the literature regarding vasculitis and chemotherapy.

Listeria monocytogenes infectious periaortitis: a case report from the infectious disease standpoint

Background

Endograft infection is a rare but extremely dangerous complication of aortic repair (25–100% of mortality). We describe here the first case of Listeria monocytogenes abdominal periaortitis associated with a vascular graft. We also discuss the differential diagnosis of periaortitis and provide a literature review of L. monocytogenes infectious aortitis.

Case presentation

Nine months after endovascular treatment of an abdominal aortic aneurysm (abdominal stent graft), a 76-year-old man was admitted for severe abdominal pain radiating to the back. Laboratory tests were normal apart from elevated C-reactive protein (CRP). Injected abdominal computed tomography (CT) showed infiltration of the fat tissues around the aortic endoprosthesis and aneurysmal sac expansion; positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) showed a hypermetabolic mass in contact with the endoprosthesis. Blood cultures were negative. At surgical revision, an infra-renal peri-aortic abscess was evident; post-operative antibiotic therapy with ciprofloxacin and doxycycline was started. Cultures of intraoperative samples were positive for L. monocytogenes. Results were further confirmed by a broad-range polymerase chain reaction (PCR) and next-generation sequencing. Antibiotic treatment was switched to intravenous amoxicillin for 6 weeks. Evolution was uneventful with decrease of inflammatory parameters and regression of the abscess.

Conclusion

An etiologic bacterial diagnosis before starting antibiotic therapy is paramount; nevertheless, culture-independent methods may provide a microbiological diagnosis in those cases where antimicrobials are empirically used and when cultures remain negative.

Acute non-traumatic disease of the abdominal aorta

Acute pathology in the abdominal aorta is associated with significant morbidity and mortality. The most feared complication of abdominal aortic disease is acute rupture in the setting of atherosclerotic abdominal aortic aneurysm. Although frank rupture often is easily diagnosed on CT, other findings such as a hyperattenuating crescent, discontinuous intimal calcium, and draping of the aorta are subtle signs of aneurysm instability. A true aneurysm should be distinguished from a rapidly growing, saccular pseudoaneurysm in the setting of infectious aortitis, as treatment strategy differs. Acute aortic syndrome involving the abdominal aorta, such as dissection and intramural hematoma, often is an extension of thoracic aortic disease, whereas penetrating atherosclerotic ulcers occasionally involve only the abdominal aorta. The goal of treating acute aortic pathology is to repair and prevent rupture, as well as restore and maintain perfusion of the lower extremities, kidneys, and mesentery. However, both open and endovascular repair of the abdominal aorta may become acutely complicated, resulting in compromise of these goals. Examples include aortoenteric fistula, endoleak, anastomotic pseudoaneurysm, graft infection, and thrombosis or kinking of a stent graft resulting in ischemia of the limbs and mesentery.

Non-infectious aortitis in an immunosuppressed renal transplant recipient with IgA nephropathy

A 54-year-old woman presented with atypical chest pain, fever and malaise. She was immunosuppressed with three agents following a living-donor kidney transplant 1 year previously. Her native kidney failure was secondary to biopsy-demonstrated crescentic IgA nephropathy, with systemic involvement. A CT pulmonary angiogram revealed an inflammatory cuff of soft tissue around the descending thoracic aorta suggesting aortitis. Inflammatory markers were elevated. Given her immunosuppression, the patient was screened extensively for infective causes and was empirically commenced on intravenous meropenem. After 72 hours of no clinical or serological response to antibiotic therapy, negative microbiological investigations and worsening inflammation on serial imaging, she was commenced on high-dose methylprednisolone for presumed inflammatory aortitis. Symptoms and inflammatory markers rapidly normalisedand the patient was discharged home on oral prednisolone. A clinical diagnosis of IgA-related aortitis was made. Imaging 3 months later showed complete resolution of the aortitis.