Infected aortic aneurysm and inflammatory aortic aneurysm--in search of an optimal differential diagnosis

Rare case of inflammatory abdominal aortic aneurysm with an aortocaval fistula

Inflammatory abdominal aortic aneurysms (IAAA) are a distinct subcategory of abdominal aortic aneurysms that make up roughly 5%-10% of all abdominal aortic aneurysm (AAA) cases. Inflammatory AAA (IAAA) is distinguished from traditional atherosclerotic AAA by the triad of thickened aneurysm wall, extensive perianeurysmal/retroperitoneal fibrosis, and dense adhesions of adjacent abdominal organs. The purpose of this report is to examine the clinical course of a rare case of inflammatory abdominal aortic aneurysm with aortocaval fistula.

Endovascular treatment of a mycotic aneurysm in an immunocompromised child with acute leukemia-case report and review of the literature

Mycotic aneurysms are dilatations of an artery, a rare but severe complication arising from infectious obliteration of the vessel wall. Thoracic aneurysms often present with unspecific symptoms and multiple diagnostic and therapeutic challenges. In an advanced state, they have an increased risk of perforation and a high mortality rate. The surgical therapeutic approach has a high perioperative complication rate. In this study, we report a case of a thoracic mycotic aortic aneurysm in an immunocompromised pediatric patient caused by Klebsiella pneumoniae bacteremia. A combination of prompt antibacterial treatment and minimally invasive stent implantation showed a good outcome, avoiding possible severe surgical problems.

Percutaneous closure versus surgical repair for ruptured sinus of valsalva aneurysm: A systematic review and meta-analysis

Objectives

Ruptured sinus of Valsalva aneurysm (RSVA) often has an abrupt onset, and can chest pain, acute heart failure, and even sudden death. The effectiveness of different treatment modalities remains controversial. Thus, we completed a meta-analysis to evaluate the efficiency and safety of traditional surgery vs. percutaneous closure (PC) for RSVA.

Methods

We carried out a meta-analysis using PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), WanFang Data, and the China Science and Technology Journal Database. The primary outcome was comparing in-hospital mortality between the two procedures, and the secondary outcome was documenting postoperative residual shunts, postoperative aortic regurgitation, and length of hospital stay in the two groups. Differences were expressed as odds ratios (ORs) with 95% confidence intervals (CIs) to assess the relationships between predefined surgical variables and clinical outcomes. This meta-analysis was conducted using Review Manager software (version 5.3).

Results

The final qualifying studies included 330 patients from 10 trials (123 in the percutaneous closure group, and 207 in the surgical repair group). When PC was compared to surgical repair, there were no statistically significant differences in in-hospital mortality (overall OR: 0.47, 95%CI 0.05-4.31, P = 0.50). However, percutaneous closure did significantly decrease the average length of hospital stay (OR: -2.13, 95% CI -3.05 to -1.20, P < 0.00001) when compared to surgical repair, but there were no significant between-group differences in the rates of postoperative residual shunts (overall OR: 1.54, 95%CI 0.55-4.34, P = 0.41) or postoperative aortic regurgitation (overall OR: 1.54, 95%CI 0.51-4.68, P = 0.45).

Conclusion

PC may become a valuable alternative to surgical repair for RSVA.

Mycotic Thoracic Aortic Aneurysm: Epidemiology, Pathophysiology, Diagnosis, and Management

Mycotic thoracic aortic aneurysm (MTAA) is an aneurysm of the aorta caused by infection of the vessel tissue through microbial inoculation of the diseased aortic endothelium. It is most commonly caused by bacteria. Rarely, it can be caused by fungi. However, viral aortic aneurysm has never been reported. Depending on the area and time period investigated, the infections organism discovered may vary significantly. Little is known about the natural history of MTAA due to its rarity. It is not known if they follow the same pattern as other TAAs. However, it is unclear whether MTAA follows a similar clinical course. The combination of clinical presentation, laboratory results, and radiographic results are used to make the diagnosis of MTAA. Treatment of MTAA is complex since patients frequently present at a late stage, frequently with fulminant sepsis, as well as concomitant complications such as aneurysm rupture. While medical treatment, including antibiotics, is recommended, surgery is still the mainstay of management. Surgery to treat MTAA is complicated and carries a high risk of morbidity and mortality and includes both open repairs and endovascular ones. In this review, we explore the etiology, pathogenesis, clinical presentations, diagnostic modalities as well as treatment management available for MTAA.

Identification of a miRSNP Regulatory Axis in Abdominal Aortic Aneurysm by a Network and Pathway-Based Integrative Analysis

Abdominal aortic aneurysm (AAA) refers to local abnormal expansion of the abdominal aorta and mostly occurs in elderly men. MicroRNA (miRNA) is single-stranded RNA consisting of 18-25 nucleotides. It plays a key role in posttranscriptional gene expression and in the regulation of human functions and disease development. miRNA exerts its function mainly through the binding of complementary base pairs to the 3' regulatory region of mRNA transcripts. Therefore, miRNA-related single-nucleotide polymorphisms (miRSNPs) can affect miRNA expression and processing kinetics. miRSNPs can be classified based on their location: miRSNPs within miRNA-producing genes and miRSNPs within miRNA target genes. Increasing evidence indicates that miRSNPs play an important role in the pathogenic kinetics of cardiovascular diseases. The aim of this study was to identify potential miRNAs and integrate them into a miRSNP-based disease-related pathway network, the results of which are of great significance to the interpretation of the potential mechanisms and functions of miRSNPs in the pathogenesis of diseases.

Imaging characteristics and diagnostic accuracy of FDG-PET/CT, contrast enhanced CT and combined imaging in patients with suspected mycotic or inflammatory abdominal aortic aneurysms

Purpose

To evaluate the diagnostic accuracy and specific imaging characteristics of positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (PET/CT), contrast enhanced CT (CE-CT), and a combined imaging approach (CE-PET/CT) in patients with infectious/mycotic (MAA), inflammatory (IAA), and non-infected, non-inflammatory abdominal aortic aneurysm (AAA).

Materials and methods

In this single-center retrospective cohort study, all imaging data sets of 29 consecutive patients with clinically suspected MAA or IAA were anonymised with different, reshuffled identification numbers and retrospectively and independently analysed by two experienced readers, blinded to all clinical patient data. Readers determined the presence or absence and MAA, IAA and AAA and of predefined imaging characteristics (e.g. fluid collection), and measured metabolic activity and wall thickness of all aneurysms. A multidisciplinary team of specialists served as standard of reference and re-evaluated every clinical case, considering all clinical, laboratory, microbiological, histopathological and imaging results, including all follow-up examinations.

Results

Diagnostic accuracy was higher in PET/CT as compared to CE-CT in differentiating AAA from MAA and IAA: area under the receiver operating characteristic curve (AUC-ROC) 0.81 (95% confidence intervals 0.69–0.92) and 0.63 (0.52–0.74) (P = 0.027). Specific imaging characteristics were significantly associated with different types of aneurysms (P<0.05), i.e. very high metabolic activity and dorsal sparing of metabolic activity in PET/CT and wall thickening in CE-CT were indicative for IAA; fat stranding and fluid collections in CE-CT were associated with MAA; while low metabolic acitivity and absence of wall thickening in PET/CT, and less fat stranding and absence of wall thickening in CE-CT were indicative for non-infected, non-inflammatory AAA.

Conclusion

Specific imaging characteristics of PET/CT and CE-CT may be helpful in differentiating between MAA, IAA, and non-infected, non-inflammatory AAA.

Eosinophilic Granulomatosis Polyangiitis (EGPA) Masquerading as a Mycotic Aneurysm of the Abdominal Aorta: Case Report and Review of Literature

Introduction

Aortic involvement leading to aortitis in eosinophilic granulomatosis polyangiitis (EGPA) is infrequent, and only 2 cases have been reported so far in the literature. Even more so, aortic aneurysm, secondary to EGPA, has never been reported and remains a diagnostic and therapeutic challenge. Case Presentation. We present a 63-year-old Caucasian male patient with a prior diagnosis of EGPA presenting with abdominal pain, nausea, and loose stools to the emergency department. Physical examination showed periumbilical tenderness. He had no peripheral eosinophilia but had high C-reactive protein and procalcitonin levels. CT abdomen revealed a mycotic aneurysm involving the infrarenal abdominal aorta. The patient declined surgical repair initially and was treated with IV antibiotics only. Unfortunately, 24 hours later, the aneurysm ruptured, leading to emergent axillofemoral bypass surgery. Surgical biopsy showed aortitis, periaortitis, and active necrotizing vasculitis.

Conclusion

Abdominal aneurysms should be considered a complication of EGPA, and earlier immunosuppressive therapy should be considered to prevent further complications.

"Undiagnosed aortic coarctation with 2 simultaneous acute aortic syndromes: Intramural hematoma and mycotic aneurysm"

Acute aortic syndrome can be a fatal pathology if not diagnosed and managed early. Although acute aortic syndrome is more often a diagnosis of adulthood, it may occasionally afflict the pediatric patients. We herein present a case of a 5-year-old female that was discovered to have multiple acute and congenital aortic abnormalities after presenting to the emergency department with infectious symptoms and lower extremity pain. Acute aortic syndrome may not be a top differential consideration in children with acute chest pain; however, it is important to consider because delayed diagnosis and management can have fatal implications.

Gallium-67 Scan with Single Photon Emission Computed Tomography for the Evaluation and Monitoring of Infected Abdominal Aortic Aneurysms: A 10-Year Case Series

Purpose

This study aimed to evaluate the role of gallium-67 single photon emission computed tomography (SPECT) with contrast computed tomography (CT) in the evaluation and monitoring of infected abdominal aortic aneurysms (IAAA).

Methods

Materials and A retrospective cohort analysis was performed using prospectively collected data of consecutive patients with IAAA in Princess Margaret Hospital in Hong Kong between January 2010 and December 2020. The patients were identified using the Radiology Information System.

Results

All five patients had proven IAAA on CT and/or metabolic imaging. Among them, three were further supported by positive blood culture results. Gallium-67 SPECT with contrast CT was useful in the detection of residual disease, monitoring, and detection of recurrence.

Conclusion

Gallium-67 SPECT with contrast CT is helpful for evaluating IAAA. It serves an important role in guiding management, especially during long-term follow-up.

Infections of the aorta

Infection of the aorta continues to be a clinical challenge with high morbidity and mortality. The incidence varies between 0.6 and 2.6%. There has been a steady increase in graft infections, especially endograft infections, due to increased procedures (0.2 to 5%). Staphylococcus species remains the most common organism; however, gram-negative and rare causative agents are also reported. The clinical presentation can be very diverse and a high degree of suspicion is necessary to diagnose them. Sometimes, they may present as an emergency with rupture or fistulation. Diagnosis is based on a triad of clinical features, microbial cultures and imaging. Culture-specific antibiotics are mandatory during the entire course, but seldom cure alone. Surgical management remains the standard of care and involves an integrated approach involving debridement, reconstruction and use of adjuncts. Various aortic substitutes have been described with advantages and limitations. Pericardial tube grafts have emerged as a good option. Endo-vascular options are practiced mostly as a bridge to definitive surgery. A small role for conservative management is described. Aortic fistulation to the gut and airway carries a very high mortality. There are no large series in the literature to define guideline-directed treatment and most often it is a customized solution. The 30-day mortality remains close to 30%. Outcomes depend on multiple factors including patient's age, the timing of presentation, diagnosis, causative organism, host status and the treatment strategy adopted.

Surgical repair of ruptured sinus of Valsalva aneurysm: 13-year single center experience

BACKGROUND AND AIM

Untreated ruptured sinus of Valsalva aneurysms ultimately develop into heart failure, thereby affecting patients' survival. We retrospectively analyzed our 13-year experience of the surgical repair for ruptured sinus of Valsalva aneurysm to study the optimal surgical strategy, operative risk and long-term surgical outcome.

METHODS

Twenty-six patients underwent surgical repair of ruptured sinus of Valsalva aneurysm from January 2008 to February 2020. Follow-up data were obtained from the outpatient department records and telephone calls.

RESULTS

Patch closure of ruptured sinus of Valsalva aneurysm was done in all the 26 patients, most often through the transaortic (69%) and dual-chamber approach (23%). Aortic valve repair was done in one patient while seven patients underwent aortic valve replacement for associated significant aortic regurgitation. There was one in-hospital mortality because of noncardiac cause. The median duration of postoperative hospital stay was 8 days (range, 6-11 days). Follow-up data were available for 89% (23/26) patients. The mean follow-up period was 69 ± 43 months (range, 7-147 months). All survivors were in New York Heart Association functional Class I or II. There was no late death. One patient required rehospitalization for recurrent ruptured sinus of Valsalva aneurysm. There was no recurrent or new-onset significant aortic regurgitation and prosthesis-related complications in late follow-up.

CONCLUSION

Surgical repair for ruptured sinus of Valsalva aneurysm carries an acceptable low operative risk and excellent long-term outcome. Though high-risk population, an early diagnosis and optimal surgical approach can prevent worsening of symptoms and consequent heart failure.

Clinical Outcomes of Atypical Inflammatory Variants of Abdominal Aortic Aneurysm

Background

Most abdominal aortic aneurysms are degenerative atherosclerotic aneurysms. Inflammatory or infected abdominal aortic aneurysms, which show a slightly different clinical course, are rarely encountered in clinical settings. Therefore, we aimed to investigate the clinical course of these variants of abdominal aortic aneurysms.

Methods

This retrospective study included 32 patients with atypical inflammatory or infected abdominal aortic aneurysms who underwent emergent graft replacement between November 1997 and December 2017. Patients were followed up at the outpatient clinic for a mean period of 4.9±6.9 years. We analyzed the patients' clinical course and compared it with that of patients with atherosclerotic abdominal aortic aneurysms.

Results

There was 1 surgical mortality (3.0%) in a case complicated by aneurysmal free rupture. In 2 cases of infected abdominal aortic aneurysms, anastomotic complications developed immediately postoperatively. During the follow-up period, 10 patients (30%) developed graft complications, and 9 of them underwent reoperations; of these, 2 patients (22.2%) died of postoperative complications after the second operation, whereas 2 patients survived despite graft occlusion.

Conclusion

Patients with inflammatory abdominal aneurysms frequently develop postoperative graft complications requiring secondary surgical treatment, so they require close mandatory postoperative follow-up.

Recent progress on nanoparticles for targeted aneurysm treatment and imaging

An abdominal aortic aneurysm (AAA) is a localized dilatation of the aorta that plagues millions. Its rupture incurs high mortality rates (~80-90%), pressing an urgent need for therapeutic methods to prevent this deadly outcome. Judiciously designed nanoparticles (NPs) have displayed a unique potential to fulfill this need. Aneurysms feature excessive inflammation and extracellular matrix (ECM) degradation. As such, typically inflammatory cells and exposed ECM proteins have been targeted with NPs for therapeutic, diagnostic, or theranostic purposes in experimental models. NPs have been used not only for encapsulation and delivery of drugs and biomolecules in preclinical tests, but also for enhanced imaging to monitor aneurysm progression in patients. Moreover, they can be readily modified with various molecules to improve lesion targeting, detectability, biocompatibility, and circulation time. This review updates on the progress, limitations, and prospects of NP applications in the context of AAA.

Infected thoracic aortic aneurysm caused by Clostridium ramosum: A case report

A 73-year-old man undergoing conservative management of acute aortic dissection (Stanford type B) was diagnosed with infected aortic aneurysm based on clinical findings of aortic dilatation and recurrent laryngeal nerve paralysis. We performed total aortic arch replacement with a synthetic graft and omentopexy; and Clostridium ramosum was isolated from resection specimens. Infected aortic aneurysms are rare but may lead to death from aortic dissection or rupture. C. ramosum infection is rare and has seldom been reported, and thus no treatment guidelines, including antibiotic therapy, have been established. Therefore, it is necessary to accumulate a larger number of cases of aortic aneurysm infected by C. ramosum. To date, there has been no reported case of infected aortic aneurysm due to C. ramosum. Here, we report a case of infected aortic aneurysm due to C. ramosum. <Learning objective: Infected aortic aneurysm is a life-threatening condition because of the possibility of aortic dissection and rupture. Infected aortic aneurysms are often caused by Staphylococcus aureus and Salmonella species, and there has been no report of aortic aneurysm infected by C. ramosum. Regarded as a non-pathogenic intestinal bacterium, C. ramosum is seldom identified as a causative bacterium. In this case, dilatation of aorta progressed rapidly, requiring early surgical treatment.>.

Mycotic aortic aneurysms treated by endovascular repair: initial experience in a single center

INTRODUCTION

Mycotic aortic aneurysm (MAA) is an uncommon cause of aneurysmal aortic disease. However, it may have an aggressive presentation and a complicated early outcome. Endovascular aneurysm repair (EVAR) of MAA is emerging as an alternative to open repair (OR) for the treatment of these aneurysms, particularly in high-risk surgical patients. We report a single-center experience with the endovascular management of mycotic aortic aneurysms.

MATERIAL AND METHODS

Two mycotic abdominal aortic aneurysms were treated with an endovascular stent graft at Centre Hospitalier Régional du Val de Sambre, Belgium. The mean follow-up was 15 months. Technical success was achieved in all two patients. CT-scan follow up showed shrinkage of the aneurysm sac, with no evidence of infection along the stent graft and no signs of endoleakage in all patients. One patient died during the follow-up period from a cause unrelated to the aneurysm.

CONCLUSION

EVAR is an effective and safe option and might be a suitable alternative to OR in the absence of predictors of poor prognosis for the treatment of non-complicated forms of MAA.

Surgical Treatment of Symptomatic Aortic Aneurysm in a Patient with Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis: Case Report and Review of the Literature

Vasculitis is an heterogeneous group of syndromes, which shares inflammation of blood vessel wall as the main feature. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis, with few or no immune deposits, predominantly affecting small vessels (i.e., capillaries, venules, arterioles, and small arteries), associated with ANCAs specific for myeloperoxidase or proteinase 3. Clinical manifestations may be heterogeneous but an involvement of lungs and kidneys frequently occurs. AAV of large vessels is a very rare condition whose standard therapy is medical approach. Surgical revascularization has been described in selected patients after medical failure or in emergent settings. We report the case of a patient affected by symptomatic infrarenal aortic aneurysm related to AAV, who underwent in-situ reconstruction by means of cryopreserved homograft.

18F-FDG PET/MRI in the diagnosis of an infected aortic aneurysm

We report a case where an integrated whole body ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/magnetic resonance imaging (MRI) is performed in the diagnostic work-up of a saccular aortic aneurysm. The integrated whole body ¹⁸F-FDG PET/MRI study answered all relevant diagnostic questions, clearly marking an infected aortic aneurysm, depicting the extent of the infected area in relation to the aortic branch vessels, and indicating the aortic lesion as the primary site of infection. The patient was successfully treated by open type V TAAA repair and pericardial graft replacement. Aortic wall infection was proven in cultures of the surgical specimen.

Metabolic Imaging as a Novel Strategy in Evaluation of Mycotic Abdominal Aortic Aneurysm: A Case Report and Brief Clinical Review

Abdominal aortic aneurysm (AAA) is an uncommon entity with high mortality. Etiologically, they are classified as inflammatory and infective (mycotic), the latter being less common. Clinical presentation, laboratory investigations, and treatment for these may considerably overlap. However, choice of management and the need for surgical intervention depends on factors such as size and progression of aneurysm, persistent symptoms, and presence or absence of distant pathology. Although computed tomography (CT) is the gold standard for AAA, in selected cases, especially in infected AAA, fluorodeoxyglucose positron emission tomography-CT can provide valuable information.

Outcomes of open and endovascular repair of inflammatory abdominal aortic aneurysms

Objective Reports on inflammatory aortic abdominal aneurysm treatment are scarce. Traditionally, open surgery has been validated as the gold standard of treatment; however, high technical skills are required. Endovascular aortic repair has been suggested as a less invasive treatment by some authors offering good results. The purpose of our study was to report our experience and outcomes in the treatment of inflammatory aortic abdominal aneurysm using both approaches. Material and methods A retrospective review and data collection of all patients treated for inflammatory aortic abdominal aneurysm between 2000 and 2015 was done in one academic center. Diagnosis of inflammatory aortic abdominal aneurysm was based on preoperative CT-scan imaging. Type of treatment, postoperative and long-term morbidity and mortality are described. Abdominal compressive symptoms (hydronephrosis) severity and relief after treatment are described. Results Thirty-four patients with intact inflammatory aortic abdominal aneurysm were included. Twenty-nine (85.3%) patients were treated by open means and the remaining five (14.7%) with endovascular aortic repair. Nearly 90% were considered high-risk patients. Median follow-up was 46 months (range 24-112). The two groups were comparable, except for the age and preoperative hydronephrosis. There was no statistical significance in blood transfusion requirements, intensive care hospitalization, 30-day and long-term mortality between the two groups. Preoperative hydronephrosis was diagnosed in four (13.8%) patients in the open surgery group and three (60%) patients in the endovascular aortic repair group. Improvement of hydronephrosis was recognized in three out of the four patients in the open repair group and two out of the three in the endovascular aortic repair group. Renal function remained stable in both groups during follow-up. Conclusions Open surgery remains a safe and valid option for the treatment of inflammatory aortic abdominal aneurysm. Although our study included a small number of patients with endovascular aortic repair treatment, results are promising. Further randomized controlled studies may be necessary to assess long-term effectiveness of endovascular aortic repair treatment in this disease.

Infected abdominal aortic aneurysm due to Escherichia coli

Early diagnosis of infected abdominal aortic aneurysm (IAAA) is still a medical challenge due to its diverse and non-specific symptoms and signs. The most common responsible pathogens are Salmonella, Staphylococcus, Campylobacter and Streptococcus species. The authors report the case of a 67-year-old man, admitted for high fever and finally diagnosed with Escherichia coli (E.coli)-related IAAA. The IAAA ruptured during the general anaesthesia induction, leading to an emergency surgery. The authors successfully proceeded to an open aneurysmectomy with extensive debridement and in situ graft replacement. This case emphasizes the potential for rapid IAAA expansion, its high-rupture risk and the importance of computed tomography as a diagnostic tool.

Reversal of Vascular Calcification and Aneurysms in a Rat Model Using Dual Targeted Therapy with EDTA- and PGG-Loaded Nanoparticles

Degeneration of elastic lamina and vascular calcification are common features of vascular pathology such as aortic aneurysms. We tested whether dual therapy with targeted nanoparticles (NPs) can remove mineral deposits (by delivery of a chelating agent, ethylene diamine tetraacetic acid (EDTA)) and restore elastic lamina (by delivery of a polyphenol, pentagalloyl glucose (PGG)) to reverse moderate aneurysm development. EDTA followed by PGG NP delivery led to reduction in macrophage recruitment, matrix metalloproteinase (MMP) activity, elastin degradation and calcification in the aorta as compared to delivery of control blank NPs. Such dual therapy restored vascular elastic lamina and improved vascular function as observed by improvement in circumferential strain. Therefore, dual targeted therapy may be an attractive option to remove mineral deposits and restore healthy arterial structures in moderately developed aneurysms.

Chimney-Graft as a Bail-Out Procedure for Endovascular Treatment of an Inflammatory Juxtarenal Abdominal Aortic Aneurysm

Inflammatory and juxtarenal Abdominal Aortic Aneurysm (j-iAAA) represents a technical challenge for open repair (OR) due to the peculiar anatomy, extensive perianeurysmal fibrosis, and dense adhesion to the surrounding tissues. A 68-year-old man with an 11 cm asymptomatic j-iAAA was successfully treated with elective EVAR and chimney-graft (ch-EVAR) without postprocedural complications. Target vessel patency and normal renal function are present at 24-month follow-up. The treatment of j-iAAA can be technically challenging. ch-EVAR is a feasible and safe bail-out method for elective j-iAAA with challenging anatomy.

[Acute rupture of an abdominal aortic aneurysm revealing Takayasu arteritis]

Arterial aneurysms are most commonly (60% of cases) located in the infrarenal abdominal aorta. An inflammatory mechanism is involved in only 10% of cases. Infrarenal abdominal aortic aneurysms revealing Takayasu's disease is unusual. Takayasu's disease is a rare vasculitis affecting large arteries in young people. It is 10 times more common in women. We report the case of an acute rupture of an abdominal aortic aneurysm revealing Takayasu arteritis in a 39-year-old man with an uneventful medical history.

Increased serum IgG4 levels and intimal IgG4-positive cell infiltration in rapidly growing aortic aneurysm

A 67-year-old Japanese man had been complaining of discomfort in the chest and back and feeling febrile for 2 weeks. Chest computed tomography indicated a thoracic aortic aneurysm. He occasionally showed a high fever (up to 38.0°C), even after hospital admission, irrespective of antibiotic therapy. The patient was found to have elevated serum IgG4 levels (366 mg/dL). The aneurysm demonstrated rapid growth; therefore, rifampicin-soaked woven Dacron synthetic graft replacement was performed 22 days after admission. Immunohistostatining of the resected aorta segment showed an IgG4-positive plasma cell infiltrate within the intimal layer neighboring the cholesterol-rich atheromatous plaque. After surgery, the patient’s serum IgG4 level dropped acutely; however, it did not reach the normal range. The possible role of IgG4 in the development or suppression of aortic remodeling, as well as in atherogenesis, among patients with rapidly growing aortic aneurysm requires further investigation.

Retroperitoneal fibrosis in a patient with gastric cancer manifested by lower extremity edema and hydrocele

Herein we report a 57-year-old man with lower extremity edema and swelling in the scrotum who was found to have a periaortic soft tissue mass and hydronephrosis by computed tomography. With the most plausible diagnosis of retroperitoneal fibrosis, corticosteroid therapy was initiated; however, it did not improve his symptoms. Upper gastroscopy performed on day 20 post admission showed ulcerative regions with an irregular border and fusion of thickened rugae at the gastric angle; the diagnosis of gastric adenocarcinoma was confirmed histologically. It is important to always be aware of unrecognized malignancies that are accompanied by retroperitoneal fibrosis.