Giant cell aortitis with histopathologic and clinical response to steroid therapy: A case report

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.

Surgery for autoimmune aortitis: unanswered questions

Background

The aorta is rarely affected by autoimmune vasculitis, which can lead to aortic dilatation requiring surgery. Autoimmune aortitis may affect one aortic segment or the entire aorta, and in some cases, the aorta may be affected at different time intervals. Because of the rarity of the disease and the limited cases described in the literature, management of autoimmune aortitis is still controversial. We aimed to review the current literature evidence regarding these controversial aspects for the management of autoimmune aortitis and give recommendations based on this evidence.

Main text

Immunosuppressants are generally indicated in vasculitis to halt the progression of the disease; however, its role after the occurrence of aortic dilatation is debatable since further aortic dilatation would eventually occur because of the weakness of the arterial wall. In patients with a localized ascending aortic dilatation who required surgery, the optimal approach for the distal aorta is not known. If the probability of disease progression is high, it is not known whether the patients would benefit from postoperative immunosuppressants or further distal aortic intervention may be required. The risk of rupture of the weakened aortic wall was not established, and it is debatable at which diameter should these patients have surgery. In patients with previous ascending surgery for autoimmune aortitis, the endovascular management of the distal aortic disease has not been studied. The inflammatory process may extend to affect the aortic valve or the coronary vessels, which may require special attention during the procedure.

Conclusion

Patients with diagnosed autoimmune aortitis are prone to the development of the distal aortic disease, and endovascular intervention is feasible in those patients. Patients with concomitant aortic valve can be managed with the aortic valve-sparing procedure, and preoperative screening for coronary disease is recommended. Immunosuppressants should be used early before aortic dilatation, and its role postoperatively is controversial.

Giant-cell aortitis: an unusual case of Bentall operation

Noninfectious ascending aortitis is a very rare cause of ascending aortic aneurysm. We report a case of the truly fortuitous finding of this rare condition in a 67-year-old man operated on for an ascending aortic aneurysm associated with dystrophic aortic valve regurgitation. Intraoperative inspection revealed dissection of the aorta just above the left main coronary artery. A modified Bentall operation was performed. The pathological diagnosis was giant cell arteritis.