Unusual coronary artery aneurysm and acute myocardial infarction in a middle-aged man with systemic lupus erythematosus

Giant left anterior descending artery aneurysm in a patient with active systemic lupus erythematosus: a case report

BACKGROUND

Although not common, coronary artery aneurysms (CAAs) can develop to over 8 mm in diameter to become giant CAAs. In the context of systemic lupus erythematosus (SLE), autoantibody- and immune complex-mediated atherosclerosis is believed to be the most prevalent cause of aneurysm.

CASE PRESENTATION

We report the case of a 53-year-old female SLE patient who presented to our hospital with radiating chest pain. Coronary angiography revealed a giant aneurysm in the middle segment of the left anterior descending artery (LAD) and distal subtotal occlusion in the left circumflex artery (LCX). Laboratory testing also identified risk factors such as an abnormal pulmonary enzyme profile, dyslipidemia, and nephritis parameters.To prevent thromboembolism, anticoagulation and antiplatelet therapy were administered. In addition, one stent was implanted at the distal end of the LCX and repeated coronary angiography verified restoration of TIMI grade III flow.The patient was discharged with resolved chest pain. During 6 months of follow-up, the patient is in good health.

CONCLUSIONS

Our case study, together with 16 recent comparable reports, emphasizes the need for coronary aneurysm screening in SLE patients. It is necessary that thromboembolism, anticoagulation and antiplatelet therapy were administered for CAA.

Multiple coronary aneurysms and acute myocardial infarction in a female patient with rhupus: case report and literature review

Coronary artery aneurysms (CAA) are an infrequent cause of coronary artery disease in both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), most occurring as a result of acute coronary syndromes (ACS). Until now, no cases of CAA have been described in a patient with rhupus syndrome (RhS). Differentiating whether CAA stem from primary vasculitis, atherosclerosis, or a combination of both continues to pose a significant challenge. We present the first described clinical case of a 43-year-old patient with RhS and multiple CAA identified by the presentation of an acute myocardial infarction. The presence of multiple cardiovascular risk factors and the absence of inflammatory findings, both in PET-CT and arterial biopsy, favored an atherosclerotic versus a vasculitic etiology of the CAA. At the time of the aneurysms diagnosis, the patient showed no signs of SLE activity and only moderate RA activity, which underscores the importance of screening for silent coronary aneurysms in these patients, even in subjects exhibiting little apparent activity from their underlying disease. This case also exemplifies the severe impact of atherosclerotic burdens on such patients, demanding vigilance and aggressiveness in its prevention, early diagnosis, and treatment. We hypothesize that RhS could engender an even greater risk of presenting CAA than either SLE or RA on their own, which therefore warrants more careful follow-up in these patients.

Giant coronary aneurysm in a patient with systemic lupus erythematosus

Coronary aneurysm is rare in SLE and confirmation of etiology is usually made at postmortem examination. We encountered a giant aneurysm with multiple stenotic segments of the coronary arteries in a patient with SLE who had previous history of AAA/TAA. Resection of the aneurysm and coronary artery bypass graft were successfully performed. Histology of the coronary arterial wall showed severe damage of the media with inflammatory cell infiltration, indicating that the aneurysm was caused by arteritis. The aneurysm may have developed during the long course of inactive stage of SLE, emphasizing the need for screening of coronary lesions in the management of SLE.

Coronary artery aneurysms in patients with hyper IgE recurrent infection syndrome

Hyper IgE recurrent infection syndrome (HIES, or Job's syndrome) is a primary immunodeficiency characterized by recurrent skin and lung infections, eczema, elevated serum immunoglobulin E (IgE) levels, and various connective tissue and skeletal system abnormalities including characteristic facies, scoliosis, joint hyperextensibility, retained primary dentition, craniosynostosis, osteopenia, and pathologic fractures. We have identified two patients with aneurysmal coronary artery disease. One was a forty-three-year-old man with HIES and coronary artery aneurysms and ectasia identified on cardiac catheterization following myocardial infarction. The other was a 48-year-old man with coronary artery ectasia-aneurysm identified after cardiac catheterization for evaluation of chest pain. Although connective tissue abnormalities are common in HIES, this is the first report of coronary artery aneurysms in HIES. Further studies are necessary to determine the incidence, pathogenesis, and optimal therapy of these arterial abnormalities in HIES.

Diffuse Nonatherosclerotic Coronary Aneurysms

Coronary artery aneurysms are uncommon, usually associated with atherosclerosis and rarely involve all 3 main coronary arteries. Sudden death from documented thrombosis within large coronary aneurysms has been rarely reported. The authors report a case of a previously healthy 36-year-old male who presented with myocardial infarction complicated by sudden cardiac death. The patient was successfully resuscitated, and coronary angiography revealed diffuse, severe aneurysmal disease without evidence of atherosclerosis. A thrombus was visualized in a large aneurysm of the proximal left anterior descending artery, and there was total occlusion of a second diagonal branch, presumably due to thrombus embolization. The patient had no history of Kawasaki disease, and evaluation revealed no inflammatory or autoimmune condition. Optimal treatment and prognosis for patients with nonatherosclerotic coronary aneurysms remains unclear. Our patient was treated medically with chronic warfarin and low-dose aspirin therapy and recovered without complication.