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Raizada A, Trivedi D. Isolated Idiopathic Aortitis in a Young Female Presenting With Exertional Chest Pain: A Case Report. Cureus 2024; 16:e63415. [PMID: 39077254 PMCID: PMC11284509 DOI: 10.7759/cureus.63415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/31/2024] Open
Abstract
Aortitis is a general term that describes inflammation of the aorta. In most cases, this inflammation is caused by an autoimmune etiology or an infectious etiology. In some instances, the underlying etiology may not be clear, and the diagnosis given is idiopathic aortitis. Cases of idiopathic aortitis are usually diagnosed based on histopathologic findings. Here, we present a case involving a 31-year-old female presenting with acutely worsening exertional shortness of breath and left-sided chest pain. An echocardiogram revealed a severely reduced ejection fraction with severe aortic regurgitation and diffusely increased aortic intima-media thickness. Bioprosthetic aortic valve replacement was performed with histology, showing findings consistent with aortitis, and the patient received the diagnosis of idiopathic aortitis. This case highlights the need to consider aortitis as a differential in young patients presenting with exertional chest pain and severe aortic insufficiency.
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Affiliation(s)
- Amit Raizada
- Internal Medicine, New York Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Dhaval Trivedi
- Internal Medicine, New York Presbyterian Brooklyn Methodist Hospital, New York City, USA
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2
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Younger DS. Headaches and Vasculitis. Neurol Clin 2024; 42:389-432. [PMID: 38575258 DOI: 10.1016/j.ncl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability making this a disorder of paramount importance to all clinicians. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. Primary neurologic vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY, USA; Department of Neurology, White Plains Hospital, White Plains, NY, USA.
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Allam MN, Baba Ali N, Mahmoud AK, Scalia IG, Farina JM, Abbas MT, Pereyra M, Kamel MA, Awad KA, Wang Y, Barry T, Huang SS, Nguyen BD, Yang M, Jokerst CE, Martinez F, Ayoub C, Arsanjani R. Multi-Modality Imaging in Vasculitis. Diagnostics (Basel) 2024; 14:838. [PMID: 38667483 PMCID: PMC11049623 DOI: 10.3390/diagnostics14080838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/03/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Systemic vasculitides are a rare and complex group of diseases that can affect multiple organ systems. Clinically, presentation may be vague and non-specific and as such, diagnosis and subsequent management are challenging. These entities are typically classified by the size of vessel involved, including large-vessel vasculitis (giant cell arteritis, Takayasu's arteritis, and clinically isolated aortitis), medium-vessel vasculitis (including polyarteritis nodosa and Kawasaki disease), and small-vessel vasculitis (granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis). There are also other systemic vasculitides that do not fit in to these categories, such as Behcet's disease, Cogan syndrome, and IgG4-related disease. Advances in medical imaging modalities have revolutionized the approach to diagnosis of these diseases. Specifically, color Doppler ultrasound, computed tomography and angiography, magnetic resonance imaging, positron emission tomography, or invasive catheterization as indicated have become fundamental in the work up of any patient with suspected systemic or localized vasculitis. This review presents the key diagnostic imaging modalities and their clinical utility in the evaluation of systemic vasculitis.
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Affiliation(s)
- Mohamed N. Allam
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Nima Baba Ali
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Mohammed Tiseer Abbas
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Moaz A. Kamel
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Kamal A. Awad
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Yuxiang Wang
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Steve S. Huang
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA (B.D.N.)
| | - Ba D. Nguyen
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA (B.D.N.)
| | - Ming Yang
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA (B.D.N.)
| | | | - Felipe Martinez
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA (B.D.N.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
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Younger DS. Systemic vasculitis and headache. Curr Opin Neurol 2023; 36:631-646. [PMID: 37865837 PMCID: PMC10624412 DOI: 10.1097/wco.0000000000001223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system or so called neurovasculitides, lead to pervasive injury and disability making these disorder of paramount importance to clinicians. RECENT FINDINGS Headache is an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. A suspicion of vasculitis based on the history, clinical examination, or laboratory studies warrants prompt evaluation and treatment to forestall progression and avert cerebral ischemia or infarction. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary adult and pediatric CNS vasculitides predicated on achievements in primary systemic forms. SUMMARY Vasculitis can be diagnosed with certainty after intensive evaluation that includes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, tempered by the recognition of anticipated medication side effects.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY; Department of Neurology, White Plains Hospital, White Plains, New York, USA
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Kaymakci M, Elfishawi M, Langenfeld HE, Crowson CS, Weyand CM, Koster MJ, Warrington KJ. The epidemiology of pathologically confirmed clinically isolated aortitis: a North American population-based study. Clin Exp Rheumatol 2023; 41:956-960. [PMID: 37073641 PMCID: PMC10406423 DOI: 10.55563/clinexprheumatol/3vdshi] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/03/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVES Clinically isolated aortitis (CIA) refers to inflammation of the aorta without signs of systemic vasculitis or infection. Population-based data on the epidemiology of CIA in North America is lacking. We aimed to investigate the epidemiology of pathologically confirmed CIA. METHODS Residents of Olmsted County, Minnesota were screened for thoracic aortic aneurysm procedures with current procedural terminology codes between January 1, 2000, and December 31, 2021, using the resources of the Rochester Epidemiology Project. The medical records of all patients were manually reviewed. CIA was defined as histopathologically confirmed active aortitis diagnosed by evaluation of aortic tissue obtained during thoracic aortic aneurysm surgery in the absence of any infection, rheumatic disease, or systemic vasculitis. Incidence rates were age and sex adjusted to the 2020 United States total population. RESULTS Eight incident cases of CIA were diagnosed during the study period; 6 (75%) of them were female. Median (IQR) age at diagnosis of CIA was 78.3 (70.2-78.9) years; all were diagnosed following ascending aortic aneurysm repair. The overall age and sex adjusted annual incidence rate of CIA was 8.9 (95% CI, 2.7-15.1) per 1,000,000 individuals over age 50 years. The median (IQR) duration of follow-up was 8.7 (1.2-12.0) years. The overall mortality compared to the age and sex matched general population did not differ (standardised mortality ratio: 1.58; 95% CI, 0.51-3.68). CONCLUSIONS This is the first population-based epidemiologic study of pathologically confirmed CIA in North America. CIA predominantly affects women in their eighth decade and is quite rare.
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Affiliation(s)
- Mahmut Kaymakci
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Mohanad Elfishawi
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, and Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Cornelia M Weyand
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Matthew J Koster
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Carrer M, Vignals C, Berard X, Caradu C, Battut AS, Stenson K, Neau D, Lazaro E, Mehlen M, Barret A, Nyamankolly E, Lifermann F, Rispal P, Illes G, Rouanes N, Caubet O, Poirot-Mazeres S, Vareil MO, Alleman L, Millon A, Huvelle U, Valour F, Ferry T, Cazanave C, Puges M. Retrospective Multicenter Study Comparing Infectious and Noninfectious Aortitis. Clin Infect Dis 2023; 76:e1369-e1378. [PMID: 35792621 DOI: 10.1093/cid/ciac560] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Determining the etiology of aortitis is often challenging, in particular to distinguish infectious aortitis (IA) and noninfectious aortitis (NIA). This study aims to describe and compare the clinical, biological, and radiological characteristics of IA and NIA and their outcomes. METHODS A multicenter retrospective study was performed in 10 French centers, including patients with aortitis between 1 January 2014 and 31 December 2019. RESULTS One hundred eighty-three patients were included. Of these, 66 had IA (36.1%); the causative organism was Enterobacterales and streptococci in 18.2% each, Staphylococcus aureus in 13.6%, and Coxiella burnetii in 10.6%. NIA was diagnosed in 117 patients (63.9%), mainly due to vasculitides (49.6%), followed by idiopathic aortitis (39.3%). IA was more frequently associated with aortic aneurysms compared with NIA (78.8% vs 17.6%, P < .001), especially located in the abdominal aorta (69.7% vs 23.1%, P < .001). Crude and adjusted survival were significantly lower in IA compared to NIA (P < .001 and P = .006, respectively). In the IA cohort, high American Society of Anesthesiologists score (hazard ratio [HR], 2.47 [95% confidence interval {CI}, 1.08-5.66]; P = .033) and free aneurysm rupture (HR, 9.54 [95% CI, 1.04-87.11]; P = .046) were significantly associated with mortality after adjusting for age, sex, and Charlson comorbidity score. Effective empiric antimicrobial therapy, initiated before any microbial documentation, was associated with a decreased mortality (HR, 0.23, 95% CI, .08-.71]; P = .01). CONCLUSIONS IA was complicated by significantly higher mortality rates compared with NIA. An appropriate initial antibiotic therapy appeared as a protective factor in IA.
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Affiliation(s)
- Mathilde Carrer
- Infectious and Tropical Diseases Department, Centre hospitalier universitaire Bordeaux, Bordeaux, France
| | - Carole Vignals
- Infectious and Tropical Diseases Department, Centre hospitalier universitaire Bordeaux, Bordeaux, France
| | - Xavier Berard
- Department of Vascular Surgery, Centre hospitalier universitaire Bordeaux, Bordeaux, France
| | - Caroline Caradu
- Department of Vascular Surgery, Centre hospitalier universitaire Bordeaux, Bordeaux, France
| | - Anne-Sophie Battut
- Department of Vascular Surgery, Clinique Mutualiste de Pessac, Pessac, France
| | - Katherine Stenson
- St George's University Hospitals NHS Foundation Trust, Imperial College Healthcare, London, United Kingdom
| | - Didier Neau
- Infectious and Tropical Diseases Department, Centre hospitalier universitaire Bordeaux, Bordeaux, France
| | - Estibaliz Lazaro
- Internal Medicine and Infectious Disease Department, Centre hospitalier universitaire Bordeaux, Bordeaux, France
| | - Maxime Mehlen
- Infectious and Tropical Diseases Department, Centre hospitalier universitaire Bordeaux, Bordeaux, France
| | - Amaury Barret
- Internal Medicine and Infectious Diseases Department, Centre hospitalier Arcachon, Arcachon, France
| | - Elsa Nyamankolly
- Infectious and Tropical Diseases Department, Centre hospitalier Dax, Dax, France
| | | | - Patrick Rispal
- Infectious and Tropical Diseases Department, Centre hospitalier Agen, Agen, France
| | - Gabriela Illes
- Infectious and Tropical Diseases Department, Centre hospitalier Mont de Marsan, Mont de Marsan, France
| | - Nicolas Rouanes
- Polyvalent Medicine Department, Centre hospitalier Périgueux, Périgueux, France
| | - Olivier Caubet
- Internal Medicine Department, Centre hospitalier Libourne, Libourne, France
| | | | - Marc-Olivier Vareil
- Infectious and Tropical Diseases Department, Centre hospitalier Bayonne, Bayonne, France
| | - Laure Alleman
- Infectious and Tropical Diseases Department, Centre hospitalier Bayonne, Bayonne, France
| | - Antoine Millon
- Department of Vascular Surgery, Centre hospitalier universitaire Lyon, Lyon, France
| | - Ugo Huvelle
- Department of Vascular Surgery, Centre hospitalier universitaire Lyon, Lyon, France
| | - Florent Valour
- Infectious and Tropical Diseases Department, Centre hospitalier universitaire Lyon, Lyon, France
| | - Tristan Ferry
- Infectious and Tropical Diseases Department, Centre hospitalier universitaire Lyon, Lyon, France
| | - Charles Cazanave
- Infectious and Tropical Diseases Department, Centre hospitalier universitaire Bordeaux, Bordeaux, France
| | - Mathilde Puges
- Infectious and Tropical Diseases Department, Centre hospitalier universitaire Bordeaux, Bordeaux, France
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Mayer A, Sperry A, Quimson L, Rhee RL. Long-Term Clinical and Radiographic Outcomes in Patients With Clinically Isolated Aortitis. ACR Open Rheumatol 2022; 4:1013-1020. [PMID: 36250477 DOI: 10.1002/acr2.11504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/02/2022] [Accepted: 09/08/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The optimal management of patients with incidentally found clinically isolated aortitis (CIA) after aneurysm repair is unclear. This study compared long-term surgical and clinical outcomes after surgical repair of thoracic aortic aneurysm between patients with CIA and patients with noninflammatory etiologies. METHODS This is a matched cohort study. Patients with CIA were identified by histopathology following open thoracic aortic aneurysm repair. Two comparators without inflammation on pathology were matched to each patient by year of surgical repair. Outcomes included surgical complications, new vascular abnormalities on imaging, and death. RESULTS One hundred sixty-two patients were included: 53 with CIA and 109 matched comparators. Median follow-up time was similar between groups (CIA 3.7 vs. comparator 3.3 years, P = 0.64). There was no difference in postoperative complications, surgical revision, or death between groups. Only 32% of patients with CIA saw a rheumatologist in the outpatient setting and 33% received immunosuppressive treatment. On surveillance imaging, no difference was seen in new or worsening aortic aneurysms, but there were significantly more vascular abnormalities in branch arteries of the thoracic aorta in patients with CIA (39% vs. 11%, P < 0.01). CONCLUSION Among patients who underwent surgical repair of a thoracic aortic aneurysm, patients with CIA were more likely than noninflammatory comparators to develop radiographic abnormalities in aortic branch arteries. Notably, there was no difference in risk of new aortic aneurysms or surgical complications despite most patients with CIA never receiving immunosuppression. This suggests that more selective initiation of immunosuppression in CIA may be considered after aortic aneurysm repair.
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Affiliation(s)
- Adam Mayer
- The University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia
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Mustafa A, Weilg P, Young L, Anzalone C, Hagau D. Isolated Abdominal Aortitis Following a Urinary Tract Infection. Cureus 2021; 13:e18902. [PMID: 34804739 PMCID: PMC8599397 DOI: 10.7759/cureus.18902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 11/05/2022] Open
Abstract
A 49-year-old female with a history of sporadic episodes of scleritis was initially seen by her primary care physician (PCP) due to a two-day history of cramping abdominal pain, new elevated high blood pressure, increased urinary frequency, and urgency. The patient was diagnosed with an acute cystitis supported by a positive urine culture for a pan sensitive Escherichia coli; however, after two courses of antibiotics as an outpatient, her blood pressure (BP) remained markedly elevated, and her abdominal pain got worse which prompted a computed tomography (CT) abdomen and pelvis with contrast revealing inflammatory changes consistent with aortitis. The diagnosis was supported by a magnetic resonance angiography (MRA) which showed wall thickening and enhancement extending for approximately 4.8 cm involving the abdominal aortic wall just prior to the bifurcation. An extensive work up including CTA, US doppler of four-limbs, and fluorodeoxyglucose (FDG)-positron emission tomography (PET) confirmed the isolated abdominal aortitis. After infectious etiologies were ruled out, the patient was started on prednisone 60 mg daily which resulted in marked improvement of her symptoms. After a four-month taper of steroids, the patient had complete resolution of her symptoms, with no signs of recurrence.
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Affiliation(s)
- Ala Mustafa
- Internal Medicine, MercyOne North Iowa Medical Center, Mason City, USA
| | - Pablo Weilg
- Rheumatology, Boston Medical Center, Boston, USA
| | - Larry Young
- Rheumatology, University of Miami, Coral Gables, USA
| | | | - Denisa Hagau
- Cardiology, MercyOne North Iowa Medical Center, Mason City, USA
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Shchetynska-Marinova T, Amendt K, Sadick M, Keese M, Sigl M. Aortitis - An Interdisciplinary Challenge. In Vivo 2021; 35:41-52. [PMID: 33402448 DOI: 10.21873/invivo.12230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 12/24/2022]
Abstract
The term 'aortitis' comprises a heterogeneous spectrum of diseases, with varied etiology and clinical presentations, whose common characteristic is the inflammation of the aortic wall. Since aortitis can mimic almost all common cardiovascular disorders, its clinical recognition remains a challenge. Some cases of aortitis remain undetected for a long time and may be diagnosed after severe life-threatening complications have already arisen. The diagnosis of aortitis is based on the presence of homogeneous circumferential thickening of the aortic wall detected on aortic imaging, or typical histological features in combination with clinical findings and laboratory parameters. Management of aortitis is usually conservative (immunosuppressive drugs in noninfectious aortitis; antimicrobial drugs in infectious). However, if vascular complications such as aortic aneurysm, rupture, or steno-occlusive events appear, aortic surgery or endovascular therapy may be required. This review article summarizes the current knowledge regarding the etiology, clinical presentation, diagnosis, and treatment of inflammatory diseases of the aorta to promote better clinical management of these entities.
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Affiliation(s)
- Tetyana Shchetynska-Marinova
- First Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Klaus Amendt
- Vascular Center Oberrhein, Internal Medicine I, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
| | - Maliha Sadick
- Clinic for Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Keese
- Department of Vascular Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Sigl
- First Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany;
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Arafat AA. Surgery for autoimmune aortitis: unanswered questions. THE CARDIOTHORACIC SURGEON 2019. [DOI: 10.1186/s43057-019-0008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Shukla P, Sen A, Bhalla A, D'Cruz D. Idiopathic aortitis presenting as pyrexia of unknown origin and delirium. Br J Hosp Med (Lond) 2018; 79:586-587. [PMID: 30290748 DOI: 10.12968/hmed.2018.79.10.586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Praphull Shukla
- Specialist Registrar, Department of Ageing and Health, St Thomas' Hospital, London SE1 7EH
| | - Arup Sen
- Specialist Registrar, Department of Ageing and Health, St Thomas' Hospital, London
| | - Ajay Bhalla
- Consultant Physician in Stroke, Geriatric and General Medicine, Department of Ageing and Health, St Thomas' Hospital, London
| | - David D'Cruz
- Consultant Rheumatologist, Department of Rheumatology, St Thomas' Hospital, London
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Diagnosis and differential diagnosis of large-vessel vasculitides. Rheumatol Int 2018; 39:169-185. [PMID: 30221327 DOI: 10.1007/s00296-018-4157-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/10/2018] [Indexed: 12/13/2022]
Abstract
There are no universally accepted diagnostic criteria for large-vessel vasculitides (LVV), including giant cell arteritis (GCA) and Takayasu arteritis (TAK). Currently, available classification criteria cannot be used for the diagnosis of GCA and TAK. Early diagnosis of these two diseases is quite challenging in clinical practice and may be accomplished only by combining the patient symptoms, physical examination findings, blood test results, imaging findings, and biopsy results, if available. Awareness of red flags which lead the clinician to investigate TAK in a young patient with persistent systemic inflammation is helpful for the early diagnosis. It should be noted that clinical presentation may be highly variable in a subgroup of GCA patients with predominant large-vessel involvement (LVI) and without prominent cranial symptoms. Imaging modalities are especially helpful for the diagnosis of this subgroup. Differential diagnosis between older patients with TAK and this subgroup of GCA patients presenting with LVI may be difficult. Various pathologies may mimic LVV either by causing systemic inflammation and constitutional symptoms, or by causing lumen narrowing with or without aneurysm formation in the aorta and its branches. Differential diagnosis of aortitis is crucial. Infectious aortitis including mycotic aneurysms due to septicemia or endocarditis, as well as causes such as syphilis and mycobacterial infections should always be excluded. On the other hand, the presence of non-infectious aortitis is not unique for TAK and GCA. It should be noted that aortitis, other large-vessel involvement or both, may occasionally be seen in various other autoimmune pathologies including ANCA-positive vasculitides, Behçet's disease, ankylosing spondylitis, sarcoidosis, and Sjögren's syndrome. Besides, aortitis may be idiopathic and isolated. Atherosclerosis should always be considered in the differential diagnosis of LVV. Other pathologies which may mimic LVV include, but not limited to, congenital causes of aortic coarctation and middle aortic syndrome, immunoglobulin G4-related disease, and hereditary disorders of connective tissue such as Marfan syndrome and Ehler-Danlos syndrome.
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13
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Schmidt J, Duhaut P. Atteinte aortique dans la maladie de Horton. Rev Med Interne 2016; 37:239-44. [DOI: 10.1016/j.revmed.2015.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 11/12/2015] [Accepted: 12/21/2015] [Indexed: 01/16/2023]
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Espitia O, Samson M, Le Gallou T, Connault J, Landron C, Lavigne C, Belizna C, Magnant J, de Moreuil C, Roblot P, Maillot F, Diot E, Jégo P, Durant C, Masseau A, Brisseau JM, Pottier P, Espitia-Thibault A, Santos AD, Perrin F, Artifoni M, Néel A, Graveleau J, Moreau P, Maisonneuve H, Fau G, Serfaty JM, Hamidou M, Agard C. Comparison of idiopathic (isolated) aortitis and giant cell arteritis-related aortitis. A French retrospective multicenter study of 117 patients. Autoimmun Rev 2016; 15:571-6. [PMID: 26903476 DOI: 10.1016/j.autrev.2016.02.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/14/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of the study was to compare clinical/imaging findings and outcome in patients with idiopathic (isolated aortitis, IA) and with giant cell arteritis (GCA)-related aortitis. METHODS Patients from 11 French internal medicine departments were retrospectively included. Aortitis was defined by aortic wall thickening >2mm and/or an aortic aneurysm on CT-scan, associated to inflammatory syndrome. Patients with GCA had at least 3 ACR criteria. Aortic events (aneurysm, dissection, aortic surgeries) were reported, and free of aortic events-survival were compared. RESULTS Among 191 patients with non-infectious aortitis, 73 with GCA and 44 with IA were included. Patients with IA were younger (65 vs 70 years, p=0.003) and comprised more past/current smokers (43 vs 15%, p=0.0007). Aortic aneurisms were more frequent (38% vs 20%, p=0.03), and aortic wall thickening was more pronounced in IA. During follow-up (median=34 months), subsequent development of aortic aneurysm was significantly lower in GCA when compared to IA (p=0.009). GCA patients required significantly less aortic surgery during follow-up than IA patients (p=0.02). Mean age, sex ratio, inflammatory parameters, and free of aortic aneurism survival were equivalent in patients with IA ≥ 60 years when compared to patients with GCA-related aortitis. CONCLUSIONS IA is more severe than aortitis related to GCA, with higher proportions of aortic aneurism at diagnosis and during follow-up. IA is a heterogeneous disease and its prognosis is worse in younger patients <60 years. Most patients with IA ≥ 60 years share many features with GCA-related aortitis.
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Affiliation(s)
- Olivier Espitia
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, University Hospital of Dijon, Dijon, France
| | - Thomas Le Gallou
- Department of Internal Medicine, University Hospital of Rennes, Rennes, France
| | - Jérôme Connault
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - Cedric Landron
- Department of Internal Medicine, University Hospital of Poitiers, Poitiers, France
| | - Christian Lavigne
- Department of Internal Medicine, University Hospital of Angers, Angers, France
| | - Cristina Belizna
- Department of Internal Medicine, University Hospital of Angers, Angers, France
| | - Julie Magnant
- Department of Internal Medicine, CHRU of Tours, Tours, France
| | - Claire de Moreuil
- Department of Internal Medicine, University Hospital of Brest, Brest, France
| | - Pascal Roblot
- Department of Internal Medicine, University Hospital of Poitiers, Poitiers, France
| | | | - Elisabeth Diot
- Department of Internal Medicine, CHRU of Tours, Tours, France
| | - Patrick Jégo
- Department of Internal Medicine, University Hospital of Rennes, Rennes, France
| | - Cécile Durant
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - A Masseau
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - Jean-Marie Brisseau
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - Pierre Pottier
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | | | | | - François Perrin
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - Mathieu Artifoni
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - Antoine Néel
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - Julie Graveleau
- Department of Medicine, Hospital of Saint-Nazaire, Saint-Nazaire, France
| | - Philippe Moreau
- Department of Hematology, Hospital of Lorient, Lorient, France
| | - Hervé Maisonneuve
- Department of Hematology, Hospital of La Roche sur Yon, La Roche sur Yon, France
| | - Georges Fau
- Department of Radiology, University Hospital of Nantes, Nantes, France
| | | | - Mohamed Hamidou
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France
| | - Christian Agard
- Department of Diagnostic Cardio-vascular Imaging, University hospital of Nantes, Nantes, France.
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Patil P, Dejaco C, Dasgupta B. A pragmatic approach to imaging in large vessel vasculitis. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1056150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Inflammatory disease of the aorta: Patterns and classification of giant cell aortitis, Takayasu arteritis, and nonsyndromic aortitis. J Thorac Cardiovasc Surg 2015; 149:S170-5. [DOI: 10.1016/j.jtcvs.2014.08.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 07/28/2014] [Accepted: 08/04/2014] [Indexed: 11/17/2022]
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Patrício C, da Silva FP, Brotas V. Pulmonary oedema in the emergency room: what is hidden beyond an apparently common presentation. BMJ Case Rep 2014; 2014:bcr-2014-204131. [PMID: 24792026 DOI: 10.1136/bcr-2014-204131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiogenic flash pulmonary oedema is a common and potentially fatal cause of acute respiratory distress. Although it often results from acute decompensated heart failure, abrupt-onset aortic regurgitation can sharply rise cardiac filling pressure and, consequently, pulmonary venous pressure, leading to rapid fluid accumulation in the interstitial and alveolar spaces. We report a case of a 64-year-old woman admitted to the emergency department with a flash pulmonary oedema; a careful clinical investigation subsequently revealed a rare aetiology for this 'common' presentation. After a detailed auscultation that unmasked a diastolic cardiac murmur, an acute severe aortic insufficiency was further confirmed by echocardiography, showing inflammation and thickening of the entire aorta wall. The patient was submitted to valve replacement surgery, and histological examination, to our surprise, showed features of aortitis, remarkable for the presence of giant cells. A diagnosis of idiopathic aortitis versus inaugural giant cell arteritis was proposed and treatment started with corticosteroids.
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Affiliation(s)
- Catarina Patrício
- Department of Internal Medicine-3, Hospital de Santo António dos Capuchos, Lisboa, Portugal
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Headaches and vasculitis. Neurol Clin 2014; 32:321-62. [PMID: 24703534 DOI: 10.1016/j.ncl.2013.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Vasculitis is a spectrum of clinicopathologic disorders defined by inflammation of arteries of veins of varying caliber with variable tissue injury. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. A suspicion of vasculitis based on the history, clinical examination, or laboratory studies warrants prompt evaluation and treatment to forestall progression and avert cerebral ischemia or infarction.
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Kuzmik GA, Sang AX, Cai G, Tranquilli M, Elefteriades JA. Respecting symptoms in thoracic aortic aneurysm management: a case of symptomatic necrotizing granulomatous aortitis. Int J Angiol 2013; 21:151-4. [PMID: 23997559 DOI: 10.1055/s-0032-1315632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
A 41-year-old woman presented with chest pain of unclear etiology in the setting of a mildly dilated ascending aorta. Computed tomography angiography showed an aorta with an irregular contour and an aneurysm of 4.5 cm. There was no radiographic evidence of rupture or dissection. The patient was taken to the operating room and was found to have severe aortitis with marked localized wall thinning at imminent risk of aortic rupture. Aortic pathology demonstrated necrotizing granulomas of noninfectious etiology. This case illustrates the importance of respecting symptoms in surgical decision making for thoracic aortic aneurysms that may not meet standard interventional criteria.
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Affiliation(s)
- Gregory A Kuzmik
- Aortic Institute, Yale-New Haven Hospital, New Haven, Connecticut
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20
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Schmidt WA. Imaging in vasculitis. Best Pract Res Clin Rheumatol 2013; 27:107-18. [PMID: 23507061 DOI: 10.1016/j.berh.2013.01.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 12/09/2012] [Accepted: 12/21/2012] [Indexed: 11/17/2022]
Abstract
Vasculitides may involve small, medium-sized or large arteries. In small-vessel vasculitides imaging studies of lungs, nasal sinuses, cerebrum, heart and other organs are important for determining disease extension and disease activity. Aneurysms are a hallmark of medium-sized artery vasculitides. In large-vessel vasculitis, imaging studies depict homogeneous, circumferential wall swelling and smoothly tapered luminal narrowing. Ultrasound and high-resolution magnetic resonance imaging (MRI) show characteristic wall abnormalities in temporal and occipital arteries whereas ultrasound, MRI, MR angiography, computed tomography (CT), CT angiography and positron emission tomography delineate characteristic features in extra-cranial arteries that are affected in large-vessel giant cell arteritis, Takayasu arteritis and idiopathic aortitis. Conventional angiography has still its place for therapeutic interventions. Imaging has led to a better understanding of the nature and distribution of vasculitides. It significantly facilitates diagnosis of patients with suspected vasculitis.
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Affiliation(s)
- Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Lindenberger Weg 19, 13125 Berlin, Germany.
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Katabathina VS, Restrepo CS. Infectious and Noninfectious Aortitis: Cross-Sectional Imaging Findings. Semin Ultrasound CT MR 2012; 33:207-21. [DOI: 10.1053/j.sult.2011.12.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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