Aortitis - An Interdisciplinary Challenge

Effectiveness Of Tocilizumab In Aortitis And Aneurysms Associated With Giant Cell Arteritis

OBJECTIVE

Aortitis in Giant Cell Arteritis (GCA-aortitis) is a frequent complication that may lead to aneurysms. Tocilizumab (TCZ) was approved in GCA, but the efficacy in GCA-aortitis and aneurysms has not been analyzed to date. Our aim was to assess the effectiveness and safety of TCZ in a wide series of GCA-aortitis and aneurysms.

METHODS

Multicentre observational study with GCA-aortitis treated with TCZ. GCA was diagnosed by: a) ACR criteria, b) temporal artery biopsy, and/or c) imaging techniques. Aortitis was diagnosed mainly by PET/CT. Main outcomes were EULAR and imaging remission. Others were clinical remission, analytical normalization, corticosteroid-sparing effect, and the prevention and improvement of aneurysms.

RESULTS

196 patients with GCA-aortitis treated with TCZ. After 6 months, 72.2% reached EULAR remission but only 12% an imaging remission; increasing up-to 81.4% and 31.8%, respectively, at 24 months. A rapid clinical remission, ESR and CRP normalization was observed in 47.4%, 84.3% and 55.6%, at 1 month, increasing to 89.6%, 85.3% and 80.3% at 24 months, respectively. Aneurysms were present in 10 (5%) patients. Five of them required early surgery, while 3 others enlarged. No patient on TCZ therapy developed aneurysms during follow-up.

CONCLUSION

In patients with GCA-aortitis treated with TCZ, a rapid and maintained clinical and analytical improvement was observed. However, there was an uncoupling between clinical and EULAR remission with imaging remission.

FDG PET/CT in large vessel vasculitis

Large vessel vasculitides (LVV) such as giant cell arteritis, Takayasu arteritis and aortitis/periaortitis are characterised by immune-mediated inflammation of medium to large arteries. Clinical disease manifestations can be non-specific and diagnostic imaging plays an important role in the diagnostic pathway. In recent years, FDG PET/CT has proven to be a powerful metabolic tool that can provide a wholed body, non-invasive assessment of vascular inflammation. This review outlines the clinical features of large vessel vasculitis and the closely related entity of polymyalgia rheumatica, summarises the evidence for FDG PET/CT in the assessment of these conditions, and provides guidance for patient preparation, image acquisition and interpretation.

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.

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.

Infectious aortitis and managing it at a community military hospital

Infectious aortitis is a rare disease process which can be of fungal, viral or bacterial aetiology. This disease process is often incidentally found during concomitant infectious processes, likely due to haematogenous spread. Common sources are from cardiac, genitourinary and gastroenterologic sources. CT imaging of the aorta is essential in identifying physiological changes-wall thickness changes, ectasia and stenosis. We present a case of a female in her early 60s with a medical history of cardiomyopathy with heart failure and reduced ejection fraction, who was initially admitted for acute cholecystitis complicated by the development of gallstone pancreatitis. Imaging evaluation incidentally noted findings consistent with aortitis with a penetrating ulcer, and blood cultures were positive for Staphylococcus aureus bacteraemia, confirming her diagnosis of infectious aortitis. She was started on intravenous antibiotics, required preoperative nutritional optimisation, and subsequently underwent an open aortic resection and aortoiliac reconstruction with rifampin-soaked Dacron graft.

Comprehensive Management of Takayasu Arteritis Using Immunologic and Antithrombotic Interventions With Cerebral Circulation Support: A Case Report

A 20-year-old woman with bilateral common carotid artery stenosis was diagnosed with Takayasu arteritis (TA). She suffered from a recurrent stroke, and repeated transient ischemic attacks (TIAs) occurred due to middle cerebral artery (MCA) stenosis. The clinical course indicated that TA contributed to MCA stenosis despite the negative results for serological inflammation markers. Immunotherapy with tocilizumab and methotrexate effectively reduced disease activity and improved symptoms. Bed rest and hydration prevented further TIAs and ischemic stroke progression. Long-term monitoring of neurological symptoms and angiography findings is essential to evaluate disease severity and treatment efficacy in TA patients with negative inflammatory markers.

Large Vessel Vasculitis After the Administration of Oxford-AstraZeneca COVID-19 Vaccine

We report a case of a 52-year-old female with Large Vessel Vasculitis (LVV) after vaccination with Oxford-AstraZeneca COVID-19 vaccine. She was presented with fever, started two weeks after the second dose of vaccine. Laboratory values, revealed elevated inflammatory markers and chronic disease anaemia. All the infectious causes were excluded, and immunology tests were negative. Computed Tomography (CT) demonstrated concentric wall thickening of ascending and descending aorta. Positron Emission Tomography (PET) scan showed increased vascular fluorodeoxyglucose (FDG), compatible with LVV. Within one month of treatment with high dose glucocorticoids and iv cyclophosphamide, laboratory findings normalised, and fever resolved.

Systematic evaluation of imaging techniques and baseline characteristics in patients with suspected vasculitis

Purpose

To assess the diagnostic value of different imaging modalities in distinguishing systemic vasculitis from other internal and immunological diseases.

Methods

This retrospective study included 134 patients with suspected vasculitis who underwent ultrasound, magnetic resonance imaging (MRI), or ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) between 01/2010 and 01/2019, finally consisting of 70 individuals with vasculitis. The main study parameter was the confirmation of the diagnosis using one of the three different imaging modalities, with the adjudicated clinical and histopathological diagnosis as the gold standard. A secondary parameter was the morphological appearance of the vessel affected by vasculitis.

Results

Patients with systemic vasculitis had myriad clinical manifestations with joint pain as the most common symptom. We found significant correlations between different imaging findings suggestive of vasculitis and the final adjudicated clinical diagnosis. In this context, on MRI, vessel wall thickening, edema, and diameter differed significantly between vasculitis and non-vasculitis groups (p < 0.05). Ultrasound revealed different findings that may serve as red flags in identifying patients with vasculitis, such as vascular occlusion or halo sign (p = 0.02 vs. non-vasculitis group). Interestingly, comparing maximal standardized uptake values from PET/CT examinations with vessel wall thickening or vessel diameter did not result in significant differences (p > 0.05).

Conclusions

We observed significant correlations between different imaging findings suggestive of vasculitis on ultrasound or MRI and the final adjudicated diagnosis. While ultrasound and MRI were considered suitable imaging methods for detecting and discriminating typical vascular changes, ¹⁸F-FDG PET/CT requires careful timing and patient selection given its moderate diagnostic accuracy.

Clinical Features of Aortitis with Gastrointestinal Involvement

Few vascultides have a predilection for the aorta. Among those are Takayasu arteritis, Behcet's disease, giant cell arteritis, and infectious aortitis. Diagnosis of aortitis requires a high index of suspicion since clinical features are atypical and nonspecific. However, many patients present with gastrointestinal manifestations owing to mesenteric involvement, intestinal infarction, and hepatitis. The most common vascultides that involve the aorta are Takayasu arteritis, Behcet's disease, giant cell arteritis, and infectious arteritis. Herewith, we review the literature on epidemiology, gastrointestinal manifestations, and management of each form of aortitis that affects the gastrointestinal tract.