Letter to the editor.

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Chronic Aortic Dissection as a Cause of Fever of Unknown Origin 

In a recent issue of Southern Medical Journal, Gorospe et al (1) reported a case of a patient with aortic dissection who presented with persistent fever and other systemic symptoms. We describe a patient with a similar clinical presentation whose symptoms subsided after surgical correction of the nortic dissection.

A 69-year-old man presented with a 6-month history of fever, with temperatures of 37.5 to 38.5[degrees]C on most days, malaise, loss of appetite, 8-kg weight loss, and mild, diffuse chest pain. His medical history was significant for cigarette smoking, chronic obstructive pulmonary disease, typhoid fever, and hiatal hernia. The physical examination revealed that the patient was slim and moderately ill with a temperature of 38.4[degrees]C, breath sounds were diffusely diminished on auscultation, and pedal pulses were weakened. The rest of examination, including blood pressure, was normal.

Blood analysis revealed creatinine 1.4 mg/dl, total cholesterol 269 mg/dl, and erythrocyte sedimentation rate 57 mm in the first hour. All other results, including blood cell count, coagulation tests, protein electrophoresis, autoimmunity tests, and prostate specific antibody, were normal. Cultures of blood, sputum, and urine were negative. Serologic tests for infectious disease, including brucellosis, syphilis, hepatitis B and C, Q fever, and Lyme disease, also were negative. An electrocardiogram, chest x-rays, barium enema, and abdominal ultrasound were normal. Upper gastrointestinal endoscopy disclosed an extrinsic compression of the middle esophagus and a hiatal hernia. Echocardiography revealed a slightly increased diameter of the aortic root. Thoracic computed tomography and magnetic resonance imaging showed widening of the ascending and descending aortae, with a maximum diameter of 60 mm.

Surgical correction of the aortic dissection was performed with interposition of a composite valve-graft conduit. The postoperative course was complicated by a pneumothorax and an empyema, but the patient recovered completely and his fever disappeared.

In their review of the literature, Gorospe et al (1) found only 23 cases of aortic dissection manifested as a prolonged febrile syndrome. Another similar case has been reported. (2) The case that I describe in this letter, which involved an aortic dissection DeBakey type I or Stanford type A, has many similarities with all of those cases. For example, hypertension, the most important predisposing condition for aortic dissection, was absent in my patient, as. it was in more than half of the patients reported by Gorospe et al. (1) Chest pain, the predominant symptom in most cases of aortic dissection, was mild in my patient, as it was in most of the other patients.

This case is remarkable because of the presentation with such a prolonged febrile syndrome as well as the disappearance of all symptoms after surgery. Thus, aortic dissection may mimic conditions such as infectious, neoplastic, or autoimmune disease and must be taken into account in the differential diagnosis of patients with fever and systemic symptoms. Transesophageal echocardiography, computed tomography, and magnetic resonance imaging are reliable diagnostic procedures to perform in these patients. (3-5)

Bernardino Roca, MD, PhD

Department of Medicine

General Hospital of Castellon

Castellon, Spain

References

(1.) Gorospe L, Sendino A, Pacheco R, Alonso A, Barbado FJ, Vazquez JJ. Chronic aortic dissection as a cause of fever of unknown origin. South Med J 2002;95:1067-1070.

(2.) Dai MS, Cheng SM. Aortic dissection presenting as fever of unknown origin. Acta Cardiol 2001;56:37-38.

(3.) Evangelista A, Avegliano G, Elorz C, Gonzalez-Alujas T, Garcia del Castillo H, SolerSoler J. Transesophageal echocardiography in the diagnosis of acute aortic syndrome. J Card Surg 2002;17:95-106.

(4.) Moore AG, Eagle KA, Bruckman D, Moon BS, Malouf, JF, Fattori R, et al. Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International Registry of Acute Aortic Dissection (IRAD). Am J Cordial 2002;89:1235-1238.

(5.) Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 2002;122:311-328.