Rapidly evolving abdominal aortic aneurysm in a patient with idiopathic aortitis.

We present the case of a 77-year-old white woman who was hospitalized with influenza-like illness and subsequently developed increasingly severe abdominal pain with persistent fevers, elevated inflammatory markers, and imaging studies significant for abdominal aortitis without evidence of aneurysm. Cultures and serology remained negative, and the patient improved with corticosteroid therapy. She was readmitted 1 month later with a 5-centimeter infrarenal abdominal aortic aneurysm with critical stenosis, and successfully underwent bypass grafting. The patient initially presented to the emergency department with a 1-week history of febrile illness characterized by mild abdominal pain, diarrhea, cough with post-tussive emesis and progressive weakness. Several family members reported similar symptoms that had resolved. Comorbid medical conditions included coronary artery disease status post myocardial infarction and subsequent coronary angioplasty 6 years prior, and recently diagnosed type II diabetes mellitus. The patient also had an extensive surgical history, which included appendectomy, hysterectomy with bilateral salpingo-oophorectomy, cholecystectomy, tonsillectomy, bilateral cataract surgery, carpal tunnel release, bladder repair, breast reduction, and placement of steel plate in her pelvis secondary to multiple pelvic fractures. In the ED, patient was febrile to 104 degrees and had elevated BP of 160/90 with HR of 104. Physical exam was notable for slightly diminished breath sounds at lung bases and a diffusely tender abdomen without guarding or rebound. Peripheral pulses were intact and there were no abdominal or carotid bruits. Blood work was significant for hyponatremia and moderate hyperglycemia, as well as a normocytic anemia. Chest x-ray was normal. CT of the abdomen contained motion artifact and was initially read as significant only for hiatal hernia and mild ectasia of infrarenal dominant aorta. During hospitalization, the patient developed progressively worsening abdominal pain with persistent fever, and normocytic anemia requiring blood transfusion. Stool studies, EGD and colonoscopy were negative. Abdominal CT was reread and report addended to include findings consistent with aortitis vs. retroperitoneal fibrosis. Repeat CT confirmed this. Inflammatory markers remained elevated throughout, with ESR peaking at 130 and CRP 14.52 (N < 0.30). ANA, rheumatoid factor, VDRL and other serology, as well as blood and urine cultures, remained negative. The only other significant finding was of an IgG monoclonal gammopathy. The patient refused temporal artery and bone marrow biopsies, and was begun on corticosteroid therapy for presumptive diagnosis of aortitis. She experienced significant improvement of symptoms on steroids, and was discharged home. One month later, the patient presented to the ED with complaint of severe abdominal pain. CT of the abdomen revealed a 5-centimeter infrarenal abdominal aortic aneurysm with a critical stenosis, necessitating immediate axillobifemoral bypass graft with ligation of aneurysm. The patient did well postoperatively. Inflammatory abdominal aortic aneurysms represent only 3 to 10% of all abdominal aortic aneurysms, but due to their rapid evolution and associated risk of severe complications, early detection and intervention are key. Studies have shown MRI/MRA and PET to be more effective than CT or ultrasonography in evaluating and following these areas of arterial inflammation. In this case, however, magnetic resonance imaging was not possible due to the patient's indwelling metal plate, and PET was not available at the admitting hospital. The patient was offered the option of transferring to a nearby tertiary care center for further workup and diagnosis, but she declined. This case underscores the importance of early detection and close follow-up of patients with aortitis and inflammatory aortic aneurysms.

Sonya M. Sidhu, MD, Stephen C. Fishel, MD, Gary R. Dunkerley, MD, Paul A. Skudder, MD, and Martin S. Farber, MD. St Clare's Hospital, Schenectady, NY.