Case Presentation:
A 73‐year‐old woman with a history of peptic ulcer disease and gastroesophageal reflux presents with severe sharp epigastric pain. Patient notes severe burning pleuritic substernal chest pain with radiation to the back and pain with swallowing. Patient notes no radiation to the left arm or jaw, shortness of breath or palpitations. Patient reports nausea, fevers, and night sweats for the past week. Patient denies eye symptoms, headache, or jaw claudication. Patient was admitted one year previously with nonspecific abdominal pain, and on MRA abdomen was found to have evidence of SMA inflammation treated with steroids with clinical improvement. Patient’s physical exam includes a temperature of 102.6 and epigastric pain on palpation, but normal cardiac and pulmonary exam. Patient’s labs were significant for WBC count to 10.5, LFTs with alkaline phosphatase 328, AST 116, ALT 153, Sed rate 111. Complement levels were normal and ANA, anti‐dsDNA, RF, anti‐SM were all negative. All culture data showed no growth. While substernal burning and epigastric pain initially suggested peptic ulcer disease or GERD, alkaline phosphatase and transaminase elevation with CT abd/pelvis showing dilated bile ducts indicated a possible biliary source. EGD performed showed no PUD or active ulcerations and a normal esophagus. HIDA scan showed no active cholecystitis and normal gallbladder EF. MRCP and subsequent ERCP did not show any focal occlusion to explain LFT abnormalities. Hospital course complicated by intermittent fevers, transaminitis and increased chest pain. For further evaluation, patient underwent MRA chest which showed diffuse aortitis with branch involvement. After diagnosis made, patient was also put on IV methylprednisolone followed by prednisone with substantial decrease in pain, increased mobility and defervescence of fevers.
Discussion:
Aortitis is the inflammation of the walls of the aorta, which can be broadly differentiated into both infectious and non‐infectious causes. While infectious causes include salmonella, staphylococcal species, tuberculosis or syphilis, the most common causes of aortitis are non‐infectious, inflammatory large‐vessel vasculitides. Giant cell arteritis commonly affects elderly Caucasian women and causes widespread vascular inflammation involving the external carotid branches, aorta, and the mesenteric arteries. Takayasu arteritis is less common and affects large vessels of predominantly young Asian women. While angiography was once the gold standard for diagnosis, improvement in imaging has replaced aortography with CTA or MRA.
Conclusions:
The presentation of aortitis varies from nonspecific abdominal pain with fevers to severe aortic insufficiency, aneurysm, or dissection, all of which require prompt diagnosis and treatment for successful outcomes.