doi: 10.1161/CIRCULATIONAHA.105.583940
(Circulation. 2006;113:e768-e769.)
© 2006 American Heart Association, Inc.
Images in Cardiovascular Medicine |
A Swelling of the Right Neck and Sudden Death
From the Department of Medicine III (T.N., G.H., G.W.), Institute of Pathology (A.B.), Institute of Diagnostic and Interventional Radiology (S.O.R.P), and Department of Neurology (S.I., C.T.), Friedrich-Schiller-University Jena, Germany.
Correspondence to Thomas Neumann, MD, Department of Medicine III, Friedrich-Schiller-University Jena, Erlanger Allee 101, 07747 Jena, Germany. E-mail thomas.neumann{at}med.uni-jena.de
A 56-year-old, previously healthy man presented with a painless pulsatile tumor of the right neck (Figure 1A). The remaining clinical and neurological examination was unremarkable. Duplex sonography, CT angiography, and digital substraction angiography revealed large aneurysms of both common and internal carotid arteries (Figure 1B and 1C). Aneurysms of the brachiocephalic and both subclavian arteries were also seen. An abdominal CT showed aneurysms of the infrarenal aorta (Ø 4.8 cm), the superior mesenteric, and both common iliac arteries (Figure 2A). A chest CT was not performed. However, on reevaluation of the abdominal CT three months later, the uppermost section showed the right coronary artery with a diameter of 33 mm (Figure 2B and 2C) that had initially not been recognized. Besides an elevated erythrocyte sedimentation rate (65 mm/h) and C-reactive protein level (41.4 mg/L), laboratory tests were normal, without evidence for vasculitis secondary to other inflammatory diseases (blood count, liver and renal function tests, VDRL, p-ANCA, c-ANCA, antibodies against myeloperoxidase or proteinase 3, ANA, ds-DNA, C3, C4, CH 50). Two months later, the aneurysmatic right carotid artery was surgically replaced by a Dacron graft. Immunosuppressive therapy with prednisone (1 mg/kg per day) was started under the assumption of a large vessels vasculitis. Two days later, the patient suddenly died after a sharp thoracic pain and collapse despite cardiopulmonary resuscitation. A postmortem examination revealed a ruptured giant aneurysm (Ø 7 cm) of the right coronary artery and a ruptured hemopericardium (Figure 3A), with four liters of sanguineous liquid in the thoracic cavity. All three coronary arteries had aneurysms with large parietal thrombi. On histological examination, vasculitis of the aorta, its branches, and of medium-sized arteries in the liver and lung was found (Figure 3B).
|
|
|
In this case, Takayasu arteritis is the most convincing diagnosis. Inflammation and subsequent neointimal proliferation result in stenotic or occlusive lesions, whereas destruction of the elastica and muscularis may cause dilation or aneurysms.1 Involvement of the coronary arteries is uncommon,2–4 and coronary aneurysms are extremely rare.5 Either coronary ischemia or aneurysm rupture may be fatal. Unfortunately, no surgical or catheter intervention would have been a reasonable option for this patient for surviving this massive destructive vasculitic process.
 |
Disclosures |
|---|
 Top Disclosures References |
|---|
None.
|
References |
|---|
|
TopDisclosuresReferences |
|---|
1. Kerr GS, Hallahan CW, Giordano J, Leavitt RY, Fauci AS, Rottem M, Hoffman GS. Takayasu arteritis. Ann Intern Med. 1994; 120: 919–929.
2. Endo M, Tomizawa Y, Nishida H, Aomi S, Nakazawa M, Tsurumi Y, Kawana M, Kasanuki H. Angiographic findings and surgical treatments of coronary artery involvement in Takayasu arteritis. J Thorac Cardiovasc Surg. 2003; 125: 570–577.
3. Suzuki H, Daida H, Tanaka M, Sato H, Kawai S, Sakurai H, Yamaguchi H. Giant aneurysm of the left main coronary artery in Takayasu aortitis. Heart. 1999; 81: 214–217.
4. Matsubara O, Kuwata T, Nemoto T, Kasuga T, Numano F. Coronary artery lesions in Takayasu arteritis: pathological considerations. Heart Vessels Suppl. 1992; 7: 26–31.[CrossRef][Medline] [Order article via Infotrieve]
5. Rose AG, Sinclair-Smith CC Takayasu’s arteritis: a study of 16 autopsy cases. Arch Pathol Lab Med. 1980; 104: 231–237.[Medline] [Order article via Infotrieve]
Related Article:
Circulation 2006 113: 2373.
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||