Case Report Received: July 1, 1990 Accepted after revision: September 13, 1990
Cardiology 1991;78:78-80
Aortic Dissection Manifested as Fever of Unknown Origin M. A. M. R. J. Y.
Michael Amos Mordechai Rami Jack Yoram
Giladia Pinesa Averbucha Hershkoviza Sherezb Levoa
Departments of aMedicine T and bCardiology, Ichilow Hospital, Tel Aviv Medical Center, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Key Words Fever Aortic dissection
Abstract Aortic dissection is accompanied by fever in about one third of the patients. However, fever of unknown origin as the predominant manifestation of aortic dissection seems to be extremely rare. A review of the English literature revealed only 3 patients characterized by fever as the principal sign of aortic dissection. Herein an additional patient is reported. All 4 patients presented with pain or discomfort in the chest, back or abdomen, followed by persistent fever, lasting 5–11 weeks and associated with anemia and a high sedimentation rate. The outcome was favorable in all cases regardless of the location of the dissection or the type of treatment. A. Pines, MD, Department of Medicine T, Ichilov Hospital, 6 Weizman Street, Tel Aviv 64239 (Israel)
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Aortic dissection is quite frequently accompanied by fever and acute distress [1]. However, prolonged fever as the major manifestation of aortic dissection seems to be extremely uncommon. We describe a patient in whom aortic dissection resulted in fever of unknown origin (FUO). Report A 70-year-old female was admitted to our Department of Medicine for evaluation of fever of 6weeks duration. Seven weeks prior to her admission, the patient was seen in the emergency room following an episode of retrosternal pain. In view of a normal ECG and a chest X-ray she was discharged. The following day she was seen once again in the emergency room because of diffuse abdominal pain and a temperature of 37.7 °C. The patient was sent home, due to recurrent chest pain, however, she was finally admitted to the hospital, 5 days after her first symptom. Her medical history showed 20 years of hypertension treated with methyldopa and diuretics, and mild asthma treated with bronchodilators. Physical examination on admission was unremarkable, except for a temperature of 38.5 °C, tachycardia (96/min) and a blood pressure of 180/80 mm Hg. The routine laboratory workup was essentially normal except for a sedimentation rate of 70 mm/h. The following tests were either negative or normal: serum chemistry determinations, FT4, C3, C4, serol-ogy for syphilis, typhoid fever, Rickettsiae, Brucella, Epstein-Barr, cytomegalo and hepatitis A and B viruses,
antinuclear bodies, rheumatoid factor and uri-nalysis. A serum protein electrophoresis revealed mild elevation of the αi and o⅛ fractions. Repeat blood and urine cultures were sterile. Fever of Unknown Origin due to Aortic Dissection 79 The patient’s chest pain subsided over the following 3 days, however, the fever continued. A therapeutic trial of ampicillin for 7 days had no effect. After 12 days of hospitalization, the patient was discharged to be folio wed-up. During the following month she continued to have fever up to 38.5 °C and was therefore readmitted to our Department of Medicine. Physical examination at that time was remarkable only for fever of 38 °C and a blood pressure of 170/90. The initial laboratory evaluation revealed a normochromic normocytic anemia of 10 g/dl with a hematocrit of 30% and a sedimentation rate of 115 mm/h. Chest radiographs taken in posteroanter-ior, lateral and oblique views showed only mildly enlarged left ventricle. Since the patient first presented with chest pain we proceeded with echocardiography performed on the first day of her second admission. This procedure revealed dissection of the aorta (fig. 1), which was confirmed by an aortography and a CT scan. The dissection began distal to the aortic arch and down to the level of just above the renal arteries. In view of the patient’s asthma, ß-blockers were avoided and verapamil (480 mg/day) was administered to lower the blood pressure. The patient defervesced spontaneously 3 days following her admission. Over the ensuing 6 months she remained asymptomatic and afebrile and her hematocrit and sedimentation rate returned to normal range. Comment Aortic dissection is accompanied by fever in about one third of the patients. Hirst et al. [1] have described 505 patients with aortic dissection. Data regarding temperature were available for 178 cases of whom 31% had fever above 37.7 °C and 8% above 39 °C. FUO, namely a prolonged fever of more than 2–3 weeks duration, as a chief complaint, has not been described in any of these patients. FUO as the predominant manifestation of aortic dissection seems to be extremely rare. A review of the English literature revealed only three articles totalling 6 Fig. 1. Echocardiogram demonstrating dissection of the descending aorta. Note the line (arrows) separating the true (a) from the false (b) lumen. patients characterized by fever as the principal sign of aortic dissection [2–4]. In 3 of these 6 patients the fever seemed to be a manifestation of bacterial endocarditis rather than of aortic dissection. These patients had in addition regurgitant murmurs, rapidly progressive congestive heart failure, conjunctival petechiae and anemia. The other 3 patients resemble the one described herein: they all presented with pain or discomfort in the chest, back or abdomen, followed by persistent fever, lasting 5–11 weeks and associated with anemia and a high sedimentation rate. The outcome was favorable in all cases regardless of the location of the dissection or the type of treatment. Noteworthy is the fact that in the present patient 80 Giladi/Pines/Averbuch/Hershkoviz/Sherez/Levo
Downloaded by: Chinese University of Hong Kong 137.189.171.235 - 10/24/2016 5:33:41 PM
chest radiographs taken in posteroanterior, lateral and oblique views did not show widening of the aorta even when retrospectively reviewed. In all previously described cases chest radiographs provided the first clue to diagnosis.
Downloaded by: Chinese University of Hong Kong 137.189.171.235 - 10/24/2016 5:33:41 PM
Our patient, together with the 3 previously described patients, illustrates that, on rare occasions, aortic dissection might be manifested by the triad of prolonged fever, anemia and a high sedimentation rate, without concurrent pain. Aortic dissection should therefore be added to the list of rare causes of FUO. In the presence of a painful aortic dilatation, elevated erythrocyte sedimentation rate and fever one should also consider the diagnosis of inflammatory aortic aneurysm [5]. The various imaging modalities will help to differentiate this condition from a noninflammatory dissecting aneurysm. In conclusion, physicians should bear the diagnosis of aortic dissection when facing patients with prolonged fever, especially following an episode of chest, back or abdominal pain. References Hirst AE, Johns VJ, Kim SW: Dissecting aneurysm of the aorta: A review of 505 cases. Medicine 1958;37:217–279. Murray HW, Mann JJ, Genecin A, McKusick VA: Fever with dissecting aneurysm of the aorta. Am J Med 1976;61:140–144. Mackowiak PA, Lipscomb KM, Mills LJ, Smith JW: Dissecting aortic aneurysm manifested as fever of unknown origin. JAMA 1976;236:1725– 1727. Ruderman A, Mackowiak PA, Smith JW: Fever as a manifestation of dissecting aneurysm of aorta. Am J Cardiol 1979;44:581–582. Ponnell RC, Hollier LH, Lie JT, et al: Inflammatory abdominal aortic aneurysms: A thirty years review. J Vase Surg 1985;2:859–869.
Cardiology 1991;78:78-80
Aortic Dissection Manifested as Fever of Unknown Origin M. A. M. R. J. Y.
Michael Amos Mordechai Rami Jack Yoram
Giladia Pinesa Averbucha Hershkoviza Sherezb Levoa
Departments of aMedicine T and bCardiology, Ichilow Hospital, Tel Aviv Medical Center, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Key Words Fever Aortic dissection
Abstract Aortic dissection is accompanied by fever in about one third of the patients. However, fever of unknown origin as the predominant manifestation of aortic dissection seems to be extremely rare. A review of the English literature revealed only 3 patients characterized by fever as the principal sign of aortic dissection. Herein an additional patient is reported. All 4 patients presented with pain or discomfort in the chest, back or abdomen, followed by persistent fever, lasting 5–11 weeks and associated with anemia and a high sedimentation rate. The outcome was favorable in all cases regardless of the location of the dissection or the type of treatment. A. Pines, MD, Department of Medicine T, Ichilov Hospital, 6 Weizman Street, Tel Aviv 64239 (Israel)
Downloaded by: Chinese University of Hong Kong 137.189.171.235 - 10/24/2016 5:33:41 PM
Aortic dissection is quite frequently accompanied by fever and acute distress [1]. However, prolonged fever as the major manifestation of aortic dissection seems to be extremely uncommon. We describe a patient in whom aortic dissection resulted in fever of unknown origin (FUO). Report A 70-year-old female was admitted to our Department of Medicine for evaluation of fever of 6weeks duration. Seven weeks prior to her admission, the patient was seen in the emergency room following an episode of retrosternal pain. In view of a normal ECG and a chest X-ray she was discharged. The following day she was seen once again in the emergency room because of diffuse abdominal pain and a temperature of 37.7 °C. The patient was sent home, due to recurrent chest pain, however, she was finally admitted to the hospital, 5 days after her first symptom. Her medical history showed 20 years of hypertension treated with methyldopa and diuretics, and mild asthma treated with bronchodilators. Physical examination on admission was unremarkable, except for a temperature of 38.5 °C, tachycardia (96/min) and a blood pressure of 180/80 mm Hg. The routine laboratory workup was essentially normal except for a sedimentation rate of 70 mm/h. The following tests were either negative or normal: serum chemistry determinations, FT4, C3, C4, serol-ogy for syphilis, typhoid fever, Rickettsiae, Brucella, Epstein-Barr, cytomegalo and hepatitis A and B viruses,
antinuclear bodies, rheumatoid factor and uri-nalysis. A serum protein electrophoresis revealed mild elevation of the αi and o⅛ fractions. Repeat blood and urine cultures were sterile. Fever of Unknown Origin due to Aortic Dissection 79 The patient’s chest pain subsided over the following 3 days, however, the fever continued. A therapeutic trial of ampicillin for 7 days had no effect. After 12 days of hospitalization, the patient was discharged to be folio wed-up. During the following month she continued to have fever up to 38.5 °C and was therefore readmitted to our Department of Medicine. Physical examination at that time was remarkable only for fever of 38 °C and a blood pressure of 170/90. The initial laboratory evaluation revealed a normochromic normocytic anemia of 10 g/dl with a hematocrit of 30% and a sedimentation rate of 115 mm/h. Chest radiographs taken in posteroanter-ior, lateral and oblique views showed only mildly enlarged left ventricle. Since the patient first presented with chest pain we proceeded with echocardiography performed on the first day of her second admission. This procedure revealed dissection of the aorta (fig. 1), which was confirmed by an aortography and a CT scan. The dissection began distal to the aortic arch and down to the level of just above the renal arteries. In view of the patient’s asthma, ß-blockers were avoided and verapamil (480 mg/day) was administered to lower the blood pressure. The patient defervesced spontaneously 3 days following her admission. Over the ensuing 6 months she remained asymptomatic and afebrile and her hematocrit and sedimentation rate returned to normal range. Comment Aortic dissection is accompanied by fever in about one third of the patients. Hirst et al. [1] have described 505 patients with aortic dissection. Data regarding temperature were available for 178 cases of whom 31% had fever above 37.7 °C and 8% above 39 °C. FUO, namely a prolonged fever of more than 2–3 weeks duration, as a chief complaint, has not been described in any of these patients. FUO as the predominant manifestation of aortic dissection seems to be extremely rare. A review of the English literature revealed only three articles totalling 6 Fig. 1. Echocardiogram demonstrating dissection of the descending aorta. Note the line (arrows) separating the true (a) from the false (b) lumen. patients characterized by fever as the principal sign of aortic dissection [2–4]. In 3 of these 6 patients the fever seemed to be a manifestation of bacterial endocarditis rather than of aortic dissection. These patients had in addition regurgitant murmurs, rapidly progressive congestive heart failure, conjunctival petechiae and anemia. The other 3 patients resemble the one described herein: they all presented with pain or discomfort in the chest, back or abdomen, followed by persistent fever, lasting 5–11 weeks and associated with anemia and a high sedimentation rate. The outcome was favorable in all cases regardless of the location of the dissection or the type of treatment. Noteworthy is the fact that in the present patient 80 Giladi/Pines/Averbuch/Hershkoviz/Sherez/Levo
Downloaded by: Chinese University of Hong Kong 137.189.171.235 - 10/24/2016 5:33:41 PM
chest radiographs taken in posteroanterior, lateral and oblique views did not show widening of the aorta even when retrospectively reviewed. In all previously described cases chest radiographs provided the first clue to diagnosis.
Downloaded by: Chinese University of Hong Kong 137.189.171.235 - 10/24/2016 5:33:41 PM
Our patient, together with the 3 previously described patients, illustrates that, on rare occasions, aortic dissection might be manifested by the triad of prolonged fever, anemia and a high sedimentation rate, without concurrent pain. Aortic dissection should therefore be added to the list of rare causes of FUO. In the presence of a painful aortic dilatation, elevated erythrocyte sedimentation rate and fever one should also consider the diagnosis of inflammatory aortic aneurysm [5]. The various imaging modalities will help to differentiate this condition from a noninflammatory dissecting aneurysm. In conclusion, physicians should bear the diagnosis of aortic dissection when facing patients with prolonged fever, especially following an episode of chest, back or abdominal pain. References Hirst AE, Johns VJ, Kim SW: Dissecting aneurysm of the aorta: A review of 505 cases. Medicine 1958;37:217–279. Murray HW, Mann JJ, Genecin A, McKusick VA: Fever with dissecting aneurysm of the aorta. Am J Med 1976;61:140–144. Mackowiak PA, Lipscomb KM, Mills LJ, Smith JW: Dissecting aortic aneurysm manifested as fever of unknown origin. JAMA 1976;236:1725– 1727. Ruderman A, Mackowiak PA, Smith JW: Fever as a manifestation of dissecting aneurysm of aorta. Am J Cardiol 1979;44:581–582. Ponnell RC, Hollier LH, Lie JT, et al: Inflammatory abdominal aortic aneurysms: A thirty years review. J Vase Surg 1985;2:859–869.
