Emerg Radiol DOI 10.1007/s10140-014-1199-z
CASE REPORT
Core curriculum illustration: infectious aortitis F. A. Mann
Received: 22 January 2014 / Accepted: 23 January 2014 # Am Soc Emergency Radiol 2014
Abstract This is the sixth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www. aseronline.org/curriculum/toc.htm.
Keywords Aortitis . CT
Findings Inspection of the retroperitoneum (aorta, inferior vena cava, and perivascular lymph nodes) reveals, in addition to expected findings of complex atheromata associated with her known PVD, a segment of non-aneurysmal (diameter 3.6 cm) thoracoabdominal aorta showing eccentric and focally enhancing thickened wall (mural thickness 15 mm) with asymmetric stranding of the retroperitoneal perivascular fat (Fig. 1). No critical aortic or branch vessel narrowing or occlusions are shown. The aorta is modestly displaced from the spine. No intramural gas, spondylodisciitis or retroperitoneal abscess are present. No other cause for intra-abdominal sepsis and pain is found.
History A 63-year-old febrile woman with rigors, who has recently undergone sequential treatments for swine influenza (oseltamivir phosphate [Tamiflu®, Genentech USA, Inc]) and pneumococcal pneumonia with bacteremia (intravenous penicillin), presents with increasing upper abdominal and back pain, elevated sedimentation rate, and leukocytosis (20,000 WBC/mm3). She has a history of severe peripheral vascular disease (PVD) and remote splenectomy. She is empirically started on intravenous antibiotics and, as recommended in the ACR Appropriateness Criteria™ for “Acute Abdominal Pain and Fever or Suspected Abdominal Abscess” presenting with fever without recent abdominal surgery [1], an intravenous contrast enhanced CT of the abdomen and pelvis is performed.
F. A. Mann (*) Integra Imaging, PS 1229 Madison, Suite 900, Seattle, WA 98104, USA e-mail: [email protected]
Discussion Despite its non-specific clinical presentation with pain (chest, abdomen, and/or back) and constitutional symptoms (fever, malaise, etc.), susceptible patients (e.g., older or immunocompromised patients with abnormal aortas) with untreated pyogenic infectious aortitis (e.g., Staphylococcus aureus, Salmonella species, Streptococcus pneumoniae, etc.) typically die, and as many as half of treated patients succumb [2, 3]. Early diagnosis requires emergency radiologists to consider the diagnosis and actively search for suggestive imaging findings: enhancing, thickened aortic wall with eccentric periaortic stranding, and with or without aneurysm [4]. Upper limits of thickness of the aortic wall vary by patient gender (men slightly greater than women), presence of chronic systemic arterial hypertension (generally thicker), advancing age, and location (ascending [
CASE REPORT
Core curriculum illustration: infectious aortitis F. A. Mann
Received: 22 January 2014 / Accepted: 23 January 2014 # Am Soc Emergency Radiol 2014
Abstract This is the sixth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www. aseronline.org/curriculum/toc.htm.
Keywords Aortitis . CT
Findings Inspection of the retroperitoneum (aorta, inferior vena cava, and perivascular lymph nodes) reveals, in addition to expected findings of complex atheromata associated with her known PVD, a segment of non-aneurysmal (diameter 3.6 cm) thoracoabdominal aorta showing eccentric and focally enhancing thickened wall (mural thickness 15 mm) with asymmetric stranding of the retroperitoneal perivascular fat (Fig. 1). No critical aortic or branch vessel narrowing or occlusions are shown. The aorta is modestly displaced from the spine. No intramural gas, spondylodisciitis or retroperitoneal abscess are present. No other cause for intra-abdominal sepsis and pain is found.
History A 63-year-old febrile woman with rigors, who has recently undergone sequential treatments for swine influenza (oseltamivir phosphate [Tamiflu®, Genentech USA, Inc]) and pneumococcal pneumonia with bacteremia (intravenous penicillin), presents with increasing upper abdominal and back pain, elevated sedimentation rate, and leukocytosis (20,000 WBC/mm3). She has a history of severe peripheral vascular disease (PVD) and remote splenectomy. She is empirically started on intravenous antibiotics and, as recommended in the ACR Appropriateness Criteria™ for “Acute Abdominal Pain and Fever or Suspected Abdominal Abscess” presenting with fever without recent abdominal surgery [1], an intravenous contrast enhanced CT of the abdomen and pelvis is performed.
F. A. Mann (*) Integra Imaging, PS 1229 Madison, Suite 900, Seattle, WA 98104, USA e-mail: [email protected]
Discussion Despite its non-specific clinical presentation with pain (chest, abdomen, and/or back) and constitutional symptoms (fever, malaise, etc.), susceptible patients (e.g., older or immunocompromised patients with abnormal aortas) with untreated pyogenic infectious aortitis (e.g., Staphylococcus aureus, Salmonella species, Streptococcus pneumoniae, etc.) typically die, and as many as half of treated patients succumb [2, 3]. Early diagnosis requires emergency radiologists to consider the diagnosis and actively search for suggestive imaging findings: enhancing, thickened aortic wall with eccentric periaortic stranding, and with or without aneurysm [4]. Upper limits of thickness of the aortic wall vary by patient gender (men slightly greater than women), presence of chronic systemic arterial hypertension (generally thicker), advancing age, and location (ascending [
