Current Controversies in Large-Vessel Inflammatory Vasculitis and Thoracic Aortic Aneurysm Disease

Cardiology-Rheumatology Intersections in Aortitis and Aortic Aneurysms: Focus on Early Recognition and Management

Aortitis is an uncommon cause of aortic aneurysms. Arterial inflammation can lead to irreversible vascular damage. Early recognition is necessary for treatment to prevent permanent consequences of vessel inflammation.

Acute aortoiliac thrombosis and mitral valve regurgitation as acute onset of eosinophilic granulomatosis with polyangiitis in a 26-year-old patient

We present a rare case of eosinophilic granulomatosis with polyangiitis (EGPA), involving a 26-year-old woman with a history of asthma and nasal polyps. The patient presented with acute aortoiliac thrombosis and mitral insufficiency, which was successfully treated with thrombolysis, aortic thromboendarterectomy, and valve replacement. Peripheral hypereosinophilia with eosinophilic infiltration of the heart led to the diagnosis of antineutrophilic cytoplasmic antibody-negative EGPA. Treatment with prednisone and mepolizumab was started, resulting in a positive outcome. This case showcases an unusual manifestation of EGPA with large size vessel involvement and requiring surgical and pharmacological treatment. It also highlights the importance of early detection for timely intervention and an improved prognosis.

Role of temporal artery resection in Horton's arteritis (Review)

Horton's arteritis is found in the literature under various names, such as temporal arteritis, Horton's disease senile arteritis, granulomatous arteritis or giant cell arteritis (GCA). The pathogenic mechanism is the result of an inflammatory cascade triggered by a still unknown factor that causes dendritic cells in vessels to recruit T cells and macrophages, which form granulomatous infiltrates. The clinical picture consists of a daily headache with temporal localization, with moderate to severe intensity, unilateral or bilateral, with a history of months, years. Other changes may include pain in the cheek or tongue during chewing (claudication), weight loss, generalized fatigue, low-grade fever, and frequent pain in the limbs, in the context of coexisting rheumatic polymyalgia. Visual symptoms represent a special category, involving blurred vision, scotomas, and even sudden blindness. Histopathological examination of the temporal artery biopsy reveals focal thickening of the intima, with interruption of the lamina propria, with transmural inflammatory infiltrates, sometimes with multinucleated giant cells. In this article, we aim to review the role of temporal artery resection in the diagnosis of Horton's arteritis, but we also discuss the hypothesis of a potential therapeutic benefit of this procedure. However, there are also clinical situations in which there has been a considerable improvement in clinical symptoms and especially in vision deficit, with the improvement of the visual field after surgery performed for biopsy. It is difficult to estimate the influence of temporal artery resection alone, given that most patients also have concomitant cortisone treatment. However, in some cases, the rapid improvement of symptoms immediately after surgery, with the improvement of visual acuity and visual field, along with the disappearance of the headaches, can create the premises for future studies on a therapeutic contribution of temporal artery resection in GCA.

Aortitis masquerading as intramural hematoma: When to observe, when to operate? A case report

Radiologic evidence of aortic disease is not always consistent with the diagnosis. With a lack of accompanying symptoms or with an atypical presentation, diagnosis, and management of aortic pathology rely greatly on imaging techniques. We report the case of a 58-year-old female who presented with incidental radiographic findings consistent with a type A aortic intramural hematoma and a vague left-sided chest discomfort. After follow-up, imaging was consistent with disease progression and hematoma expansion; the affected segment was resected and pathology reported lymphoplasmacytic aortitis as the underlying etiology of the imaging findings rather than an intramural hematoma. The patient lacked symptoms or serology consistent with the rheumatologic disease, and the postoperative course was uneventful. The management of a suspected ascending intramural hematoma is controversial, especially when the patient presents with atypical signs and symptoms. Features of disease progression may warrant urgent surgical intervention.

Familial risks between giant cell arteritis and Takayasu arteritis and other autoimmune diseases in the population of Sweden

Giant cell arteritis (GCA, also called temporal arteritis) is a rare and Takayasu arteritis (TA) is an even rarer autoimmune disease (AID), both of which present with inflammatory vasculitis of large and medium size arteries. The risk factors are largely undefined but disease susceptibility has been associated with human leukocyte antigen locus. Population-level familial risk is not known. In the present nation-wide study we describe familial risk for GCA and for GCA and TA with any other AID based on the Swedish hospital diagnoses up to years 2012. Family relationships were obtained from the Multigeneration Register. Familial standardized incidence ratios (SIRs) were calculated for offspring whose parents or siblings were diagnosed with GCA, TA or any other AID. The number of GCA patients in the offspring generation was 4695, compared to 209 TA patients; for both, familial patients accounted for 1% of all patients. The familial risk for GCA was 2.14, 2.40 for women and non-significant for men. GCA was associated with 10 other AIDs and TA was associated with 6 other AIDs; both shared associations with polymyalgia rheumatica and rheumatoid arthritis. The results showed that family history is a risk factor for GCA. Significant familial associations of both GCA and TA with such a number of other AIDs provide evidence for polyautoimmunity among these diseases.