Lupus Aortitis Successfully Treated with Moderate-dose Glucocorticoids: A Case Report and Review of the Literature

Abdominal Pain in a Female with Lupus - Opening the Pandora's Box

Systemic lupus erythematosus (SLE) is an autoimmune disease that can involve multiple organ systems. The most common form of vasculitis seen in SLE is small vessel vasculitis. Aortitis in SLE or antiphospholipid syndrome is an extremely rare complication. Here, we present a 32-year-old female who presented with a history of prolonged abdominal pain, who was evaluated and diagnosed to have aortitis as an unusual involvement in SLE with secondary antiphospholipid antibody syndrome.

Isolated Aortitis: Workup and Management

The finding of aortitis, often incidentally noted on surgical resection, should prompt evaluation for secondary causes including large-vessel vasculitis. In a large proportion of cases, no other inflammatory cause is identified and the diagnosis of clinically isolated aortitis is made. It is unknown whether this entity represents a more localized form of large-vessel vasculitis. The need for immunosuppressive therapy in patients with clinically isolated aortitis remains unclear. Patients with clinically isolated aortitis warrant imaging of the entire aorta at baseline and regular intervals because a significant proportion of patients have or develop abnormalities in other vascular beds.

Spectrum of Large and Medium Vessel Vasculitis in Adults: Primary Vasculitides, Arthritides, Connective Tissue, and Fibroinflammatory Diseases

Purpose of Review

To provide a comprehensive overview of the spectrum of large and medium vessel vasculitis in adults with primary vasculitides, arthritides, connective tissue, and fibroinflammatory diseases as well as vasculitis mimics, for an efficient differential diagnosis and initial diagnostic approach.

Recent Findings

Imaging has had a tremendous impact on the diagnosis of medium to large vessel vasculitis, now often replacing histopathologic confirmation and identifying new disease manifestations (e.g., intracranial disease in giant cell arteritis; vascular manifestations of IgG4-related disease). Novel diseases or syndromes involving blood vessels have been described (e.g., VEXAS-Syndrome with polychondritis). The use of the terms “medium” or “large” vessel varies considerably between medical specialties.

Summary

The differential diagnosis of large and medium vessel vasculitis is becoming increasingly complex as new entities or disease manifestations of known inflammatory rheumatic diseases are regularly identified. A more precise and widely recognized definition of the vessel sizes would make future research more comparable.

Aortitis is an under-recognized manifestation of antiphospholipid syndrome: A case report and literature review

Aortitis is a classic manifestation of large vessel vasculitis. Antiphospholipid syndrome (APS), sometimes known as Hughes syndrome, is an acquired autoimmune disorder that manifests clinically as recurrent venous or arterial thrombosis. Patients with APS may also suffer from various underlying diseases, most frequently systemic lupus erythematosus (SLE). Catastrophic antiphospholipid syndrome (CAPS) is a rare but serious complication of APS characterized by failure of several organs due to diffuse microcirculatory thrombi. Its main manifestations involve the kidneys, lungs, heart and central nervous system, and require early diagnosis and rapid therapeutic management. While APS can affect virtually any blood vessel, aortitis is not a known symptom of APS. We report the case of a 36-year-old patient with APS and SLE who presented with CAPS during pregnancy, with no concomitant SLE flare. The first manifestation of CAPS was aortitis, preceding renal, cardiac and haematological manifestations. The outcome was favourable with combined treatment including corticosteroids, anticoagulants, plasma exchange and rituximab. We then carried out a literature search for papers describing the presence of aortitis in APS and/or SLE. In the cases of aortic involvement identified in the literature, including another case of CAPS, the occurrence of aortitis in SLE, often associated with the presence of antiphospholipid antibodies/APS, suggests that aortitis should be considered as an under-recognized manifestation and potential non-criterion feature of APS.

Aortitis: An Unusual Inflammatory Complication of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can involve any organ system. Vasculitides are classified according to the predominant vessel involved such as large vessel, medium vessel, or small vessel vasculitis. Of these, Takayasu arteritis, Behcet's disease, relapsing polychondritis, and immunoglobulin G4 (IgG4)-related disease predominantly involve large vessels. The most common form of vasculitis seen in SLE is small vessel vasculitis. Aortitis in SLE is an extremely rare complication. This is a case report of a 21-year-old female patient with a history of SLE with overlap syndrome of primary biliary cirrhosis and autoimmune hepatitis associated with antiphospholipid syndrome (APS), who presented with a one-week history of left-back burning lumbar pain, radiating to the flank, which increased with changes in position associated with intermittent claudication. In the angiography images and the positron emission tomography (PET) scan, a hypometabolic left para-aortic oval image was noted, corresponding to the presence of a contained hematoma in an abdominal aorta rupture. Later, she underwent vascular surgery and hemodynamics, performing thoracoabdominal aortic reconstruction together with aortorenal bypass and left nephrectomy. Pathology fundings of the left kidney correspond with class IV lupus nephritis, and the resection sample of the thoracoabdominal aneurysm showed a marked thinning and fragmentation of elastic fibers, areas of fibrosis of the wall with severe IgG4 negative lymphoplasmacytic infiltrate in the immunohistochemical study, establishing the diagnosis of aortitis.