A case of aneurysm of the pulmonary artery

A CASE

OF ,1NI~:URYXM

OF THE

PULMONARY

ARTERY*

EURYSM of the pulmonary &cry is a relativeIy rare condition but one which occurs with sufficient frequency that it must be considered in the differential diagnosis of media&in& tumors. Wahl and Gardl in 1931 were able t.o collect. only seventy proved cases, and Scott2 in 1934 found ninety cases recorded in the literature. Among 915 cases of aneurysm, Crisps3 found four whieh involved the pulmonary artery, and Costa4 found only one such case in 20,000 autopsies. Additional. eases have been reported by several authors,5 not, all of which, however, were proved by necropsy. Syphilitic aortitis is frequently a11 etiological agent although it is less prominent in pulmonary than in a,ortic aneurysms. Peek,” in a.11extensive review of syphilis of the pulmonary artery, found only twelve absolutely proved cases. He states that the main trunk is involved almost exclusively and that the gummatous type of lesion is more common than the productive form, the reverse of that found in the systemic aorta. dtheromatous changes in t,hc smaller branches of the pulmonary artery may increase the pressure in that circuit. so that a dilat.ation of a similarly involved large vessel may occur. Rarsne? believes that arteriosclerotic changes are more frequently the cause of aneurysm of the pulmonary artery than of the systemic aorta. Other etiological factors include congenital malformations of the heart, which throw unusual strain on the pulmonary aorta, endocarditis, trauma, pneumothorax, and congenital defeet,s of the pulmonary vessels. The age incidence of aneurysm of the pulmonary artery is considerably lower than that of aortic aneurysm, since 40 per cent of the patients are under thirty years of age, whereas only 18 per cent of aortic aneurysms occur before this age.l The infrequency of aneurysm of the pulmonary artery may be accounted for by the lower pressure and lesser strain on the vessel walls within this circuit, and also by the lower incidence of syphilitic involvement of the pulmonary vessels. CASE REPORT D. I?., a white male ages1 fifty-nine years, was atlmitted to the University Hospital hecause of a sharp pain which a.ppexred first in the left shoulder and later in the axillary region. The pain in the shoulder radiated to the left elhow and was agThat zn the axillary region was not influenced by motion or gravated by motion. respiration but was worse at night, and was rarely present during the day. On several occasions the left hand and forearm became cold and whit,e, with intensification of the shoulder pain. There had been no edema, shortness of breath, anginoid *From

the

Department

of Internal

Jledicine, 350

State

University

of Iowa.

The patient had 1la.d gonorrhea fourteen pain, or other evidences of eardias disease. years before, but no history of a syphilitic infection was obtained. The left upper thorax was more prominent than t.he right and the expansion of The right cardiac border was beneath the sternum this area was slightly restricted. and the left border of dullness in the fifth interspace was just outside the midThere was a visible impulse in the second and third intercostal elavicular line. spaces and on palpation over this area a systolic impulse, a diastolic impact, and Dullness extended S cm. to the left of the mid a rough systolic thrill were felt. sternal line in the second interspace, 10 cm. in the thir,d, and S cm. in the fourth. Auscultation over the area of abnormal pulsation revealed a very loud, rough systolic murmur ending in an accentuated and tympanitic second sound. The murmur was transmitted to the entire left upper thorax but not to the vessels of the neck. The aortie second sound was normal and only a faint, systolic murmur was heard: which was not transmitted upward. A soft systolic murmur was also heard at the apex. There were 110 diastolic murmurs, and the cardiac mechanism was normal. The pulsaThe blood pressure was 139/73 in the right, and 134JS4 in the left arm.

Fig.

1.

tion in all accessible peripheral arteries was normal and symmetrical. There was no tracheal tug and no pulsation in the suprasternal notch. A slight degree of cyanosis was noted on the lips and finger tips. The pupils were irregular but responded to light and in accommodation. The nasal septum was intact, and the reflexes and sensations were normal. Motion of the left shoulder was limited by pain, but there was no crepitation, muscle atrophy, or other objective evidence of joint involvement. The Wassermann reaction was strongly positive. Fluoroscopic examination showed a well-outlined, rounded shadow in the region of the pulmonic curve on the left. This ha,d a definite expansile pulsation. In the oblique and lateral views this shadow was separated from the heart and from the thoracie aorta. Right posterior oblique and left lateral roentgenogrsms showed a tumor in the left hilus area extending laterally but not posteriorly. The thoracie aorta was uninvolved. A roentgen-kymogram showed a pulsating tumor mass. The patient received ten intramuscular injections of bismuth and was discharged from the hospital. He returned six months later; having taken potassium iodide gr. xv daily during the interval. The pain in the shoulder and elboow had entirely ,disappeared, and he experienced only a throbbing sensation in the left upper chest. He was feeling much

372

THE

.IMERICsS

HE$RT

JOURKial,

better and was able to do light work, although there was no change in the physical or roentgenological findings. The patient returned to his home and continued to do light work without discomfort. Five months later, however, he died very suds de&y from what was interpreted by his physician as a ruptured aneurysm.

The physical signs of aneurysm of the pulmonary artery as given by Henschens are as follows: 1. Prominence, dullness and an x-ray shadow in the second and third left intercostal spaces. 2. Pulsation and thrill in the same area. 3. A loud, superficial, rasping systolic murmur. 4. Absence of signs of aortic aneurysm. 5. Absence of dilatation of the left heart. 6. Right-sided cardiac hypertrophy. 7. Intense cyanosis, congestion, hemoptysis and substernal pain. If the aneurysm is uncomplica,ted by other valvular or vascular changes, there is no reason to suspect right ventricular hypertrophy ; and since the cyanosis and congestion depend on pressure phenomena or cardiac insufficiency, they are not necessarily present. This case presents the essential diagnostic features, and, although terminating fatally, the subjective improvement for a period of a year after antisyphilitic therapy was very striking.

1. Wahl, 9. 3.

4. * n.

ii. 7. s.

H. R., and Card, B. L.: Aneurysm of the Pulmonary Artery, Surg. Gynee. Obstt. 52: 1129, 1931. Scott, R. B.: Aneurysm of the Pulmonary Artery, Lancet 1: 567, 1934. Crisps, quoted by Kappeli: Ueber einen Fall von Aneurysma der Pulmonxlarterie, Ztschr. f. klin. Med. 123: 603, 1333. Costa, quoted by Kappeli. D’Aunoy, R.., and von Haam, E.: J. Path. & Bact. 38: 39, 1934. Calandre, L.: Arch. cardiol. y hemat. 14: 111, 1933. Luisads, A. : Mincrva med. 2: 431, 1.934. Borahetti. U. : Riforma med. 50: 1075. 1934. Ho&, L.I Fortschr. a. d. Geb. d. Wmigenstrahlen 50: 349, 1934. Esser. A.: Ztschr. f. Ereislaufforsch. 24: 747, 1932. Vogl,‘A.: Med. Elin. 27: 1352, 1931. Muscel, N., Lazeanu, E., and Stoichitza, N.: Arch, d. ma1 da coeur 26: 140, 1933. Guenard, F., and Caubet : Arch. d. ma1 du coeur 26: 261; 1933. Liidin. M.: Acta radiol. 14: 254. 1933. de tisiol. 8: ‘523, 1932. Va,done, A. : Arch. Pathologic Anatomy of Syphilis of the Pulmonary Artery, Arch. Peck, S. M.: Path. & Lab. Med. 4: 365, 1927. Productive Cicntricial Syphilitic Disease of the Pulmonary Karsner, H. T.: Artery, Arch. Int. Med. 51: 367, 1933. Innere Med. X6-127: 595. cler Arteria pulmonalis, Hens&en : Das Aneurysma Quoted by Wahl and Gard.1