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Aneurysm of the gluteal artery secondary to polyarteritis nodosa
CASE REPORTS
Aneurysm
of the Gluteal to Polyarteritis
J. GOSTIGIAN, M.D. AND
R. J. SCHLITT,
From tbe Department of Surgery, Veterans Administration Hospital, Pbiladelpbia, Pennsylvania.
M.D., Philadtlpbia,
Pennsylvania
Iished by histologic section. Previous hospitalizations prior to this admission were for some manifestation of poIyarteritis nodosa. The patient’s last biopsy of muscIe specimen, done on December 27, 1960, was again diagnostic of poIyarteritis nodosa. At time of admission the patient’s bIood pressure was 140/100 mm. Hg, puIse 80, temperature 37.~~~. Significant findings were Iimited to the Ieft buttock, which was extremeIy tender to paIpation. No erythema or induration were noted. The left buttock was smaIIer in size when compared with the right buttock. Deep tendon reffexes were generaIIy hypoactive. The resuIts of Iaboratory studies on admission and throughout his hospita1 stay were within norma Iimits. FoIIowing the patient’s admission to the hospital, surgica1 consuItation was obtained for evaluation of a painfu1 mass in the Ieft buttock. Examination at time of consuItation revealed a mass approximateIy I I cm. in diameter. This mass was extremeIy tender to paIpation. However, with increase in pressure of the palpating hand, the mass was noted to be puIsating. On cIose visual examination, pulsation of the entire Ieft buttock was aiso noted. Upon auscuItation, a systoIic bruit was audibIe. Diagnosis of an aneurysm invoIving the Ieft gluteal artery was made. Immediate surgery was advised. The patient was taken to the operating room and pIaced under generti1 endotrachea1 anesthesia. The Ieft interna iliac artery was ligated by means of a transabdominal approach, in order to decrease bIood flow to the aneurysm. Before Iigation of the artery, an operative arteriogram was obtained (roentgenograms were not avaiIabIe). The abdominal wound was closed, and the patient was placed in a prone position. Pulsation in the Ieft buttock had ceased after ligation of the interna iliac artery on the left side. The incision in the
of the gIuteaI artery have been described in the EngIish and foreign language Iiterature. The most recent article on the subject in the EngIish Iiterature is in NEURYSMS
A
I937 [Il. The majority of aneurysms invoIving the gIutea1 artery are either traumatic or spontaneous in origin [2-q]. When we searched the Iiterature, we found no reference to aneurysms of the gIutea1 artery resulting from polyarteritis nodosa. The foIIowing patient was treated at the Veterans Administration Hospital in PhiIadeIphia. CASE
Artery Secondary Nodosa
REPORT
The patient was a forty-six year old Negro man admitted to the Philadelphia Veterans Administration HospitaI for the sixth time on December 15, 1960, with a co&pIaint of pain in the Ieft buttock and a coId feeIing in the genitalia for approximateIy four weeks prior to admission. WhiIe at work the patient first noted the onset of severe, aching pain in the Ieft periana1 area radiating to the Ieft portion of the buttock and calf. He also reported numbness of the buttock and posterior aspect of the thigh, associated with the pain. BoweI movements did not appear to increase the severity of the pain. No bIeeding or discharge from the anus was reported. Pain increased progressively in severity up to the point at which bedclothes could not be toIerated because they wouId further aggravate the pain. Pain was constant. No urinary tract symptoms appeared. In 1946, prior to the patient’s discharge from the army, diagnosis of poIyarteritis nodosa was estab-
Accepted for pubIication February 20, 1962. 267
American
Journal
of Surgery.
Volume
IOY, February
1963
Gostigian
and
buttock began at the posterior-superior part of the iliac spine, extended IateraIIy and down aIong the Iateral margin of the buttock, and bisected the greater trochanter. The buttock flap was reflected mediaIIy, and the sciatic nerve was isoIated and retracted Iaterally. The aneurysm sac was noted to be inferior to the pyriformis muscle. In the course of dissection of the aneurysm, the sac was entered inadvertentIy and contro1 of blood loss was obtained by pressure over the pyriformis muscIe. Dissection was continued, and the aneurysm was Iigated at its neck and excised. Hemostasis was satisfactory. The wound was closed in Iayers, and a Penrose drain was left in pIace. PostoperativeIy, the patient had an uneventful course. Sutures were removed on the seventh postoperative day. The patient was discharged, symptom-free, on the fifteenth postoperative day.
SchIitt
consistent. He also noted Iow back pain which was severe and radiated to both Iegs. No gastrointestina1 bleeding was reported. Physical examination showed generaIized abdomina1 tenderness upon deep paIpation and tenderness to palpation and rigidity in the Ieft flank. PeripheraI p&es were easily paIpabIe. Heart and Iungs appeared to be normal. Chest roentgenograms at time of admission faiIed to revea1 any abnormality. HemogIobin was I I .$ gm. per cent, and the hematocrit was 38 per cent. Microscopic examination of the urine reveaIed many bacteria. Urine culture grew proteus and Escherichia coIi. On the fourth day after admission, the patient suddenIy coughed-up some bright red bIood, feI1 back in bed and died. Autopsy revealed an aneurysm of the thoracic aorta, which had ruptured into the lung.
and
COMMENTS
CIinicopathoIogic correIation of po1yarteriti.s nodosa was first made in 1866 by KussmauI and Maier, aIthough Iesions simiIar in description were recorded 200 years ago. PoIyarteritis predominantIy affects the medium sized arteries, usuaIIy at the bifurcation, and may also invoIve the smaI1 arterioIes. Aneurysms invoIving the smaIIer arteries and arteriores, particuIarIy in the abdomina1 cavity, are not uncommon in patients with poIyarteritis nodosa. PeripheraI neuropathies may be caused by invoIvement of nutrient vessels to the periphera1 nerves, or by involvement of Iarger vesseIs producing pain, numbness, tingling and, Iater, paraIysis and atrophy of the invoIved muscIes
SUMMARY
A forty-six year old Negro man was admitted to the hospita1 with symptoms of severe pain and a tender mass in the Ieft buttock. Diagnosis of a gIutea1 artery aneurysm secondary to poIyarteritis was made. The aneurysm was excised. The patient recovered and was discharged after an uneventfu1 postoperative course. Seven months Iater, the patient was readmitted with severe, generalized symptoms. After four days, he died of a ruptured aneurysm of the thoracic artery. REFERENCES
[r;l* The symptoms and signs of this patient were thought to be caused by compression of the nerves, biood vessels and surrounding structures by the expanding aneurysm sac. The patient was readmitted on July 24, I 961, with a three week history of vomiting foIIowing meaIs, and “gnawing” type of pain in the epigastric area. Four days prior to admission, the pain in the abdomen became more severe
DEITCH, H. I. and ROGAN, J. Gluteal aneurysm. Lancet, I: 1516, 1937. 2. ADAMS, A. W. GIuteaI aneurysm and rupture. Lancer, I.
I:
697, 1923.
1. HAGGARD. W. D. Lination of the internal iIiac arterv for enoknous gIn;eaI aneurysm. Ann. Surg., 7g: 520, 1922. 4. MAGUIRE, D. GIuteaI aneurysm. Ann. Surg., 84: 760, 1926. 3. MCCOMBS, R. P. PoIyarteritis. Disease of tbe Month, 63, 1960.
268
Aneurysm
of the Gluteal to Polyarteritis
J. GOSTIGIAN, M.D. AND
R. J. SCHLITT,
From tbe Department of Surgery, Veterans Administration Hospital, Pbiladelpbia, Pennsylvania.
M.D., Philadtlpbia,
Pennsylvania
Iished by histologic section. Previous hospitalizations prior to this admission were for some manifestation of poIyarteritis nodosa. The patient’s last biopsy of muscIe specimen, done on December 27, 1960, was again diagnostic of poIyarteritis nodosa. At time of admission the patient’s bIood pressure was 140/100 mm. Hg, puIse 80, temperature 37.~~~. Significant findings were Iimited to the Ieft buttock, which was extremeIy tender to paIpation. No erythema or induration were noted. The left buttock was smaIIer in size when compared with the right buttock. Deep tendon reffexes were generaIIy hypoactive. The resuIts of Iaboratory studies on admission and throughout his hospita1 stay were within norma Iimits. FoIIowing the patient’s admission to the hospital, surgica1 consuItation was obtained for evaluation of a painfu1 mass in the Ieft buttock. Examination at time of consuItation revealed a mass approximateIy I I cm. in diameter. This mass was extremeIy tender to paIpation. However, with increase in pressure of the palpating hand, the mass was noted to be puIsating. On cIose visual examination, pulsation of the entire Ieft buttock was aiso noted. Upon auscuItation, a systoIic bruit was audibIe. Diagnosis of an aneurysm invoIving the Ieft gluteal artery was made. Immediate surgery was advised. The patient was taken to the operating room and pIaced under generti1 endotrachea1 anesthesia. The Ieft interna iliac artery was ligated by means of a transabdominal approach, in order to decrease bIood flow to the aneurysm. Before Iigation of the artery, an operative arteriogram was obtained (roentgenograms were not avaiIabIe). The abdominal wound was closed, and the patient was placed in a prone position. Pulsation in the Ieft buttock had ceased after ligation of the interna iliac artery on the left side. The incision in the
of the gIuteaI artery have been described in the EngIish and foreign language Iiterature. The most recent article on the subject in the EngIish Iiterature is in NEURYSMS
A
I937 [Il. The majority of aneurysms invoIving the gIutea1 artery are either traumatic or spontaneous in origin [2-q]. When we searched the Iiterature, we found no reference to aneurysms of the gIutea1 artery resulting from polyarteritis nodosa. The foIIowing patient was treated at the Veterans Administration Hospital in PhiIadeIphia. CASE
Artery Secondary Nodosa
REPORT
The patient was a forty-six year old Negro man admitted to the Philadelphia Veterans Administration HospitaI for the sixth time on December 15, 1960, with a co&pIaint of pain in the Ieft buttock and a coId feeIing in the genitalia for approximateIy four weeks prior to admission. WhiIe at work the patient first noted the onset of severe, aching pain in the Ieft periana1 area radiating to the Ieft portion of the buttock and calf. He also reported numbness of the buttock and posterior aspect of the thigh, associated with the pain. BoweI movements did not appear to increase the severity of the pain. No bIeeding or discharge from the anus was reported. Pain increased progressively in severity up to the point at which bedclothes could not be toIerated because they wouId further aggravate the pain. Pain was constant. No urinary tract symptoms appeared. In 1946, prior to the patient’s discharge from the army, diagnosis of poIyarteritis nodosa was estab-
Accepted for pubIication February 20, 1962. 267
American
Journal
of Surgery.
Volume
IOY, February
1963
Gostigian
and
buttock began at the posterior-superior part of the iliac spine, extended IateraIIy and down aIong the Iateral margin of the buttock, and bisected the greater trochanter. The buttock flap was reflected mediaIIy, and the sciatic nerve was isoIated and retracted Iaterally. The aneurysm sac was noted to be inferior to the pyriformis muscle. In the course of dissection of the aneurysm, the sac was entered inadvertentIy and contro1 of blood loss was obtained by pressure over the pyriformis muscIe. Dissection was continued, and the aneurysm was Iigated at its neck and excised. Hemostasis was satisfactory. The wound was closed in Iayers, and a Penrose drain was left in pIace. PostoperativeIy, the patient had an uneventful course. Sutures were removed on the seventh postoperative day. The patient was discharged, symptom-free, on the fifteenth postoperative day.
SchIitt
consistent. He also noted Iow back pain which was severe and radiated to both Iegs. No gastrointestina1 bleeding was reported. Physical examination showed generaIized abdomina1 tenderness upon deep paIpation and tenderness to palpation and rigidity in the Ieft flank. PeripheraI p&es were easily paIpabIe. Heart and Iungs appeared to be normal. Chest roentgenograms at time of admission faiIed to revea1 any abnormality. HemogIobin was I I .$ gm. per cent, and the hematocrit was 38 per cent. Microscopic examination of the urine reveaIed many bacteria. Urine culture grew proteus and Escherichia coIi. On the fourth day after admission, the patient suddenIy coughed-up some bright red bIood, feI1 back in bed and died. Autopsy revealed an aneurysm of the thoracic aorta, which had ruptured into the lung.
and
COMMENTS
CIinicopathoIogic correIation of po1yarteriti.s nodosa was first made in 1866 by KussmauI and Maier, aIthough Iesions simiIar in description were recorded 200 years ago. PoIyarteritis predominantIy affects the medium sized arteries, usuaIIy at the bifurcation, and may also invoIve the smaI1 arterioIes. Aneurysms invoIving the smaIIer arteries and arteriores, particuIarIy in the abdomina1 cavity, are not uncommon in patients with poIyarteritis nodosa. PeripheraI neuropathies may be caused by invoIvement of nutrient vessels to the periphera1 nerves, or by involvement of Iarger vesseIs producing pain, numbness, tingling and, Iater, paraIysis and atrophy of the invoIved muscIes
SUMMARY
A forty-six year old Negro man was admitted to the hospita1 with symptoms of severe pain and a tender mass in the Ieft buttock. Diagnosis of a gIutea1 artery aneurysm secondary to poIyarteritis was made. The aneurysm was excised. The patient recovered and was discharged after an uneventfu1 postoperative course. Seven months Iater, the patient was readmitted with severe, generalized symptoms. After four days, he died of a ruptured aneurysm of the thoracic artery. REFERENCES
[r;l* The symptoms and signs of this patient were thought to be caused by compression of the nerves, biood vessels and surrounding structures by the expanding aneurysm sac. The patient was readmitted on July 24, I 961, with a three week history of vomiting foIIowing meaIs, and “gnawing” type of pain in the epigastric area. Four days prior to admission, the pain in the abdomen became more severe
DEITCH, H. I. and ROGAN, J. Gluteal aneurysm. Lancet, I: 1516, 1937. 2. ADAMS, A. W. GIuteaI aneurysm and rupture. Lancer, I.
I:
697, 1923.
1. HAGGARD. W. D. Lination of the internal iIiac arterv for enoknous gIn;eaI aneurysm. Ann. Surg., 7g: 520, 1922. 4. MAGUIRE, D. GIuteaI aneurysm. Ann. Surg., 84: 760, 1926. 3. MCCOMBS, R. P. PoIyarteritis. Disease of tbe Month, 63, 1960.
268