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Pachymeningitis and Aortitis in a Patient With Antineutrophil Cytoplasmic Antibody–Associated Vasculitis
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Pachymeningitis and Aortitis in a Patient With Antineutrophil Cytoplasmic Antibodye Associated Vasculitis Thomas Nguyen, MD, and Frédéric Vandergheynst, MD
A
64-year-old woman presented with cervical and shoulder pain with elevated C-reactive protein. The workup revealed an antimyeloperoxidase antineutrophil cytoplasmic antibody-associated vasculitis (AAV), proven by biopsy. Aortic hypermetabolism was demonstrated on F-18 fluorodeoxyglucose positron emission tomography/ computed tomodensitometry (18FDG-PET/ CT) performed because of the initial suspicion of giant cell arteritis. The patient was treated with methotrexate and steroids. During follow-up, an 18FDG-PET/CT showed persistent aortic as well as cervical spine hypermetabolism (Figure, A). The latter was shown to be cervical pachymeningitis by magnetic resonance imaging (Figure, B), although the patient did not experience any neurological symptoms (Supplemental Figures 1, 2, and 3, available online at http://www.mayoclinicproceedings.org). The finding of hypermetabolism in a large vessel such as the aorta is quite unexpected in the setting of AAV, which mainly involves small vessels, but this finding has been described.1 In contrast, cervical pachymeningitis in the setting of AAV has, to the best of our knowledge, never been found by 18FDG-PET/CT, notably in 2 recently published case series on the clinical value of 18FDG-PET/CT in AAV.1,2 This exceptional case brings additional data to the concept that 18FDG-PET/CT may identify more organ involvement than usual organ screening identifies. ACKNOWLEDGEMENT The authors thank Didier Blocklet, MD, for providing the 18FDG-PET/CT fusion images.
SUPPLEMENTAL ONLINE MATERIAL Supplemental material can be found online at http://www.mayoclinicproceedings.org. 1. Soussan M, Abisror N, Abad S, et al. FDG-PET/CT in patients with ANCA-associated vasculitis: case-series and literature review. Autoimmun Rev. 2014 Feb;13(2):125-131. 2. Ito K, Minamimoto R, Yamashita H, et al. Evaluation of Wegener’s granulomatosis using 18F-fluorodeoxyglucose positron emission tomography/computed tomography. Ann Nucl Med. 2013 Apr;27(3):209-216.
From the Department of Internal Medicine, Erasme University Hospital, Brussels, Belgium.
FIGURE. A, 18FDG-PET/CT fusion image with aortic and cervical hypermetabolism. B, Sagittal view of cervical magnetic resonance image with pachymeningitis (arrow).
Mayo Clin Proc. n November 2014;89(11):e115 n http://dx.doi.org/10.1016/j.mayocp.2014.03.021 www.mayoclinicproceedings.org n ª 2014 Mayo Foundation for Medical Education and Research
e115
Pachymeningitis and Aortitis in a Patient With Antineutrophil Cytoplasmic Antibodye Associated Vasculitis Thomas Nguyen, MD, and Frédéric Vandergheynst, MD
A
64-year-old woman presented with cervical and shoulder pain with elevated C-reactive protein. The workup revealed an antimyeloperoxidase antineutrophil cytoplasmic antibody-associated vasculitis (AAV), proven by biopsy. Aortic hypermetabolism was demonstrated on F-18 fluorodeoxyglucose positron emission tomography/ computed tomodensitometry (18FDG-PET/ CT) performed because of the initial suspicion of giant cell arteritis. The patient was treated with methotrexate and steroids. During follow-up, an 18FDG-PET/CT showed persistent aortic as well as cervical spine hypermetabolism (Figure, A). The latter was shown to be cervical pachymeningitis by magnetic resonance imaging (Figure, B), although the patient did not experience any neurological symptoms (Supplemental Figures 1, 2, and 3, available online at http://www.mayoclinicproceedings.org). The finding of hypermetabolism in a large vessel such as the aorta is quite unexpected in the setting of AAV, which mainly involves small vessels, but this finding has been described.1 In contrast, cervical pachymeningitis in the setting of AAV has, to the best of our knowledge, never been found by 18FDG-PET/CT, notably in 2 recently published case series on the clinical value of 18FDG-PET/CT in AAV.1,2 This exceptional case brings additional data to the concept that 18FDG-PET/CT may identify more organ involvement than usual organ screening identifies. ACKNOWLEDGEMENT The authors thank Didier Blocklet, MD, for providing the 18FDG-PET/CT fusion images.
SUPPLEMENTAL ONLINE MATERIAL Supplemental material can be found online at http://www.mayoclinicproceedings.org. 1. Soussan M, Abisror N, Abad S, et al. FDG-PET/CT in patients with ANCA-associated vasculitis: case-series and literature review. Autoimmun Rev. 2014 Feb;13(2):125-131. 2. Ito K, Minamimoto R, Yamashita H, et al. Evaluation of Wegener’s granulomatosis using 18F-fluorodeoxyglucose positron emission tomography/computed tomography. Ann Nucl Med. 2013 Apr;27(3):209-216.
From the Department of Internal Medicine, Erasme University Hospital, Brussels, Belgium.
FIGURE. A, 18FDG-PET/CT fusion image with aortic and cervical hypermetabolism. B, Sagittal view of cervical magnetic resonance image with pachymeningitis (arrow).
Mayo Clin Proc. n November 2014;89(11):e115 n http://dx.doi.org/10.1016/j.mayocp.2014.03.021 www.mayoclinicproceedings.org n ª 2014 Mayo Foundation for Medical Education and Research
e115