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Tuberculous Aneurysm of the Aorta Presenting with Uncontrolled Hypertension
Tuberculous Aneurysm of the Aorta Presenting with Uncontrolled Hypertension Bradley T. Strnad, MD, J. Kevin McGraw, MD, Eric V. Heatwole, MD, and Paul Clark, MD Mycotic aneurysm secondary to tuberculous infection of the aorta is a rare entity with less than 50 cases having been described in the literature. Clinical presentation is usually a consequence of the aneurysm, including pain, palpable mass, or hypovolemia secondary to leak. Definitive treatment is surgical, with nearly 30 documented successful cases. The authors present a case of tuberculous aortitis with mycotic aneurysms that presented with uncontrolled hypertension and occlusion of the right renal artery that underwent successful surgical repair. Index terms:
Aneurysm, aortic
•
Aortitis
•
Aneurysm, mycotic
•
Hypertension, renal
J Vasc Interv Radiol 2001; 12:521–523
MYCOTIC aneurysm secondary to tuberculous infection of the aorta is a rare entity (1). Clinical presentation is usually a consequence of the aneurysm, including pain, palpable mass, or hypovolemia secondary to leak (2). We present a case of tuberculous aortitis that presented with hypertension and occlusion of the right renal artery.
CASE REPORT The patient is a 25-year-old man from Liberia with a history of poorly controlled hypertension and cardiomyopathy who came to the United States for medical treatment. He complained of fatigue, weight loss, night sweats, and recurrent cervical adenopathy over a 2-year period of time. He was becoming increasingly dyspneic with exertion and was unable to climb more than one flight of stairs. On initial physical examination, he was found to be moderately hypertensive despite multiple medications. He had prominent non-tender adenopa-
From the Center for Vascular and Interventional Radiology (B.T.S., J.K.M., E.V.H.) and Department of Vascular Surgery (P.C.), St. Vincent Mercy Medical Center, Department of Radiology, 2213 Cherry Street, Toledo, Ohio 43608. Received August 4, 2000; revision requested September 28; revision received November 13; accepted November 15. Address correspondence to J.K.M.; E-mail: jkmcgraw@ hotmail.com © SCVIR, 2001
thy of the right axilla and neck. His admission chest radiograph demonstrated cardiomegaly with pulmonary edema. His cardiac enzymes were negative for an acute myocardial infarction. A cardiac echo showed dilated cardiomyopathy with severe biventricular dysfunction with a left ventricular ejection fraction of 15%– 20%. An excisional biopsy of his palpable cervical node was performed after his purified protein derivative became highly reactive. The biopsy results demonstrated florid necrotizing granulomas with positive culture for acid-fast bacilli (Fig 1). He was treated for tuberculous lymphadenitis with a four-medication regimen. His cardiac status failed to improve despite intravenous medicine, and further evaluation with cardiac catheterization showed minimal disease of the coronary vessels. However, a cursory evaluation of the renal arteries demonstrated occlusion of the right renal artery. Interventional radiology was consulted to evaluate the renal arteries for possible treatment. The patient returned a week and a half later for renal arteriography. His creatinine level at this time was 1.4 mg/dL. The angiogram demonstrated multiple saccular aneurysms of the thoracic and abdominal aorta, with occlusion of the right renal artery origin with reconstitution distally. There was also a smooth 2-cm narrowing of the left renal artery (Fig 2). The following
Figure 1. Histologic examination of a cross-section from a cervical lymph node demonstrates a necrotizing granuloma (arrow) (Hematoxylin & eosin staining, magnification ⫻250).
day, under cardiopulmonary bypass, the patient underwent thoracoabdominal aneurysm resection with placement of a Hemashield graft (Meadox Medical; Princeton, NJ) and reimplantation of the celiac and superior mesenteric arteries. An aorta-toleft-renal-artery bypass was performed with use of the left greater saphenous vein. Multiple specimens were sent for pathologic analysis, including the aneurysmal aorta and multiple iliac lymph nodes. All nodes showed hyperplasia. The abdominal aorta contents were organized fibrin thrombus without inflammation. The aneurysmal aortic walls demonstrated intimal
521
522
•
Tuberculous Aneurysm of the Aorta
April 2001
JVIR
Figure 2. Arch (a) and upper (b) abdominal aortograms demonstrate multiple irregular saccular pseudoaneurysms (arrows). (c) Abdominal aortogram demonstrates occlusion of the right renal artery (curved arrow), smooth narrowing of the left renal artery (arrowhead), and irregular pseudoaneurysms (arrows).
hyperplasia, transmural fibrosis, and chronic inflammation. The specimens were all negative for granulomas and acid-fast bacilli. Worsening renal function with creatinine levels reaching 8.0 mg/dL complicated the postoperative course. The patient eventually required hemodialysis with placement of a right forearm arteriovenous fistula. Nearly a year after his initial aneurysm repair, follow-up aortography demonstrated the graft to be intact with complete occlusion of the left renal bypass.
DISCUSSION Tuberculous infection of the aorta (tuberculous aortitis) is a rare entity that was first described by Weigert in 1882 (3). Seventeen years later, Kamen (4) described mycotic aneurysms of the aorta secondary to tuberculosis. More than 100 cases of tuberculous aortitis have been described in the literature in the interim, with nearly half involving aneurysms (2). Herndon (5) described the first attempt at surgical repair in 1952. Unfortunately, the patient died within a week of the surgery. Rob (6) performed the first
successful surgical repair in 1955. Since that time, almost 30 reports of successful surgical treatment have been described (7). Our patient was alive and doing well 18 months after his surgical repair. Three mechanisms have been proposed and generally accepted for the pathogenesis of tuberculous aortitis (8). The first and most common is by direct extension from a nearby focus of an infected lymph node or abscess. The other two and less common causes are direct implantation on the inner vessel wall and hematogenous spread to the adventitia by the vasa vasorum. The latter is believed to have been the mechanism in our case. Before the antibiotic era, the majority of tuberculous aneurysms of the aorta were diagnosed postmortem (1). With increasing clinical awareness, successful antibiotic therapy, and improved imaging, the number of antemortem diagnoses is sure to increase. Common clinical presentations include persistent pain in the chest, abdomen, or back; palpable or radiographically visible paraaortic mass; and shock from hypovolemia or major bleeding (2). Our patient was unique
in that his mycotic aneurysms were discovered incidentally while investigating his uncontrolled hypertension and cardiomyopathy. Tuberculous aneurysms of the aorta continue to be a rare entity. However, with the resurgence of tuberculosis from the increase in immunocompromised patients as a result of illness and medical therapy, more cases are sure to be encountered in the future. With the advent of antibiotics and improved surgical techniques, an acceptable outcome can be expected if the diagnosis is made in a timely fashion (ie, before rupture or additional complication). Perhaps the field of interventional radiology can some day play a role in the management of this rare but deadly manifestation. References 1. Silbergleit A, Arbulu A, Defever BA, Nedwicki EG. Tuberculous aortitis. JAMA 1965; 193:83– 85. 2. Long R, Guzman R, Greenberg H, Safneck J, Hershfield E. Tuberculous mycotic aneurysm of the aorta: review of published medical and surgical experience. Chest 1999; 115:522–531. 3. Weigert C. Ueber venetuberkel und thre beziehung zur tuberculosen
Volume 12
Number 4
blutinfection. Virchows Arch Pathol Anat 1882; 88:307–379. 4. Kamen L. Aortenruptur auf tuberculoser grundlage. Beitr Pathol Anat 1895; 17:416 – 419. 5. Herndon JH, Galt J, Austin DJ. Ruptured tuberculous false aneurysm of the
Strnad et al
abdominal aorta. Tex State J Med 1952; 48:336 –338. 6. Rob CG, Eastcott HHG. Aortic aneurysm due to tuberculous lymphadenitis. Br J Med 1955; 1:378 –379. 7. Allins AD, Wagner WH, Cossman DV, Gold RN, Hiatt JR. Tuberculous infec-
•
523
tion of the descending thoracic and abdominal aorta: case report and literature review. Ann Vasc Surg 1999; 13:439 – 444. 8. Volini FI, Olfield RC, Thompson JR, Kent G. Tuberculosis of the aorta. JAMA 1962; 181:78 – 83.
Aneurysm, aortic
•
Aortitis
•
Aneurysm, mycotic
•
Hypertension, renal
J Vasc Interv Radiol 2001; 12:521–523
MYCOTIC aneurysm secondary to tuberculous infection of the aorta is a rare entity (1). Clinical presentation is usually a consequence of the aneurysm, including pain, palpable mass, or hypovolemia secondary to leak (2). We present a case of tuberculous aortitis that presented with hypertension and occlusion of the right renal artery.
CASE REPORT The patient is a 25-year-old man from Liberia with a history of poorly controlled hypertension and cardiomyopathy who came to the United States for medical treatment. He complained of fatigue, weight loss, night sweats, and recurrent cervical adenopathy over a 2-year period of time. He was becoming increasingly dyspneic with exertion and was unable to climb more than one flight of stairs. On initial physical examination, he was found to be moderately hypertensive despite multiple medications. He had prominent non-tender adenopa-
From the Center for Vascular and Interventional Radiology (B.T.S., J.K.M., E.V.H.) and Department of Vascular Surgery (P.C.), St. Vincent Mercy Medical Center, Department of Radiology, 2213 Cherry Street, Toledo, Ohio 43608. Received August 4, 2000; revision requested September 28; revision received November 13; accepted November 15. Address correspondence to J.K.M.; E-mail: jkmcgraw@ hotmail.com © SCVIR, 2001
thy of the right axilla and neck. His admission chest radiograph demonstrated cardiomegaly with pulmonary edema. His cardiac enzymes were negative for an acute myocardial infarction. A cardiac echo showed dilated cardiomyopathy with severe biventricular dysfunction with a left ventricular ejection fraction of 15%– 20%. An excisional biopsy of his palpable cervical node was performed after his purified protein derivative became highly reactive. The biopsy results demonstrated florid necrotizing granulomas with positive culture for acid-fast bacilli (Fig 1). He was treated for tuberculous lymphadenitis with a four-medication regimen. His cardiac status failed to improve despite intravenous medicine, and further evaluation with cardiac catheterization showed minimal disease of the coronary vessels. However, a cursory evaluation of the renal arteries demonstrated occlusion of the right renal artery. Interventional radiology was consulted to evaluate the renal arteries for possible treatment. The patient returned a week and a half later for renal arteriography. His creatinine level at this time was 1.4 mg/dL. The angiogram demonstrated multiple saccular aneurysms of the thoracic and abdominal aorta, with occlusion of the right renal artery origin with reconstitution distally. There was also a smooth 2-cm narrowing of the left renal artery (Fig 2). The following
Figure 1. Histologic examination of a cross-section from a cervical lymph node demonstrates a necrotizing granuloma (arrow) (Hematoxylin & eosin staining, magnification ⫻250).
day, under cardiopulmonary bypass, the patient underwent thoracoabdominal aneurysm resection with placement of a Hemashield graft (Meadox Medical; Princeton, NJ) and reimplantation of the celiac and superior mesenteric arteries. An aorta-toleft-renal-artery bypass was performed with use of the left greater saphenous vein. Multiple specimens were sent for pathologic analysis, including the aneurysmal aorta and multiple iliac lymph nodes. All nodes showed hyperplasia. The abdominal aorta contents were organized fibrin thrombus without inflammation. The aneurysmal aortic walls demonstrated intimal
521
522
•
Tuberculous Aneurysm of the Aorta
April 2001
JVIR
Figure 2. Arch (a) and upper (b) abdominal aortograms demonstrate multiple irregular saccular pseudoaneurysms (arrows). (c) Abdominal aortogram demonstrates occlusion of the right renal artery (curved arrow), smooth narrowing of the left renal artery (arrowhead), and irregular pseudoaneurysms (arrows).
hyperplasia, transmural fibrosis, and chronic inflammation. The specimens were all negative for granulomas and acid-fast bacilli. Worsening renal function with creatinine levels reaching 8.0 mg/dL complicated the postoperative course. The patient eventually required hemodialysis with placement of a right forearm arteriovenous fistula. Nearly a year after his initial aneurysm repair, follow-up aortography demonstrated the graft to be intact with complete occlusion of the left renal bypass.
DISCUSSION Tuberculous infection of the aorta (tuberculous aortitis) is a rare entity that was first described by Weigert in 1882 (3). Seventeen years later, Kamen (4) described mycotic aneurysms of the aorta secondary to tuberculosis. More than 100 cases of tuberculous aortitis have been described in the literature in the interim, with nearly half involving aneurysms (2). Herndon (5) described the first attempt at surgical repair in 1952. Unfortunately, the patient died within a week of the surgery. Rob (6) performed the first
successful surgical repair in 1955. Since that time, almost 30 reports of successful surgical treatment have been described (7). Our patient was alive and doing well 18 months after his surgical repair. Three mechanisms have been proposed and generally accepted for the pathogenesis of tuberculous aortitis (8). The first and most common is by direct extension from a nearby focus of an infected lymph node or abscess. The other two and less common causes are direct implantation on the inner vessel wall and hematogenous spread to the adventitia by the vasa vasorum. The latter is believed to have been the mechanism in our case. Before the antibiotic era, the majority of tuberculous aneurysms of the aorta were diagnosed postmortem (1). With increasing clinical awareness, successful antibiotic therapy, and improved imaging, the number of antemortem diagnoses is sure to increase. Common clinical presentations include persistent pain in the chest, abdomen, or back; palpable or radiographically visible paraaortic mass; and shock from hypovolemia or major bleeding (2). Our patient was unique
in that his mycotic aneurysms were discovered incidentally while investigating his uncontrolled hypertension and cardiomyopathy. Tuberculous aneurysms of the aorta continue to be a rare entity. However, with the resurgence of tuberculosis from the increase in immunocompromised patients as a result of illness and medical therapy, more cases are sure to be encountered in the future. With the advent of antibiotics and improved surgical techniques, an acceptable outcome can be expected if the diagnosis is made in a timely fashion (ie, before rupture or additional complication). Perhaps the field of interventional radiology can some day play a role in the management of this rare but deadly manifestation. References 1. Silbergleit A, Arbulu A, Defever BA, Nedwicki EG. Tuberculous aortitis. JAMA 1965; 193:83– 85. 2. Long R, Guzman R, Greenberg H, Safneck J, Hershfield E. Tuberculous mycotic aneurysm of the aorta: review of published medical and surgical experience. Chest 1999; 115:522–531. 3. Weigert C. Ueber venetuberkel und thre beziehung zur tuberculosen
Volume 12
Number 4
blutinfection. Virchows Arch Pathol Anat 1882; 88:307–379. 4. Kamen L. Aortenruptur auf tuberculoser grundlage. Beitr Pathol Anat 1895; 17:416 – 419. 5. Herndon JH, Galt J, Austin DJ. Ruptured tuberculous false aneurysm of the
Strnad et al
abdominal aorta. Tex State J Med 1952; 48:336 –338. 6. Rob CG, Eastcott HHG. Aortic aneurysm due to tuberculous lymphadenitis. Br J Med 1955; 1:378 –379. 7. Allins AD, Wagner WH, Cossman DV, Gold RN, Hiatt JR. Tuberculous infec-
•
523
tion of the descending thoracic and abdominal aorta: case report and literature review. Ann Vasc Surg 1999; 13:439 – 444. 8. Volini FI, Olfield RC, Thompson JR, Kent G. Tuberculosis of the aorta. JAMA 1962; 181:78 – 83.