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Survival After Aortic Dissection in Giant Cell Arteritis

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Survival After Aortic Dissection in Giant Cell Arteritis 332 Letters to the editor pressure or hypotensive episodes were technique and rating scale for abnormalities of the thorax, without intravenous contrast seen in scleroderma and related disorders. recorded during the trial. Among the side Arthritis Rheum 1981; 24: 1159-65. medium (because of asthma), showed a effects, mild flushing (35%) and headache 9 Ferri C, La Civita L, Zignego A et al. Plasma normal mediastinum but a small rim of L, Ann Rheum Dis: first published as 10.1136/ard.55.5.332 on 1 May 1996. Downloaded from (24%) were the most frequent in isradipine levels of endothelin-I in mixed cryoglobulin- pleural fluid on the left. aemia patients. Br J Rheumatol 1994; 33: recipients. 689-90. At follow up, the patient complained of This study has demonstrated the favour- 10 Yanagisawa M, Kurihara H, Kimura S, et al. A right thigh claudication. Radiofemoral delay able effects of isradipine on patients with novel potent vasoconstrictor peptide pro- was noted. CT of the abdomen showed Raynaud's phenomenon; moreover, it is the duced by vascular endothelial cells. Nature internal displacement ofcalcified atheroma in 1988; 332: 411-5. first to demonstrate a significant reduction 11 Levin E R. Endothelins [review]. N Engl J Med the aorta, suggesting aortic dissection. Mag- in plasma concentrations of ET-1 during 1995; 333: 356-63. netic resonance imaging (MRI) confirmed calcium antagonist treatment. The most this as distal to the origin of the left sub- usual manifestations of Raynaud's phenom- clavian artery, extending to the aortic bifur- enon are pain and numbness in the fingers, cation. Eight weeks after discharge, he devel- which in some subjects can be complicated Survival after aortic oped headaches, aching thighs and jaw by skin ulcers5 requiring prompt inter- claudication with temporal artery tenderness. vention.3 4 In the present study, isradipine dissection in giant cell Prednisolone 30 mg daily was begun with was able to reduce the frequency, severity, arteritis rapid improvement. Clinical improvement and disabling nature of acute attacks of correlated with his ESR decreasing to normal Raynaud's phenomenon; this result agrees Acute aortic dissection in giant cell arteritis and with gradual resolution of the radio- with previous experience of the use of is rare and usually fatal. It is associated with femoral delay. calcium antagonists in patients with hypertension and is commoner in females. Raynaud's phenomenon,' 3 4 and reflects an We describe two patients who were diagnosed PATIENT 2 appropriate selection of patients to receive in life and who survived on medical treatment A 68 year old white women presented with the treatment. In addition, the clinicosero- alone for a prolonged period: one for two five days of worsening anterior pleuritic chest logical manifestations and changes in capil- years; the other still alive at three years. A pain radiating to the left, sweats, nausea, and laroscopic findings in this series of patients, third patient who required aortic grafting has an increased temperature. She had a history including those with type I and type II survived 14 years. A literature review of osteoarthrosis, euthyroid Graves' ophthal- Raynaud's phenomenon, were relatively revealed 43 other cases, with only three mopathy, Raynaud's phenomenon, and long- homogeneous. survivors on medical care alone. standing hypertension. Temporal arteritis The clinical improvement of our patients had been diagnosed on biopsy eight years with Raynaud's phenomenon in response to Case reports previously, following a characteristic illness isradipine was reflected in a reduction in PATIENT 1 accompanied by an ESR of 121 mm/lst h. plasma concentrations ofET-1. Although the A 68 year old white male presented with Prednisolone for three years had achieved pathophysiological ftmction of ET-1 remains acute chest pain on exertion radiating to the remission. unknown,"3 a number of vascular disorders back, accompanied by dyspnoea and On admission, the patient was pyrexial at are characterised by increased concentrations sweating. He had noted weight loss of more 37 70C. The heart rate was 110 beat/min with of this vasoactive peptide." How isradipine than 7 kg over the previous months. A history no radiofemoral delay, and the blood pressure may influence the titres ofET-1 is difficult to of back and neck ache was ascribed to was 140/90 mm Hg, equal in both arms. There explain but, because ET-l is released in spondylosis, and shoulder pain to a rotator was dullness to percussion at both lung bases response to ischaemic stimuli," we hypothe- cuff lesion. His pulse was 60 beats/min and bronchial breathing at the left base. ESR sise that isradipine is able to induce a change regular, and his blood pressure was 150/70 was 86 mmnlst h, and the leucocyte count I1-4 in ET-l concentrations indirectly, by improv- mm Hg. An ejection murmur was noted at with a neutrophilia. ECG showed left ventri- ing tissue perfusion. The findings of this the left sternal edge. Examination was other- cular hypertrophy. Chest radiograph showed preliminary investigation merit further in- wise unremarkable. bilateral small pleural effusions and a markedly http://ard.bmj.com/ vestigation in larger series of patients with The patient developed intermittent pyrexia widened mediastinum. CT of the thorax and Raynaud's phenomenon. over the next three weeks, and experienced abdomen revealed a dilated thoracic aorta with frequent left sided stabbing chest pain. The a dissection in the descending portion. Trans- LUCA LA CIVITA leucocyte count increased from normal to DIIJA GIUGGIOLI oesophageal echocardiography (TOE) initially MARIA GRAZIA DEL CHICCA 14-5 with a neutrophilia. Erythrocyte sedi- suggested dissection commencing at the aortic GIOVANNI LONGOMBARDO mentation rate (ESR) peaked at 94 mm/lst root; however, repeat CT, arch aortography GIAMPIERO PASERO h and C reactive protein (CRP) at 260 mg/l. and MRI confirmed type B dissection. The CLODOVEO FERRI on September 25, 2021 by guest. Protected copyright. Istituto Patologia Medica and Blood and urine cultures were negative, and patient was treated with a [3 blocker to main- Fisiologia Clinica (CNR), autoantibody screen was normal. The tain normal blood pressure, and prednisolone University ofPisa, Pisa, Italy electrocardiogram (ECG) showed left ven- at a dose of 20 mg. The pain resolved and she tricular hypertrophy, confirmed by trans- was discharged, remaining well and normo- Correspondence to: Dr Luca La Civita, Istituto di Patologia Medica I, University of Pisa, via Roma thoracic echocardiogram, which showed no tensive for two years. Mediastinal widening 67, 56126 Pisa, Italy. other abnormality. Chest radiograph showed then began to accelerate, MRI imaging con- minor atelectasis at both lung bases. Indium finning a grossly dilated dissecting descending 1 Cleophas T J M, Niemeyer M G. Raynaud's labelled leucocyte scan showed some media- aorta and dilatation of the ascending aorta syndrome, an enigma after 130 years. stinal uptake. Computed tomography (CT) (figure). She died soon afterwards. Angiology 1993; 43: 196-209. 2 Biondi M L, Marasini B, Bassani C, Ago- stoni A. Increased plasma endothelin levels in patients with Raynaud's phenomenon. NEngl JMed 1991; 324: 1139-40. 3 Wollersheim H, van Zwieten P A. Treatment of Raynaud's phenomenon. Eur Heart J 1993; 14:147-9. 4 La Civita L, Pitaro N, Rossi M, et al. Amlodipine in the treatment of Raynaud's phenomenon: a double-blind placebo- controlled crossover study. Clin Drug Invest 1996; 11 (suppl): 126-31. 5 Kallenberg C G M, Pastoor G W, Wouda A, The T. Antinuclear antibodies in patients with Raynaud's phenomenon: clinical signifi- cance of anticentromere antibodies. Ann Rheum Dis 1982; 41: 382-7. 6 Allen E V, Brown G E. Raynaud's disease: a critical review of a minimal requisite for diagnosis. Am J Med Sci 1932; 183: 187-200. 7 Ferri C, Bernini L, Cecchetti R, et al. Cutaneous and serological subset of systemic sclerosis. Their relevance in diagnosis, severity and prognosis of the disease. J Tl weighted axial MR images. Left: Normalflow void in the dilated ascending aorta and a complex Rheumatol 1991; 18: 1826-32. signalpattern in the descending aorta at the origin ofthe dissection. Right: At the level ofthe dilated 8 Maricq H R Widefield capillary microscopy: aortic root, showing the two lumina in the descending thoracic aorta. Letters to the editor 333 Summary ofcases ofaortic dissection associated with giant ceUl arteritis reported in the literature Correspondence to: Dr A M L Lever. Source Number Age Sex Hypertension Comments 1 Klein R G, Hunder G G, Stanson A W, ofcases (yr) Sheps S G. Large artery involvement in giant cell (temporal) arteritis. Ann Intern Med 1975; Ann Rheum Dis: first published as 10.1136/ard.55.5.332 on 1 May 1996. Downloaded from Broch 19472 1 68 F + First recorded case (case report) 83: 806-12. Klein 1975' 3 66 F NK Series of 248 cases of GCA. All 3 sudden deaths; 2 Broch A J, Ytrehus 0. Tre nye tilfelle av arteritis 73 F NK diagnosed at postmortem examination temporalis. Nord Med 1947; 34: 1111. 70 F NK 3 Nakashima Y, Kurozumi T, Sueshi K, Larson 19844 2 NK F + Postmortem series of 161 acute dissections; 'healed Tanaka K. Dissecting aneurysm: a NK F + aortitis' found in both clinicopathological and histopathologic study Leonard 1979' 2 62 F NK Postmortem series of 171 acute dissections of 111 autopsied cases. Hum Pathol 1990; 21: 74 F + 291-6. BMJ 19606 1 70 M + Known GCA. Sudden death (case report) 4 Larson E W, Edwards W D. Risk factors for Save-Soderbergh 2 85 F + Postmortem series of 9 sudden deaths in GCA aortic dissection: a necropsy study of 161 19867 79 F + cases. AmJ Cardiol 1984; 53: 849-55. Nordt 1991'4 1 70 F - Acute myocardial infarction caused by dissection; 5 Leonard J C, Hasleton P S.
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