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An unusual emphysema

  • Massimo R. Mannarino
    Correspondence
    Corresponding author at: Unit of Internal Medicine, Angiology and Arteriosclerosis Diseases, Department of Medicine, University of Perugia, Hospital “Santa Maria della Misericordia”, Piazzale Menghini, 1-06129, Perugia, Italy. Tel.: +39 075 5783172; fax: +39 075 5784022.
    Affiliations
    Unit of Internal Medicine, Angiology and Arteriosclerosis Diseases, Department of Medicine, University of Perugia, Perugia, Italy
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  • Francesco Di Filippo
    Affiliations
    Unit of Internal Medicine, Angiology and Arteriosclerosis Diseases, Department of Medicine, University of Perugia, Perugia, Italy
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  • Anna Maria Scarponi
    Affiliations
    Unit of Internal Medicine, Angiology and Arteriosclerosis Diseases, Department of Medicine, University of Perugia, Perugia, Italy
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      1. Introduction

      An 87 year-old woman with a history of hypertension, type 2 diabetes and post-menopausal osteoporosis presented with a 5-day history of low-grade intermittent fever, epigastric pain and shortness of breath. At admission, patient was normotensive but tachycardic (HR 106 beats/min) and tachypneic (RR 26 breaths/min), and oxygen saturation was 96% while she was breathing ambient air. Respiratory examination revealed decreased breath sounds in the left base with dullness on percussion; examination of heart and abdomen was unremarkable. Initial laboratory work-up showed neutrophilic leukocytosis (WBC 22.500/mm3, neutrophils 92%) and elevated values of erythrocyte sedimentation rate (120 mm/h), C-reactive protein (18 mg/dL) and procalcitonin (0.2 ng/mL). Electrocardiogram showed sinus tachycardia and troponin I was within normal limits. Blood and stool cultures were negative.
      A chest X-ray disclosed aortic ectasia and left sided pleural effusion.
      A computed tomography scan of the chest revealed the presence of descending thoracic aortic aneurysm with focal dissection and multiple bubbles of gas infiltrating the aortic wall (Fig. 1. Panels A & B).
      Figure thumbnail gr1
      Fig. 1Panels A & B. Transverse and coronal views of contrast-enhanced chest computed tomography showing descending thoracic aortic aneurysm of 40 mm in maximal diameter with focal dissection and multiple bubbles of gas infiltrating the aortic wall (arrows). Panels C & D. Transverse and coronal views of control contrast-enhanced chest computed tomography showing disappearance of gas bubbles within the aortic wall but increase in aortic diameter from 40 to 97 mm, dissection extension and expansion of the false lumen (asterisks).
      What is the diagnosis?

      2. Diagnosis and discussion

      This clinical–radiological picture is consistent with emphysematous infectious aortitis. The patient was started on meropenem for suspected infection by gas-forming bacteria and surgery was planned. Fever disappeared on the fifth day and general condition improved. After two weeks, chest CT scan showed disappearance of aortic wall gas bubbles but dramatic increase in aortic diameter, dissection extension and expansion of the false lumen (Fig. 1. Panels C & D). The patient underwent urgent surgery with endovascular stent-graft repair but unfortunately died 48 h later for presumed aortic rupture.
      Clostridium septicum, a rare cause of infectious aortitis [
      • Seder C.W.
      • Kramer M.
      • Long G.
      • Uzieblo M.R.
      • Shanley C.J.
      • Bove P.
      Clostridium septicum aortitis: report of two cases and review of the literature.
      ], was isolated from aortic blood sample collected during surgery.
      Infectious aortitis is a rare entity and diagnosis may be challenging because presenting symptoms are often nonspecific [
      • Lopes R.J.
      • Almeida J.
      • Dias P.J.
      • Pinho P.
      • Maciel M.J.
      Infectious thoracic aortitis: a literature review.
      ]. Hypertension and diabetes, aortic trauma and congenital aortic abnormalities are known risk factors. Imaging is the cornerstone for the diagnosis and thickening of the aortic wall, periaortic edema and infiltration of peri-aortic tissue are common findings on CT.
      Most commonly bacteria, but also fungi, may infect the aortic wall via hematogenous spread, extension from nearby infection or direct inoculation [
      • Lopes R.J.
      • Almeida J.
      • Dias P.J.
      • Pinho P.
      • Maciel M.J.
      Infectious thoracic aortitis: a literature review.
      ]; unfortunately, microbiological diagnosis is often lacking because blood cultures are negative in up to 50% of cases. Notwithstanding, the presence of gas bubble in or around the aortic wall on imaging, is suggestive of infection caused by gas-forming organisms, such as Clostridium.

      Conflicts of interests

      The authors state that they have no conflicts of interest.

      Acknowledgments

      The authors thank Dr F. Verzini (Division of Vascular and Endovascular Surgery, University of Perugia, Ospedale S. Maria della Misericordia, Perugia), and Dr. M. Fisher and Dr. M. S. Franceschini (Department of Radiology, Santa Maria della Misericordia Hospital, Perugia) for their contributions to the management of the case.

      References

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        • Almeida J.
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        Infectious thoracic aortitis: a literature review.
        Clin Cardiol. Sep 2009; 32: 488-490