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    Home > Active Ingredient News > Immunology News > The 71-year-old man with acute back pain, the story behind the "back" is not simple... The wind list is finalized

    The 71-year-old man with acute back pain, the story behind the "back" is not simple... The wind list is finalized

    • Last Update: 2021-10-22
    • Source: Internet
    • Author: User
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    *Only for medical professionals to read for reference.
    That's right, it's also related to rheumatism! Summary of the situation: An elderly man with a history of "abdominal aortic aneurysm" was admitted to the hospital with acute back pain.
    After admission, the examination found "aortic dissection", and his pathological diagnosis was confirmed after the operation
    .

    Not much to say, let’s take a look at the case together~ Case introduction The patient is a 71-year-old male who presented to the doctor with "acute back pain for 5 days" this time
    .

    The patient informed the doctor that the back pain suddenly started 5 days ago and there were no other accompanying symptoms
    .

    Although it seems to be a relatively common symptom, when the patient talked about the past, the attending physician became worried.
    .
    .
    The patient continued: "About 1 year ago, an abdominal aortic aneurysm was accidentally found during an ultrasound examination during the physical examination
    .

    "One year before admission, CT examination revealed that the diameters of the aortic arch and abdominal aorta were enlarged to approximately 3.
    7 cm and 4.
    4 cm, respectively (Figure 1)
    .

    Figure 1.
    CT showed 1 year before admission (a) the aortic arch was dilated, with a diameter of about 3.
    7 cm; (b) the abdominal aorta was dilated with a diameter of about 4.
    4 cm.
    At the time, the patient underwent aortic endovascular repair (EVAR), after EVAR The abdominal aorta was intact and was followed up in the outpatient clinic
    .

    The patient also informed that he had a history of "hypertension" and "lumbar spinal stenosis", and a brother died of "ruptured abdominal aortic aneurysm"
    .

    On admission, physical examination revealed that the patient had low fever and elevated blood pressure
    .

    The electrocardiogram revealed complete right bundle branch block, and laboratory tests revealed a decrease in platelet count, an increase in C-reactive protein, and hyperactivity of the fibrinolytic system
    .

    Upon admission, the patient's complete CT showed that from the ascending aorta to the descending aorta, thickening and dissection of the aortic wall were visible (Figure 2)
    .

    Figure 2.
    Enhanced CT scan on admission (a and b): Thickening and dissection of the aortic wall can be seen from the ascending aorta to the descending aorta (as indicated by the arrow).
    Therefore, the patient was diagnosed with aortic dissection (Stanford A type)
    .

    The patient underwent ascending aorta replacement
    .

    Sure enough, this is not a simple "back pain".
    Although the aortic dissection has been clear, is there any special reason behind the patient's aneurysm and dissection? Continue to look down: Observe roughly the ascending aorta resected, about 90mm in diameter, with dissection and mild atherosclerotic changes
    .

    Histology suggests that giant cell granulomas can be seen around the dissection, accompanied by lymphocyte infiltration (Figure 3)
    .

    Figure 3.
    Histopathological findings of aortic dissection.
    EVG staining indicates that the granuloma is located under the intima and the inner elastic layer is partially destroyed
    .

    Inflammatory cells, breakage of elastic fibers, and granuloma formation were also observed near the outer membrane, including multinucleated giant cells
    .

    Intimal thickening and organizing thrombosis can be seen in the false cavity
    .

    Immunohistochemistry showed that CD68-positive cells were seen near the inner membrane
    .

    The result of Alcian blue staining on the elastic fiber tear was negative
    .

    There were no manifestations of Takayasu arteritis (TKA) such as blood supply vessel stenosis or adventitia fibrosis
    .

    The patient has aortic dissection accompanied by the formation of giant cell granuloma of the ascending aorta.
    It is speculated that giant cell arteritis (GCA) is more likely.
    Taking into account the patient’s age, clinical manifestations, laboratory tests and imaging examinations, etc.
    , there is no It was found that other organ diseases, sarcoidosis and other types of vasculitis did not meet the criteria for diseases
    .

    The patient underwent ascending aorta replacement without obvious manifestations of active vasculitis and did not receive glucocorticoid therapy for about 4 years
    .

    Case Summary A 71-year-old male patient developed acute back pain and was diagnosed with an aortic dissection (Stanford type A) and underwent ascending aorta replacement
    .

    The resected ascending aorta has aortic dissection and multinucleated giant cell granuloma.
    The granuloma is located near the intima and the inner elastic layer is partially destroyed.
    It is speculated that the possibility of diagnosis of GCA is high, and the postoperative condition is relatively stable
    .

    This case is derived from a case report published in Cardiovascular Pathology in 2020
    .

    Combining this case, let's learn about GCA together~GCA is one of the most common large and medium vasculitis.
    Vasculitis mainly affects the arterial branches at the beginning of the aortic arch, as well as the distal arteries of the aorta and the small and medium arteries
    .

    The typical patient presents with temporal headache, tenderness of the scalp and temporal arteries, and intermittent mandibular dyskinesia
    .

    GCA is also called temporal arteritis, and it is called cranial arteritis because it involves intracranial arteries
    .

    GCA is a necrotizing arteritis of unknown cause, mainly invading the aorta and centering on elastin in the inner layer of the blood vessel, accompanied by granuloma formation, infiltration of lymphocytes, macrophages, and multinucleated giant cells, generally without fibrinous Necrosis
    .

    Due to intimal hyperplasia, the vessel wall is thickened, the lumen is narrowed and blocked, causing tissue ischemia
    .

    The incidence of thoracic aortic aneurysm in patients with GCA is 17 times higher, and it often occurs in the later stages of GCA
    .

    GCA showed a non-necrotizing granulomatous vasculitis: (1) Diffuse lymphatic mononuclear cells infiltrated the entire thickness of the artery
    .

    Fibrinoid necrosis is rare, but intimal hyperplasia is common, and intimal hyperplasia often leads to lumen occlusion
    .

    (2) Local granuloma formation
    .

    Usually, activated T cells, macrophages and multinucleated giant cells are found in granulomas
    .

    Multinucleated giant cells are often located near the inner elastic membrane and distributed along the damaged elastic membrane; however, the absence of multinucleated giant cells cannot rule out the diagnosis
    .

    Aortic disease, such as aortic aneurysm, is considered a late complication, usually several years after the onset of GCA
    .

    A case of aortic dissection caused by untreated GCA was recently reported abroad
    .

    Patients with aortic disease caused by GCA have high mortality and poor prognosis
    .

    A retrospective cohort study of 168 patients with GCA found that 27% of patients with GCA had large vessel involvement, while only 5% of patients with large vessel involvement had aortic dissection
    .

    However, in about 15% of GCA patients, since the patient has no symptoms at the beginning, the aorta has already been diseased at the time of GCA diagnosis
    .

    Therefore, prevention and timely treatment of aortic dissection and aneurysm rupture have an important impact on the prognosis of GCA
    .

    This case report is considered to be a rare case of aortic dissection caused by GCA, and TKA is one of the main diseases that require differential diagnosis
    .

    TKA and GCA have many similarities, such as clinical manifestations and the involvement of autoimmune mechanisms; however, they also have some differences, such as different types of human leukocyte antigens
    .

    In addition, there may be differences between GCA and TKA in age, granulomatous inflammation distribution, and pathological manifestations of the outer membrane
    .

    Generally speaking, TKA is more common among young women in Asia
    .

    GCA and TKA are sometimes regarded as the same disease, except for age distribution, there is no significant difference in pathological characteristics
    .

    Further research on the pathological specimens of the excised aorta is helpful for differential diagnosis, assessment of the condition and prognosis
    .

    Aortic disease usually occurs several years after the onset of GCA and is considered a late complication
    .

    The patient in this case was admitted to the hospital due to aortic dissection, and GCA was considered for the final diagnosis, which is rare in clinical practice
    .

    Clinicians still need to deeply understand the pathological mechanism of GCA, fully understand the characteristics of GCA disease, and reduce the rate of misdiagnosis and missed diagnosis
    .

    Timely treatment of aortic disease and early diagnosis are of great significance to the prognosis of the disease
    .

    Reference materials: [1]H Obikane,Fujiyoshi T,Takahashi S,et al.
    Giant cell arteritis in a patient with aortic dissection:a case report[J].
    Cardiovascular Pathology,2020,46:107206-.
    [2]Chinese Medicine Hui Rheumatology Branch.
    Guidelines for the diagnosis and treatment of polymyalgia rheumatica and giant cell arteritis[J].
    Chinese Journal of Rheumatology,2011,15(5):348-350.
    [3]Takase Y,Murakami Y, Nishi J,et al.
    A unique autopsy case of ascending aortic dissection caused by giant cell arteritis without drug therapy[J].
    Pathology International,2019,69(10).
    Source of this article: Medical Rheumatism Channel Author: Jindi Wang Yuwei Review of this article: Chen Xinpeng Deputy Chief Physician Responsible Editor: Cartridge Copyright Statement Make any promises and guarantees for the accuracy and completeness of (if any), and assume no responsibility for the outdated content and the possible inaccuracy or incompleteness of the cited information
    .

    Relevant parties are requested to check separately when adopting or using this as a basis for decision-making
    .

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