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Nihon Hinyokika Gakkai Zasshi. the... 2023A 78-year-old man, who underwent total cystectomy with ileal neobladder substitution for bladder cancer 5 years ago, had a fever since the beginning of May 2022. He was...
A 78-year-old man, who underwent total cystectomy with ileal neobladder substitution for bladder cancer 5 years ago, had a fever since the beginning of May 2022. He was hospitalized in an internal medicine ward of another hospital and was diagnosed with febrile urinary tract infection (UTI). Escherichia coli with sensitivity to almost all antibiotics was cultured in urine. Computed tomography (CT) showed that the distended neobladder with bilateral hydronephrosis contained gas and the severely athelosclerotic aorta. Even after using four antibiotics, the UTI could not be controlled. After 3 weeks of hospitalization, CT showed periaortic lymphatic swelling. Therefore, he was transferred to our hospital on 6 June due to uncontrollable UTI and lymphatic metastasis of bladder cancer. However, CT revealed that the neobladder remained distended and showed thickening of the periaortic soft tissue with gas. He was diagnosed with advanced infectious aortitis. Furthermore, he had poorly controlled diabetes mellitus of HbA1c 8.4%. Immediately after admission, an exchange of the urethral catheter and antibiotics, and blood sugar control strengthening were performed. On the second day, the patient was close to defervescence. However, on the third day, abrupt onset of loss of consciousness and abdominal swelling occurred. CT showed retroperitoneal hematoma caused by the rupture of the aorta. Then, bradycardia and respiratory arrest occurred, ventilator management and blood transfusion were performed, and the patient survived. However, his condition worsened, and he died 2 days later. The patient had undergone ileal neobladder substitution, but had infectious aortitis and died of an aortic rupture due to distended neobladder-induced UTI, poorly controlled diabetes mellitus and the severely athelosclerotic aorta.
Topics: Male; Humans; Aged; Aortitis; Diabetes Mellitus; Anti-Bacterial Agents; Cystectomy; Escherichia coli; Urinary Bladder Neoplasms
PubMed: 38246623
DOI: 10.5980/jpnjurol.114.26 -
IJID Regions Mar 2024An infectious aortic aneurysm is a rare disease entity. We report a challenging case of a 29-year-old male presenting with chest pain and constitutional symptoms. The...
An infectious aortic aneurysm is a rare disease entity. We report a challenging case of a 29-year-old male presenting with chest pain and constitutional symptoms. The patient was found to have three pseudoaneurysms of the aorta on imaging, significant pathological findings of necrotizing granulomatous lymphadenitis from a supraclavicular lymph node biopsy, and a highly suggestive clinical picture of tuberculous aortitis. He was referred to vascular surgery for intervention and discharged on antituberculous therapy for 6 months. To the best of our knowledge, only five cases of tuberculous aortic aneurysms have been reported from the Middle East and North Africa (MENA) region, all with favorable outcomes. A high index of suspicion, early detection, and prompt intervention are essential in managing such cases.
PubMed: 38234973
DOI: 10.1016/j.ijregi.2023.12.001 -
Trials Jan 2024Glucocorticoids (GC) are the standard treatment for giant cell arteritis (GCA), even though they are associated with adverse side effects and high relapse rates....
The Meteoritics Trial: efficacy of methotrexate after remission-induction with tocilizumab and glucocorticoids in giant cell arteritis-study protocol for a randomized, double-blind, placebo-controlled, parallel-group phase II study.
BACKGROUND
Glucocorticoids (GC) are the standard treatment for giant cell arteritis (GCA), even though they are associated with adverse side effects and high relapse rates. Tocilizumab (TCZ), an interleukin-6 receptor antagonist, has shown promise in sustaining remission and reducing the cumulative GC dosage, but it increases the risk of infections and is expensive. After discontinuation of TCZ, only about half of patients remain in remission. Additionally, only few studies have been conducted looking at remission maintenance, highlighting the need for alternative strategies to maintain remission in GCA. Methotrexate (MTX) has been shown to significantly decrease the risk of relapse in new-onset GCA and is already a proven safe drug in many rheumatologic diseases.
METHODS
This study aims to evaluate the efficacy and safety of MTX in maintaining remission in patients with GCA who have previously been treated with GC and at least 6 months with TCZ. We hypothesize that MTX can maintain remission in GCA patients, who have achieved stable remission after treatment with GC and TCZ, and prevent the occurrence of relapses. The study design is a monocentric, randomized, double-blind, placebo-controlled, parallel-group phase II trial randomizing 40 GCA patients 1:1 into a MTX or placebo arm. Patients will receive 17.5 mg MTX/matching placebo weekly by subcutaneous injection for 12 months, with the possibility of dose reduction if clinically needed. A 6-month follow-up will take place. The primary endpoint is the time to first relapse in the MTX group versus placebo during the 12-month treatment period. Secondary outcomes include patient- and investigator-reported outcomes and laboratory findings, as well as the prevalence of aortitis, number of vasculitic vessels, and change in intima-media thickness during the study.
DISCUSSION
This is the first clinical trial evaluating remission maintenance of GCA with MTX after a previous treatment cycle with TCZ. Following the discontinuation of TCZ in GCA, MTX could be a safe and inexpensive drug.
TRIAL REGISTRATION
ClinicalTrials.gov, NCT05623592. Registered on 21 November 2022. EU Clinical Trials Register, 2022-501058-12-00. German Clinical Trials Register DRKS00030571.
Topics: Humans; Glucocorticoids; Methotrexate; Giant Cell Arteritis; Carotid Intima-Media Thickness; Treatment Outcome; Neoplasm Recurrence, Local; Double-Blind Method; Recurrence; Randomized Controlled Trials as Topic; Clinical Trials, Phase II as Topic; Antibodies, Monoclonal, Humanized
PubMed: 38225579
DOI: 10.1186/s13063-024-07905-4 -
Science Progress 2024The treatment of infectious aortic disease is still challenging with open surgical debridement and reconstruction using biological, preferably autologous material, being...
PURPOSE.
The treatment of infectious aortic disease is still challenging with open surgical debridement and reconstruction using biological, preferably autologous material, being the treatment of choice. However, these procedures are associated with high morbidity and mortality. Endovascular therapy is often considered a bridging method only, since the biologically inactive fabric of the covered stent grafts usually cannot be treated sufficiently with anti-infective agents in the event of a (obligate) consecutive secondary graft infection. This study aims to prove the feasibility of a physician-made pericardium stent graft ex-vivo.
TECHNIQUE.
A state-of-the-art TEVAR was modified by separating the fabric from the z-stents and suturing a hand-sewn bovine pericardium tube to the bare metal. Feasibility of preparation, re-sheathing, and delivery is demonstrated in an ex-vivo model.
CONCLUSION.
This first xenogeneic stent graft could be manufactured and deployed successfully. In the future this may provide a bridging alternative for high-risk patients with infected native aortic aneurysm or aortic fistulas, eventually followed by surgical or thoracoscopic/laparoscopic debridement. Further studies on simulators or animal models are needed to test the technique and investigate its long-term durability. Additionally, this study prompts reflection on whether materials currently used should be further developed to prevent graft infections.
Topics: Humans; Animals; Cattle; Stents; Commerce; Pericardium; Physicians; Aortic Diseases
PubMed: 38196177
DOI: 10.1177/00368504231221686 -
Arthritis Research & Therapy Jan 2024To investigate the usefulness of F-FDG PET-CT for assessing large-vessel (LV) involvement in patients with suspected giant cell arteritis (GCA) and a negative temporal...
OBJECTIVE
To investigate the usefulness of F-FDG PET-CT for assessing large-vessel (LV) involvement in patients with suspected giant cell arteritis (GCA) and a negative temporal artery biopsy (TAB).
METHODS
A retrospective review of our hospital databases was conducted to identify patients with suspected GCA and negative TAB who underwent an F-FDG PET-CT in an attempt to confirm the diagnosis. The gold standard for GCA diagnosis was clinical confirmation after a follow-up period of at least 12 months.
RESULTS
Out of the 127 patients included in the study, 73 were diagnosed with GCA after a detailed review of their medical records. Of the 73 patients finally diagnosed with GCA, F-FDG PET-CT was considered positive in 61 cases (83.5%). Among the 54 patients without GCA, F-FDG PET-CT was considered positive in only eight cases (14.8%), which included 1 case of Erdheim-Chester disease, 3 cases of IgG4-related disease, 1 case of sarcoidosis, and 3 cases of isolated aortitis. Overall, the diagnostic performance of F-FDG PET-CT for assessing LV involvement in patients finally diagnosed with GCA and negative TAB yielded a sensitivity of 83.5%, specificity of 85.1%, and a diagnostic accuracy of 84% with an area under the ROC curve of 0.844 (95% CI: 0.752 to 0.936). The sensitivity was 89% in occult systemic GCA and 100% in extracranial LV-GCA.
CONCLUSION
Our study confirms the utility of F-FDG PET-CT in patients presenting with suspected GCA and a negative TAB by demonstrating the presence of LV involvement across different subsets of the disease.
Topics: Humans; Giant Cell Arteritis; Positron Emission Tomography Computed Tomography; Fluorodeoxyglucose F18; Temporal Arteries; Retrospective Studies; Biopsy
PubMed: 38172907
DOI: 10.1186/s13075-023-03254-w -
Heliyon Jan 2024It remains difficult to understand the association between the local mechanical properties of ascending thoracic aorta aneurysm (asTAA), its tissue, and its cellular and...
BACKGROUND
It remains difficult to understand the association between the local mechanical properties of ascending thoracic aorta aneurysm (asTAA), its tissue, and its cellular and molecular changes. The purpose of our study was to investigate the relationship between biomechanical properties, histopathological findings, and tissue biomarkers of asTAA.
METHODS
Intraoperative asTAA samples from 30 patients were studied. All samples were examined histologically and underwent a tensile test. We determined the tensile strength (σ, MPa), the strain (ε, mm/mm˟%), and the area under the strength-strain curve (S) along with the concentrations of tissue matrix metalloproteinases (MMP-1 et al.) and their inhibitors, their interleukins (IL) -6 -10, and their tumor necrosis factor (TNF) -α.
RESULTS
It was found that 43.3 % of asTAA patients had atherosclerosis, 3.3 % had aortitis, and 53.3 % of patients had connective tissue dysplasia. Differences in the studied parameters between these subgroups were not found. Age correlated with ε (r = -0.49) and S (r = -0.54). ε was also associated with media fibrosis degree (r = -0.5), collagen/elastin ratio (r = -0.61), and IL-10 (r = 0.52). IL-10 correlated with collagen/elastin ratio (r = -0.58), TNF-α (r = 0.77), and MMP-1 (r = 0.71).
CONCLUSION
Tissue IL-10 has a protective effect on the elastic structures of the aortic wall and is positively associated with the activity of MMP-1 and pro-inflammatory cytokines. IL-6 is associated with media fibrosis degree, and negatively affects strength-strain parameters of asTAA samples.
PubMed: 38170063
DOI: 10.1016/j.heliyon.2023.e23538 -
Cureus Nov 2023Ankylosing spondylitis can present with various extra-articular manifestations. Vascular complications due to aortic aneurysm or aortitis have been documented. However,...
Ankylosing spondylitis can present with various extra-articular manifestations. Vascular complications due to aortic aneurysm or aortitis have been documented. However, an association with intracranial vascular aneurysm is rarely reported. We report a case of a young male with positive HLA B27 ankylosing spondylitis, with extra-articular involvements, presented with recurrent unilateral headache. He was found to have an unruptured anterior communicating artery aneurysm. It was confirmed by a cerebral angiogram, and he was treated conservatively.
PubMed: 38152807
DOI: 10.7759/cureus.49509 -
The Journal of Tehran Heart Center Jul 2023Bacteria, especially staphylococcal groups, cause aortic graft infection. Infection stems from synthetic materials that repair aneurysms or artery blockages. Aortic...
Bacteria, especially staphylococcal groups, cause aortic graft infection. Infection stems from synthetic materials that repair aneurysms or artery blockages. Aortic stent infection and vegetation formation are rare, and heterogeneous presentations and ambiguous findings in routine diagnostic modalities render the diagnosis challenging. A 25-year-old man with a history of catheter-based aortic stenting for hypertension associated with severe aortic coarctation was referred to our tertiary care hospital. Five months before the presentation, the patient had been infected with COVID-19, but he recovered after mild symptoms. Nevertheless, 3 months later, he developed erythematous lesions, progressive anorexia, epigastric pain, fever, and weakness. The results of blood tests, blood cultures, transthoracic echocardiography, plain chest radiography, computed tomography angiography, and electrocardiography were unremarkable. We found severe infectious aortitis, crescent thickness surrounding the aorta, pseudoaneurysm development, and a mass with dimensions of 17 mm×8 mm within the aortic stent on transesophageal echocardiography (TEE). Broad-spectrum antibiotic therapy was initiated, and the patient was transferred to the operating room, where the infected stent and adhesive vegetation were removed. The patient recovered remarkably after the surgery and was discharged. At 6 months' follow-up, he was in good condition. Our findings highlight the significance of maintaining vigilance and a high level of clinical suspicion for the possibility of vegetation formation and aortitis as the possible sequelae of COVID-19, particularly in patients with an implanted stent. Furthermore, we strongly suggest TEE in patients with implanted stents to detect vegetation and aortitis.
PubMed: 38146409
DOI: 10.18502/jthc.v18i3.14117 -
Cureus Nov 2023Takayasu arteritis, a rare and complex vasculitis, presents unique diagnostic and management challenges, particularly when encountered in young adults. We present the...
Takayasu arteritis, a rare and complex vasculitis, presents unique diagnostic and management challenges, particularly when encountered in young adults. We present the case of a 26-year-old female with obesity, prediabetes, hepatic steatosis, an adnexal cyst, gastritis, and asthma, who was transferred to our facility due to concerns about aortitis. Her presentation to the referring institution included dysphagia, heartburn that responded to over-the-counter antacids, and recurrent episodes of stabbing chest pain, which had been occurring intermittently since the age of 17. Previous visits to the emergency room for these symptoms had been approached as gastritis, the last being two weeks before this episode. On evaluation, laboratory findings revealed elevated inflammatory markers, and subsequent imaging studies identified extensive circumferential wall thickening of the ascending thoracic aorta, suggestive of aortitis, and the patient was transferred to our institution. The patient's complex medical history and psychosocial stressors, including estrangement from her family, added to the intricacies of her case. Rheumatology consultation was instrumental in guiding further evaluation and management. A diagnosis of Takayasu arteritis with large vessel vasculitis was considered, supported by positron emission tomography-computed tomography findings showing significant metabolic activity in major arteries. The patient was initiated on prednisone therapy, pneumonia prophylaxis, and methotrexate. Ongoing monitoring for disease activity and medication side effects was emphasized. This case highlights the importance of considering rare conditions such as Takayasu arteritis in young adults with atypical presentations and underscores the need for comprehensive, multidisciplinary care that addresses not only the medical aspects but also the psychosocial well-being of the patient.
PubMed: 38073983
DOI: 10.7759/cureus.48569 -
Cureus Nov 2023Infectious aortitis is a rare disease process that presents with mortality varying from 60% to 90%, even with aggressive treatment. This is a case involving a...
Infectious aortitis is a rare disease process that presents with mortality varying from 60% to 90%, even with aggressive treatment. This is a case involving a 69-year-old male who initially presented for acute encephalopathy. The patient's past medical history included coronary disease status post coronary bypass graft, abdominal aortic aneurysm status post endograft repair, prurigo nodularis, Tangier's disease, type 2 diabetes mellitus, and stage 3b chronic kidney disease. Initially, the work-up was unrevealing for a cause of the patient's acute encephalopathy. However, astute clinical evaluation led to the diagnosis of methicillin-sensitive (MSSA) bacteremia and abdominal infectious aortitis. Prurigo nodularis is a chronic dermatologic condition characterized by the development of intensely pruritic, firm nodules or bumps on the skin associated with itching and scratching. Prurigo nodularis itself does not directly result in bacteremia. However, in rare cases, severe and persistent scratching due to prurigo nodularis can lead to breaks in the skin, creating an entry point for bacteria to spread by the hematogenous route. Certainly, it is highly unusual to have a combination of prurigo nodularis, MSSA bacteremia, and abdominal aortic aneurysm endograft infection. Given the severity of these conditions individually, the combination presents a unique and challenging clinical scenario that requires prompt and coordinated management by a multidisciplinary team. This case report aims to provide new insights into the potential risk factors, clinical course, and management strategies for these combined conditions.
PubMed: 38073942
DOI: 10.7759/cureus.48519