Tuberculous Aortitis Associated With Pleuritis and Spondylitis

A 58-year-old female had intermittent anterior chest pain for 1 year. The pain was sharp without radiation to back, and persisted for days, even at rest. She denied cold sweating, fever, dyspnoea, cough and body weight loss. Chest computed tomography (CT) disclosed segmental wall thickening at the proximal descending aorta. Intramural haematoma was initially impressed. Enhanced CT 6 months later showed no significant changes. However, persistent segmental aortic wall thickening with prevertebral extension and T4 vertebral bony erosion (Figure 1A) was found on CT Images 1 year later. The involved aorta showed mild stenosis without aortic aneurysm formation (Figure 1B). Left apical pleural thickening with subpleural infiltration was also noted (Figure 1C). Aortitis was suspected and we began the work-up of infectious and noninfectious causes. Infectious aortitis may be induced by syphilis, tuberculosis or other microorganisms. Noninfectious aortitis includes large-vessel vasculitis and other autoimmune-related aortitis (ex: rheumatoid arthritis, systemic lupus arthritis and IgG4-related disease). Tracing back her medical history, there was neither joint pain nor malar rash. Monitored vital signs showed normal systemic blood pressure without limb discrepancy. The laboratory tests including leukocytes, haemoglobin, ESR, creatinine, IgG4 and GOT/GPT were normal. Serological results like syphilis test, Widal test and antinuclear antibodies were negative. To obtain the aorta specimens, video-assisted thoracic surgery was performed. Intraoperative findings revealed left fibrotic pleura with granulomatous foci overlying left apical lung and coating the adjacent aorta (Figure 1D). On microscopic examination, granulomatous inflammation with clustered epithelioid histiocytes, Langhans giant cells and acid-fast positive bacilli was observed in specimens of lung and pleura. But the specimens of aortic wall and periaortic tissue showed only fibrotic change. No M. tuberculosis was isolated from all specimens after 8 weeks’ incubation. Under the impression of tuberculous aortitis (TA) associated with pleuritis and spondylitis, the patient received Rifater plus EMB for the first 2 months, followed by Rifinah plus EMB for 2 months. The follow-up CT displayed interval resolving of aortitis and prevertebral abscess (Figure 1E). Tuberculous aortitis can be caused by direct extension from adjacent tuberculous tissue or from blood-borne seeding via the vasa vasorum [ ]. Due to the close spatial relation between the pleurae, aorta and vertebrae, blood-borne diseased aortic vasa vasorum with directly outward extension is the supposed mechanism of the disease. Tuberculous aortitis is rare and challenging with a median delay of 18 months before initiation of anti-tuberculosis therapy [ ]. M. tuberculosis culture is usually negative in most cases. TA can be diagnosed by clinical features and histologic findings such as necrotising epithelioid cell granulomas along with Langhans giant cells [ ]. First-line anti-tuberculosis therapy for 6 to 12 months has led to satisfactory disease remission [ ]. However, open surgery should be considered when there is worsening of aortic aneurysm or stenosis despite treatment [ ].