2105 Below the Belt: Unsual Site of Aortitis in Crohn's Remission

Abstract

INTRODUCTION: Aortitis is inflammation of the vessel wall that results in luminal narrowing or vessel strictures. It can involve any part of the aorta. In patients with Crohn’s, the reported sites of aortic inflammation are aortic valve leaflets and aortic root, which can result in aortic insufficiency and aneurysmal dilation. CASE DESCRIPTION/METHODS: A 61-year-old female with stable Crohn’s disease presented with epigastric pain, non-bilious non-bloody emesis, and diarrhea. She discontinued Mesalamine 8 years ago. Laboratory studies revealed leukocytosis (12K) and erythrocyte sedimentation rate of 12. Computed Tomography showed fat deposition in the terminal ileum and cecum, mesenteric edema with new wall thickening and fat stranding of the abdominal aorta (AA) and left common iliac artery (CIA). CT angiography (CTA) revealed a 6 mm soft tissue ring around the infra-renal AA with moderate stenosis and extension into the left CIA, compatible with aortitis. Aortic biopsy was not performed given no signs of systemic vasculitis or giant cell arteritis. Infectious etiology was suspected; blood cultures, urinalysis, stool PCR, Clostridium-difficile, HIV, Syphilis, Hepatitis, QuantiFERON, Histoplasmosis, Blastomycosis, Yersinia-Enterocolitica PCR, Cryptococcal antigen, serologies for Lyme disease, Rickettsia, Coxiella, Brucella, Bartonella, and Chlamydia were all negative. Transthoracic echocardiogram showed no evidence of endocarditis. Rheumatologic workup was negative (ANA, RF, ANCAs, CRP, IgG subclasses). Systemic antibiotics were started given concern for infection but the patient did not clinically improve. Given lack of improvement on antibiotics, methylprednisolone was initiated. Repeat CTA showed persistent inflammation. Adalimumab was started with significant symptomatic improvement. At 6 month follow up the patient was asymptomatic and repeat CTA showed no evidence of inflammation. DISCUSSION: We present a rare case of infra-renal aortitis in a patient with stable Crohn’s disease. There is only one reported case of abdominal aortitis in a patient with Crohn’s, but that patient had severe fulminant disease. Our patient with Crohn’s in remission had nonspecific gastrointestinal symptoms (epigastric pain, emesis, diarrhea), and was found to have infra-renal aortitis. Aortitis carries a high risk of aortic rupture and thrombosis of small vessels. Early recognition is crucial, as immunosuppressive agents can be used to reduce the risk of life threatening clinical complications.