Inflammatory aneurysm of the abdominal aorta in a patient treated with ropinirole

Abstract

Retroperitoneal fibrosis, inflammatory aneurysm of the abdominal aorta and perianeurysmal retroperitoneal fibrosis are three closely related entities that belong to the spectrum of chronic periaortitis [1]. Retroperitoneal and pleuropulmonary fibrosis are well known but rare complications of the treatment with ergolinic dopamine agonists of Parkinson’s disease [2, 3]. To our knowledge, ropinirole, a non-ergot derived dopamine agonist, has never been associated with fibrotic complications localized to the retroperitoneal space. A 72-year-old man was admitted to our clinic because of a febrile illness with significant anorexia and fatigue. At presentation, he suffered from moderately advanced Parkinson’s disease, which was diagnosed 11 years ago. His treatment consisted of levodopa/carbidopa and ropinirole throughout his disease course. At the time of admission he was on 1.35 g/day of levodopa and 15 mg/day of ropinirole. On admission, apart from a fever of 38.5 C and the parkinsonian signs, his physical examination was unremarkable. Routine laboratory tests showed moderate normochromic-normocytic anemia (hemoglobin 8.9 g%), elevation of C-reactive protein level (14 mg%), elevated erythrocyte sedimentation rate (124 mm/ h), ferritin (1381 ng/ml) and fibrinogen (7.9 g/l). Further investigation revealed mild increase of serum IgA (510 mg/dl), beta2 microglobulin (4.03 mg/l) and total globulin level (3.7 g/dl). Extensive serological studies for autoimmune and infectious disorders were either normal or negative, whereas bone marrow aspirate and biopsy findings were compatible with reactive changes secondary to chronic inflammation. Both chest X-ray and chest CT scans showed no abnormalities. CT imaging of the abdomen revealed findings indicative of periaortic edema and inflammatory soft tissue formation without aneurysm (Fig. 1). Ropinirole withdrawal was suggested, but the patient declined. Administration of i.v. methylprednisolone at 80 mg/day resulted in complete relief of symptoms within a few days, and acute phase reactants started to decline. Similarly, anemia gradually responded to steroid therapy. The patient remained in clinical remission during steroid tapering to a maintenance dose of 10 mg/day. However, a follow-up CT examination performed 3 months later demonstrated a 4 cm saccular aneurysm arising from the right anterolateral portion of the aorta (Fig. 2). In this report we present a patient who developed inflammatory aneurysm of the abdominal aorta while on long-term treatment with ropinirole. In this disorder fibroinflammatory tissue develops around a dilated aorta, but does not cause obstructions of the adjacent structures. Inflammatory aneurysm of the abdominal aorta together with retroperitoneal fibrosis and perianeurysmal retroperitoneal fibrosis are believed to have a common autoimmune pathogenesis and share many clinical, laboratory and histological features [4]. D. Parissis (&) B’ Department of Neurology, Aristotle University of Thessaloniki, AHEPA Hospital, 1, Stilponos Kyriakidi Str, 546 36 Thessaloniki, Greece e-mail: dparissis@gmail.com