P067 AORTITIS IN ASSOCIATION WITH CROHN’S DISEASE: HOW FAR CAN CROHN’S DISEASE HIT?

Abstract

Crohn’s disease (CD) is an inflammatory disorder of unclear etiology that may involve the entire gastrointestinal tract from mouth to the perianal area and may be associated with several extraintestinal manifestations. Venous thromboembolic events represent the most common cardiovascular complication in CD. Other cardiovascular complications are extremely rare and include aortic valvular disease, aortic root dilation, aneurysms and thoracoabdominal aortitis.Case report: A 62-year-old female with a history of ileocolonic CD diagnosed 15 years ago and was on oral mesalamine. She presented with a sudden onset of moderate epigastric pain radiating to the back of one day duration. The pain was associated with nausea and 3-4 episodes of watery diarrhea. She denied fever, chills, night sweats, headache, visual disturbances, chest pain, hemoptysis, or urinary symptoms. She lived in a rural area in northern Michigan, had contact with farm animal and was consuming well water occasionally. On initial evaluation, she was hemodynamically stable and afebrile. Her pulses were symmetrical and normal. A CT of the abdomen and pelvis with contrast (figure 1A) was suggestive of abdominal aortitis and a distal ileitis. Initial workup is shown in table 1. Vascular surgery, rheumatology and infectious diseases services were consulted. An MRA of the abdomen showed a distal abdominal aortic aneurysm with moderate circumferential enhancing wall thickening. There was no evidence of systemic vasculitis, giant cell arteritis, Takayasu arteritis, or sarcoidosis. The decision was to hold on doing a vascular biopsy due to absence of constitutional symptoms. Given her epidemiological risk factors for infection, she was started on empirical antimicrobial treatment pending the results of the rest of the workup (table 1). She was approved to start on steroids after being on antimicrobials for 48 hours with negative blood cultures. The patient’s abdominal pain improved, and she remained afebrile. She was discharged on a 6-week course of antibiotics and a tapering course of prednisone. The rest of her rheumatological and infectious workup was unrevealing (table 1). A follow up MRA of the abdomen (figure 1B) showed an evidence of persistent abdominal aortitis. It was thought that this is due to her CD; she was started on oral prednisone 1 mg/kg with a taper of 10 mg weekly and adalimumab 40 mg subcutaneously every 2 weeks. Her follow up imaging 3 months later showed improvement of aortitis and no evidence of active inflammatory bowel disease. Aortitis in association with CD has been documented in few case reports and could be related to the local inflammation or the autoimmune nature of the disease. Other important causes of large vessel vasculitis must be ruled out, especially Takayasu arteritis, giant cell arteritis, sarcoidosis and infectious vasculitis. Full laboratory workup Full laboratory workup Figure 1: A) CT of the abdomen and pelvis contrast showing a new wall thickening and adjacent fat stranding to abdominal aorta and proximal left common iliac artery that was most compatible with aortitis, in addition to a wall thickening and inflammatory changes adjacent to the distal ileum suggestive of an active CD. B) A follow up MRA of the abdomen showing a persistent mild fusiform dilatation of the infrarenal abdominal aorta just above the level of the bifurcation, with periaortic inflammatory changes seen circumferentially surrounding the distal aorta and extending into the proximal left common iliac artery.