210. A Case Presentation of Tuberculous Aortitis and Vasculitis
Creators: name: Louis1, Bernadine
name: Murphy, Graine
Publisher: name: Zenodo
Year: 2022
Subjects: Vasculitis
ANCA
Abstracts
Giant Cell Arthritis
MPA
GPA
EGPA
Takayasu
IgA vasculitis

description: <strong>Introduction: </strong>Tuberculosis (TB) aortitis is a rare manifestation of TB. The presentation of TB aortitis is usually associated with disseminated disease and can lead to a multitude of complications including aneurysmal dilatation of the aorta, perforation and even death. There is often a delay in diagnosing TA, due to a lack of awareness regarding this rare presentation of extrapulmonary TB. <strong>Case Presentation: </strong>A 55-year-old Dentist of Irish descent, presented to his General Practitioner with a 2-month history of indigestion and retrosternal discomfort that failed to respond to oral Proton Pump Inhibitors. He was a fit 55-year-old gentleman who exercised avidly and was a non-smoker. His past medical history included a sigmoid colectomy in 2019 for diverticulitis, and a history of bowel obstruction in 2020 secondary to adhesions. He had no significant family history of note. He also has no known previous history of exposure to Tuberculosis. In the ensuing weeks, he developed additional symptoms of fatigue, malaise and occasional night sweats. He had no other relevant symptoms of note such as pyrexia, weight loss, cough, early morning stiffness, arthralgia or hemoptysis. His initial physical exam revealed no abnormalities. However, his laboratory investigations revealed a persistently elevated C-Reactive Protein and Erythrocyte Sedimentation Rate (above 60mg/dl and 50mm/hr respectively). <strong>Investigations: </strong>Due to his predominant upper GI symptoms he was initially investigated by surgical services. An Oesophago-Gastro-Duodenoscopy was normal, prompting a CT of thorax, abdomen and pelvis due to systemic symptoms. This revealed a 3-4mm right lower mild calcification of his abdominal aorta and common iliac vessels which were ectatic particularly on the left with stranding suggestive of vasculitis surrounding his distal aorta and proximal iliac vessels. He was thereafter referred to Rheumatology. He had ongoing systemic symptoms, intermittent epigastric pain and denied claudicating symptoms. He had no history of COViD 19 infection and was vaccinated in the weeks prior to symptom onset. A standard autoimmune screen, IgG 4 levels and Angiotensin Converting Enzyme levels were normal. HIV and syphilis testing were negative. A Positron Emission Tomography scan demonstrated significant fluoro-deoxy glucose -uptake within the right mediastinal node and a single pre-tracheal node. An endobronchial ultrasound with real- time guided transbronchial needle aspiration was then arranged. This demonstrated caseating granulomas and AFB (acid- fast bacilli) smear and cultures were positive and consistent with mycobacterium tuberculosis infection. A QuantiFERON test was positive. <strong>Differential Diagnoses and Management:</strong> The differential diagnosis for this case was wide and varied. This patient was initially investigated for upper GI pathology including possible neoplasm which could have explained his constitutional symptoms. The findings of the CT TAP were suggestive of IgG4 disease and retroperitoneal fibrosis. Normal IgG4 levels and the avidity of nodal uptake led to biopsy which confirmed the diagnosis. He was treated with 2 months of quadruple therapy isoniazid, rifampicin , ethambutol, pyrazinamide and pyridoxine. His TB cultures grew a fully sensitive organism. A repeat CT TAP after 2 months of Quadruple Therapy showed interval reduction in the size of the right hilar lymph node and significant amelioration of the vascular inflammatory changes indicative of treatment response. <strong>Conclusions:</strong> Tuberculous aortitis is an uncommon cause of large vessel vasculitis. Imaging and biopsy was critical in establishing definitive diagnosis in this case. There is some suggestion that dentists have an increased risk of tuberculosis due to working in close proximity to oral secretions. Risk factors for latent TB reactivation include immunosuppression and of relevance to the current era, there have been reports of reactivation following COViD19 infection. <strong>Disclosures: </strong>None.