Comment:
For GCA in large vessels, the incidence of aortic dissection appears to
increase over time, likely due to aortic inflammation seen in patients
with GCA2. When the aorta is affected in giant cell
arteritis, it commonly results in thoracic aortic aneurysm, with almost
a 17-fold increase compared to age and gender-matched
controls3,4. One study showed that 6% of patients
with GCA with aneurysm developed a dissection. All of these dissections
involved the thoracic aorta, mostly the ascending portion (72%), with
the size of the aneurysm ranging from 29-80 mm5.
Another study showed that in patients with GCA with aortic aneurysm and
dissection, aneurysm size was not a predictor of
dissection6.
In this case, our patient presented with shortness of breath which was
initially attributed to aortic insufficiency. On workup for her
respiratory failure, she was found to have an acute-on-chronic ascending
aortic dissection. One study noted similar findings in patients who
presented with aortic dissection. Most patients were asymptomatic, but 7
out of 37 patients in the study presented with shortness of breath due
to aortic insufficiency, and 6 out of 37 patients had congestive heart
failure on presentation7. Patients with underlying
autoimmune diseases, such as rheumatoid arthritis, should be followed
closely. Currently, there are no guidelines that suggest the amount of
time for follow up. We recommend that these patients undergo a thorough
clinical exam and imaging with CTA yearly. Additionally, those with any
aortic dilation should be followed closely for worsening aneurysm and
possible dissection. Maintaining a close relationship with the patient’s
rheumatologist and primary care physician can help ensure control of the
patient’s rheumatological disease, enabling early detection and
treatment and preventing mortality.