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.