An obese 61-year-old man who had
chronic obstructive pulmonary disease
and sleep apnea heard a "pop"
in his stomach while lifting a heavy
weight; severe abdominal pain followed.
He was short of breath the
next morning, and his physician empirically
The patient became confused
about 7 hours later and was taken to
the emergency department; at this
time he was lethargic and had a temperature
of 38.3C (101F). Examination
disclosed bilateral wheezes, rales
at the lung bases, and paraumbilical
and left upper quadrant abdominal tenderness. His white
blood cell count was elevated to 12,400/μL, with 50% segmented
neutrophils and a marked shift to the left with 47%
band neutrophils. His hemoglobin level was 12.7 g/dL,
and his hematocrit was 37.8%.
In a CT scan of the abdomen and pelvis (top), arrows
point to inflammation in the aortic wall (A) and the paraaortic
retroperitoneal fat. (I, inferior vena cava; K, kidney.)
Calcified atherosclerotic plaques were visible, but the
aorta was not dilated. There was neither retroperitoneal
hematoma nor contrast extravasation to suggest rupture.
At 24 hours, blood cultures grew Salmonella organisms.
The patient was given intravenous antibiotics for
9 days, by which time his abdominal pain had increased.
A follow-up CT scan (bottom) revealed contrast medium
protruding into the abnormal aortic wall, penetrating the
infiltrated wall of the aorta and retroperitoneum, as well as
development of an aortocaval fistula. Emergency aortectomy
and bypass were performed.
Pathologic studies of the resected aortic wall demonstrated
excessive quantities of histiocytes and neutrophils;
the numbers increased progressively from the tunica
media vasorum to the tunica adventitia to the para-aortic
tissue. The aortic wall itself was disorganized and atheromatous.
No organisms could be identified, possibly because
of the antibiotic therapy.
Aortitis is rare, but it should be considered when a
patient has fever, leukocytosis, sepsis, and abdominal pain
with or without a pulsatile mass. More than 80% of cases of
aortitis occur in men, and most patients are older than 50
years. Vascular tissue is normally resistant to infection, but
atheromatous, diseased vessels are predisposed to bacterial
seeding and growth.
Infection can occur in either
aneurysmal or nonaneurysmal aortas.
Salmonella species account for
about one third of the infections,
which usually develop following bacteremia.
The infection destroys the
tunica intima vasorum and tunica
media vasorum, leading to formation
of an aneurysm and eventual eruption.
High clinical suspicion, aggressive
antibiotic therapy, and aortectomy
with bypass are necessary to
prevent a fatal outcome.