A Rare Presentation of Thoracic Aortic Aneurysm Rupture

Abstract

Thoracic aortic aneurysm (TAA) is an uncommon clinical condition, commonly associated with atherosclerosis. It is mostly asymptomatic but aneurysm exceeding 6 cm are at risk of yearly rate of rupture or dissection of at least 6.9% and a death rate of 11.8%. We present to you a case of TAA with rupture presenting with cough, hemoptysis and pneumonitis. CASE PRESENTATION:Patient is a 68 years male who presented to the ED with cough, hemoptysis, chest discomfort for 2-3 days. He had intermittent episodes of fever. COVID test was negative 3 days ago. Past medical history was significant for HTN, Asthma, COPD, Diabetes mellitus, tobacco use disorder. Patient was afebrile with BP of 137/73, HR 72, RR 16, O2 saturation of 89% in room air. Physical examination including chest was unremarkable. Initial workup including CBC was remarkable for WBC of 12500, Hgb of 10.5, INR 0.8, PTT 24, Troponin <0.02. CXR showed findings worrisome for underlying pneumonitis in the left upper lobe. Presumptive diagnosis of community-acquired pneumonia was made, patient was treated with ceftriaxone and azithromycin but symptoms continued to persist despite the treatment. For further evaluation, CT CTA chest was performed which revealed features suggestive of ruptured thoracic aortic aneurysm. Further, angiogram revealed rupture above the level of the celiac artery. Patient then underwent endovascular thoracic stent graft placement. Patient could not be extubated following the procedure due to advanced COPD and was then transferred to ICU for close monitoring. He was subsequently extubated in the next few days and was discharged in stable condition. No complications were noted in follow-up CT angiography.DISCUSSION: Thoracic aortic aneurysm (TAA) is commonly associated with atherosclerosis but can also occur in genetic disease (Marfan syndrome, Ehler Danlos syndrome, Loeys-Dietzs syndrome, familial thoracic aortic aneurysm syndrome, aneurysms osteoarthritis syndrome), patient with bicuspid aortic valve, infection (tuberculosis, syphilis, mycotic infections), giant cell arteritis, cystic medial necrosis, trauma, familial TAA. It is present in 5.6/100,000 people. Hemoptysis is a unique symptom of TAA rupture that has been a reported due to erosion of the trachea by aneurysm or rupture of the aneurysm into lung parenchyma. Rupture risk is high in population with aneurysm size > 5 cm, smokers, COPD, advanced age, hypertension. Thoracic endovascular stent graft surgery, under epidural anesthesia, is the preferred surgical treatment especially in old TAA patients as in our case because of low morbidity, mortality and hospital stay.CONCLUSIONS: Rupture of TAAs is still very rare, but should remain on the differential for a patient with cough, hemoptysis with features of pneumonitis as it is associated with very high morbidity and mortality rates.