Perivascular carotid inflammation: an unusual case of carotidynia

Abstract

A 59-year-old woman was admitted to the hospital with a fever and rigors for 2 days. She was on chemotherapy (docetaxel, carboplatin, and trastuzumab) for her stage II invasive ductal carcinoma of the breast. Her physical exam was unremarkable except for the fever. The white blood cells were 21,200/mm(3) with 92% of neutrophils. ESR was 106 mm/h. An extensive infectious workup was negative. On day 6, while still febrile, the patient complained of a left-sided neck pain. She exhibited tenderness over the left carotid artery. A CT scan of the neck without intravenous contrast showed perivascular inflammation of the left common carotid artery, without evidence of a collection, arterial thrombosis, aneurysm, or dissection. The etiology of this finding was possibly chemotherapy related. It dramatically responded to oral prednisone. A repeat CT scan of the neck with IV contrast 2 weeks later showed a remarkable improvement. Drug reactions can simulate systemic inflammatory diseases and should always be considered in the diagnosing process.

Carotidynia after anticancer chemotherapy

“…Even though the definition of carotidynia is controversial, many case reports (6)(7)(8)10,11) have suggested carotidynia to be an idiopathic vasculitis limited to the distal common carotid artery. Our patient presented with symmetrical neck pain, accompanied by tenderness, swelling, and increased pulsations overlying the carotid artery.…”

“…(9,10,13) In a case of carotidynia presenting after chemotherapy for pancreatic cancer, gemcitabine was assumed to be the drug responsible for carotidynia, although docetaxel was used simultaneously. (9) In a case of large vessel vasculitis that included not only the carotid artery but also the aorta, suggesting the occurrence of carotidynia, the patient's symptoms presented after anticancer chemotherapy with gemcitabine, which was assumed to be the drug responsible for carotidynia, even though docetaxel was also concurrently administered.…”

“…(15) In another case of carotidynia following anticancer chemotherapy, docetaxel, carboplatin and trastuzumab, but not gemcitabine, were administered. (10) Because challenge tests using the candidate drugs were not conducted in these case reports, (9,10,13) it is difficult to determine whether these cases were ADRs, and if so, the drug responsible for carotidynia. In addition, the mechanism by which docetaxel causes vasculitis is controversial, and no cases of docetaxel-induced vasculitis in the large artery have been reported.…”

“…(4) Thus, the second edition of the IHS classifications did not include carotidynia. (5) In the last decade, carotidynia was recognised as a distinct entity because data from advanced imaging techniques for carotid vascular disease, including magnetic resonance (MR) imaging, (6)(7)(8) computed tomography (CT), (6,9,10) and ultrasonography, (6)(7)(8)(9) revealed images with features specific for carotidynia. These images showed characteristics of a thickened carotid sheath localised to the symptomatic carotid artery, while the luminal wall and blood flow were observed to be normal.…”

“…(6) However, a few reports have suggested that some medications can cause carotidynia. (9)(10)(11) Herein, we describe a case of carotidynia that occurred after anticancer chemotherapy. Although there is no definitive evidence, our findings suggest that docetaxel or granulocyte-colony stimulating factor (G-CSF) may cause carotidynia.…”