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 Table of Contents  
IMAGES IN RHEUMATOLOGY
Year : 2018  |  Volume : 13  |  Issue : 3  |  Page : 202-203

Pulmonary Artery Pseudoaneurysm in a Patient of Rheumatoid Arthritis


Department of Radiology, All Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Web Publication21-Aug-2018

Correspondence Address:
Dr. Sudipta Mohakud
Radiology All India Institute of Medical Sciences, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_31_18

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  Abstract 


Keywords: Angiography, contrast-enhanced computed tomography, pulmonary artery pseudoaneurysm, rheumatoid arthritis


How to cite this article:
Mohakud S, Singh A, Naik S, Deep N. Pulmonary Artery Pseudoaneurysm in a Patient of Rheumatoid Arthritis. Indian J Rheumatol 2018;13:202-3

How to cite this URL:
Mohakud S, Singh A, Naik S, Deep N. Pulmonary Artery Pseudoaneurysm in a Patient of Rheumatoid Arthritis. Indian J Rheumatol [serial online] 2018 [cited 2019 Oct 17];13:202-3. Available from: http://www.indianjrheumatol.com/text.asp?2018/13/3/202/228281



We report a case of pulmonary artery pseudoaneurysm (PAP) detected on contrast-enhanced computed tomography (CECT) with angiography in a patient with rheumatoid arthritis (RA) in the absence of other known causes.

Patient was a 56-year-old female who was a diagnosed to have RA 5 years ago. She was on hydroxychloroquine 200 mg once daily. She presented with one bout of hemoptysis (200–300 ml) about 3 months back. Plain CT thorax done in a peripheral hospital showed the left upper lobe consolidation, and she was given symptomatic treatment and a course of antibiotics. Thereafter, she had occasional streaks of blood in a cough. She was referred to the pulmonary medicine department in view of persistent left upper lobe consolidation with cavities on follow-up X-ray. There was no history of fever, weight loss, or diabetes. She had no history of tuberculosis, pulmonary catheterization, or trauma. On examination, the patient had mild pallor and normal body habitus. Both the upper and lower limb pulses were palpable. Small joint deformities were seen in both hands. The blood pressure was within normal limit. There were no oral, cutaneous, or genital ulcers. Clinical examination of rest of the systems was within normal limit. Rheumatoid factor (RF) was negative. The sputum was negative for acid-fast bacillus, fungus, or malignant cells.

CECT thorax showed a wide-necked round avidly enhancing lesion of size 11 mm × 10 mm arising from the left pulmonary artery suggestive of a pseudoaneurysm [Figure 1] and [Figure 2] with peripheral rim of thrombosis. It was compressing the left upper lobe bronchus with the collapse of the left upper lobe. Mucous-filled bronchi and cavities with air-fluid levels were seen in the collapsed lung [Figure 2]. No endobronchial mass, interstitial lung disease, pulmonary embolism, or pleural effusion was seen. She was administered an intravenous injection of tranexamic acid and referred for percutaneous embolization of the aneurysm to prevent mortality from sudden hemorrhage. The patient was lost to follow-up.
Figure 1: Contrast-enhanced computed tomography thorax of a 56-year-old female with rheumatoid arthritis, axial section image showing a saccular outpouching from the left pulmonary artery (large arrow) with distal consolidation due to bronchial compression. A cavity is seen within the consolidation (small arrow)

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Figure 2: Volume-rendered three-dimensional image of a 56-year-old female with rheumatoid arthritis showing the pseudoaneurysm (arrow) arising from the left pulmonary artery

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A pseudoaneurysm is a focal blood leak from the blood vessel surrounded by a single layer, either the adventitia or adjoining perivascular soft tissue with a high risk of rupture.[1] Acute PAP presents with hemoptysis, hypovolemic shock, dyspnea, and chest pain. Clinical presentation of chronic PAP ranges from asymptomatic to a cough, chest pain, hemoptysis, and recurrent pneumonia. Compression of the bronchus by a large PAP can cause cyanosis, cough, progressive dyspnea, pneumonia, fever, and bronchiectasis.[1]

It can be easily diagnosed by CECT as an avidly enhancing saccular outpouching from the pulmonary artery.[2] Percutaneous angiography further confirms the diagnosis and provides a road map for treatment by embolization.

PAP may be congenital or more commonly acquired. The most common acquired cause of PAP is iatrogenic followed by trauma. Iatrogenic causes include malpositioned  Swan-Ganz catheter More Details, right-heart catheterization, chest tube insertion, biopsies, and surgery.[1],[2],[3],[4] Other acquired causes are vasculitis, infection, pulmonary hypertension, congenital heart disease, connective tissue disorders, and neoplasm. The vasculitis commonly associated with pulmonary artery aneurysm is Behcet's syndrome, Hughes–Stovin syndrome, and Takayasu's arteritis. The underlying mechanism is vessel wall ischemia and weakening due to the involvement of the vasa vasorum. Infectious causes are tuberculosis, bacterial, and fungal infections. Connective tissue disorders such as Ehlers–Danlos syndrome, Marfan syndrome, and cystic medial necrosis predispose to aneurysm formation.[1],[3]

Rheumatoid arthritis is reported to be associated with pulmonary arterial hypertension. Rheumatoid vasculitis affecting pulmonary artery is also described in the literature.[5]

In our case, the secondary causes responsible for the formation of PAP those are described in the literature are excluded by obtaining a proper clinical history, laboratory investigations, and CECT scan. It is described that the ESR and C-reactive protein (CRP) levels are indicators of response evaluation, but RF level does not correlate well.[6] Although our patient was on continuous treatment for rheumatoid arthritis, raised ESR and CRP levels probably indicate relapse. We propose that RA may be a possible cause of PAP and the underlying mechanism may be attributed to chronic inflammatory vasculitis causing vessel wall weakness. The patient should remain in a regular follow-up of rheumatoid disease status, and there should be an alteration in the medication or its dose.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kreibich M, Siepe M, Kroll J, Höhn R, Grohmann J, Beyersdorf F. Aneurysms of the pulmonary artery. Circulation 2015;131:310-6.  Back to cited text no. 1
    
2.
Nguyen ET, Silva CI, Seely JM, Chong S, Lee KS, Müller NL, et al. Pulmonary artery aneurysms and pseudoaneurysms in adults: Findings at CT and radiography. AJR Am J Roentgenol 2007;188:W126-34.  Back to cited text no. 2
    
3.
Lafita V, Borge MA, Demos TC. Pulmonary artery pseudoaneurysm: Etiology, presentation, diagnosis, and treatment. Semin Intervent Radiol 2007;24:119-23.  Back to cited text no. 3
    
4.
Poplausky MR, Rozenblit G, Rundback JH, Crea G, Maddineni S, Leonardo R, et al. Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm formation: Three case reports and a review of the literature. Chest 2001;120:2105-11.  Back to cited text no. 4
    
5.
Yunt ZX, Solomon JJ. Lung disease in rheumatoid arthritis. Rheum Dis Clin North Am 2015;41:225-36.  Back to cited text no. 5
    
6.
Rindfleisch JA, Muller D. Diagnosis and management of rheumatoid arthritis. Am Fam Physician 2005;72:1037-47.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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