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5DIFFICULTIES OF DIFFERENTIAL DIAGNOSIS OF DISSECTING AORTIC ANEURYSM.
CLINICAL CASE
Abstract
The article deals with the problem of differential diagnosis of dissecting aortic aneurysm. There are insufficient data on this disease epidemiology today in spite of high mortality rate from this disease. This paper considers the most common classification of aortic dissection. Clinical case as an example of the challenging differential diagnosis in clinical practice is described.
Keywords
dissecting aortic aneurysm, Marfan syndrome, Ghent criteria, Stanford classification,
DeBakey classification
AUTHORS
Natalya Mikhailovna Kuzmina
Postgraduate, Izhevsk State Medical Academy, Izhevsk, Russia. E-mail: [email protected]
Nikolay Ivanovich Maximov
Proffesor, Izhevsk State Medical Academy, Izhevsk, Russia
Dissecting aortic aneurysm is defined as a destruction of the middle layer of the aortic wall provoked by intramural blood hit with the resulting aortic wall layers separation and the subsequent formation of the true and false lumens with or without communication between them. In most cases, the initiating factor is the rupture of the intima, so that the blood enters the dissection plane - in the media of the aorta. Then the next stage should be either a rupture in the case of the aorta adventitia destruction or re-entering of the blood into the lumen of the aorta through the second rupture of intima.
The global death rate from aneurysms and aortic dissections increased from 2.49 per 100 thousand inhabitants to 2.78 per 100 thousand inhabitants between 1990 and 2010, with higher rates for men. The latest data on aortic dissection epidemiology are insufficient. According to the Oxford Vascular study, the incidence of aortic dissection is estimated at six cases per hundred thousand people per year. The incidence is higher in men and increases with age. Prognosis is worse for women because of atypical manifestations and late diagnosis. The most common risk factor associated with aortic dissection is arterial hypertension, which occurs in 65-75% of people, mostly poorly controlled [1].
Diagnosis of this disease is difficult, because the symptoms are often nonspecific and patients are treated from other diseases with life-threatening complications developing.
About 0.5% of patients admitted to the intensive care unit with chest pain or back pain have aortic dissection. Two-thirds of the patients are males; the average age at the time of admission is 65 years. Currently the most common risk factor is the presence of arterial hypertension which is detected in 72% of cases. Other important risk factors include atherosclerosis, cardiac surgery and the presence of aortic aneurysm. Dissecting aneurysm epidemiology is significantly different in younger patients (under 40 years). In this cases Marfan syndrome and similar diseases have a major importance [2].
Marfan syndrome is an autosomal dominant, multisystem inherited disorder of the connective tissue, characterized by highly variable clinical manifestations. Today its diagnosis is still based on the Ghent criteria. Reconsidered in 2010 Ghent criteria are characterized by clinical orientation. Instead of many features found in Marfan syndrome, the two main and specific
features have been allocated. These features are dilatation / dissection and ectopia (subluxation) of the lens [3].
The most popular world classifications are based on the principle of localization of fenestration, direction and stages of separation in aortic dissection. According to the Stanford classification, dissections including an aneurysm of the ascending aorta and arch refer to the type A (proximal), all the others - to the type B (distal) [4].
To determine the clinical stage of the dissection, M. Wheat and colleagues classification is used, according to which the acute stage is determined by the bundle up to 2 weeks, subacute -up 3 months, chronic - more than 3 months [4]. According to the most common in Russia classification by DeBakey: type I - the defeat of the ascending and descending aorta; type II -isolated involvement of the ascending aorta; type III - the defeat of the descending aorta (Fig.1).
Type I Type II Type III DeBakey
Stanford
Type A Type B
Figure 1. Classification of dissecting aortic aneurysms
Clinical case
A 38-year-old man was admitted to the emergency department of the Republican Clinical and Diagnostic Center in Izhevsk from Glazov city hospital on 29th January 2014. On admission he complained of expressed fatigue, general weakness.
Anamnesis morbi. The patient considers himself to be ill from January 22, 2014, when dyspnea, general weakness after defecation suddenly appeared. Then he felt a short-term intensive stabbing chest pain radiating to the spine. He called an ambulance. On examination, blood pressure was 100/60 mm Hg. Electrocardiogram revealed complete blockage of the right bundle branch block. Medical assistance was provided in the form of an intramuscular injection of nonsteroidal anti-inflammatory drug because of the persisting non-intensive aching pain in the thoracic spine.
On January 23, 2014 the patient visited a primary care physician according to the place of residence in the town of Glazov. The patient complained of discomfort in the throat, feeling of "heat" in the body, stabbing pain in the back with a deep breath. On examination hyperemia of the posterior pharyngeal wall, body temperature rise up to 37.5 ° C, blood pressure 100/60 mm Hg were revealed. Work incapacity certificate was issued. These symptoms were defined as the clinical diagnosis of "acute respiratory viral infection, dorsopathies cervical-thoracic spine." The patient was recommended to undergo antiviral and symptomatic treatment, further examination in the form of an ultrasound examination of brachiocephalic vessels. On January 28, 2014 neck vessels auscultation revealed pathological changes. Echocardiography was recommended, during which on 29 January 2014 aneurysm of the thoracic aorta was revealed. On January 29, 2014 the primary care physician assigned hospitalization in Glazov city hospital. After telemedicine consultations because of the severity of identified disease and the need for further additional examination a direction on hospitalization to the Republican Clinical and Diagnostic Center in Izhevsk was given. On January 29, 2014 the patient was transported and admitted to the Department of Emergency Conditions Correction at the Republican Clinical and Diagnostic Center
in Izhevsk, then he was transferred for further observation to the Department of Anesthesiology and Intensive Care. On January 31, 2014 he was transferred to the Department of Acute Myocardial Infarction №2 for further observation.
Anamnesis vitae. Born in Glazov. Higher technical education. He didn't serve in the army due to the presence of the Military Department at the university. He works as an engineer. He is married and has a 10-year-old daughter.
Past medical history. Colds, arterial hypertension from the age of 16, mitral valve prolapse from 16 years of age, complete right bundle branch block from 18 years of age, myopia from childhood. He passed examination and dynamic observation by a cardiologist before the age of 20. No further examinations.
Allergic history. Pets (cats fur (+) rabbit fur (±), horse dander (±), house dust (++), feather pillows (±), library dust (+), mites (+) - nasal congestion, itching, lacrimation, injected sclera.
Heredity. Patient's grandfather (the male line), the father died from the rupture of an aortic aneurysm. According to the patient a daughter has chest deformation, clinodactyly, like his father.
Objective status at admission. Medium severity status. Acrocyanosis. Patient has normosthenic body build, visible pulsation of the aorta in the jugular fossa and neck vessels pulsation ("carotid dance"). There are some dysembryogenesis signs (Figure 1, 2): Gothic palate, keeled chest, thoracic spine scoliosis, webbed fingers, clinodactyly. Vesicular breathing, decreased breath sounds to the left angle of the bladebone, moist rale in the lower parts of both sides; rhythmic heart sounds, short systolic murmur at the apex of the heart, musical systolic murmur along the left sternal border, protodiastolic decreasing murmur in the aorta, loud second heart sound on the pulmonary artery; blood pressure is 120/80 mmHg, heart rate is 84 per minute. Abdomen is soft, painless. The liver does not project from under the costal arch. No edema. Costovertebral tenderness is negative on both sides.
Figure 2. Dysembryogenesis signs
Figure 3. Dysembryogenesis signs
Laboratory data. There was no evidence of anemia in the general analysis of the blood. In biochemical analysis the blood cholesterol level is 5.6 mmol / l, LDL - 2.3 mmol / L, HDL - 0.81 mmol / l, TG - 2.3 mmol / l, IA - 3.7%. High fibrinogen levels in the analysis ranging from 5.69 g / l to 10.2 g / L, activated partial thromboplastin time (APTT) is prolonged to 33.5 seconds. Troponin is negative.
Total analysis of urine is without negative dynamics.
The ELISA overall is negative for syphilis.
Hepatitis B data is negative. HIV antibodies are not present. Hepatitis C data is negative.
Qualitative reaction for occult blood in the feces is negative.
Throat culture diphtheria is negative.
Blood group 0, Rh-positive.
Electrocardiography (January 29, 2014)
ECG sinus rhythm; heart rate is 88 per minute. Complete blockade of the right bundle branch
block.
Chest X-ray from January 31, 2014
Conclusion: The increase of the left ventricle, aortic atherosclerosis, peribronchial fibrosis, relative mitral insufficiency, moderate central venous stasis.
Radiography of the heart in 3 projections with contrast esophageal (February 14, 2014)
Conclusion: aneurismal dilatation of the ascending, descending parts and the aortic arch. Atherosclerosis of the aorta. Moderate central venous stasis. Left ventricle enlargement.
Echocardiography (January 29, 2014) (Glazov)
Aorta: from the sinus of Valsalva and further extension up to 4.5-5.6 cm, with the dissection of the intima, which is cut off from the place of the fibrous ring and further is located in the sinus and the descending section of the cord on both sides; descending aorta is expanded to 4.5 cm. Aortic Valve: fibrotic cusps, opening is complete 2,6, regurgitation grade 3-4. Mitral valve: thin cusps, full opening, regurgitation of 1 degree. Pulmonary valve: without features. Pulmonary artery: at the valve level - 1.6 cm, recorded systolic laminar flow of 0.9 m / sec. The left atrium is 3.5 cm. The left ventricle: end-diastolic volume is 4.8 cm, end-diastolic size is 7.1 cm, ejection fraction is 60%. Interventricular septum is 1.3 cm; posterior wall of the left ventricle is 1.3 cm. Transverse dimension of the right ventricle is 2.9 cm. Right atrium is 3.8 cm. Summary: thoracic aorta aneurysm, acute aortic valve regurgitation grade 3-4.
Echocardiography (January 29, 2014) (Izhevsk)
Mitral valve: the cusps are without features, regurgitation is of 1 degree, the ring diameter is 36 mm. The aortic arch is 28 mm, descending part is 27 mm, the base of the aorta - ring diameter is 28 mm, on the sinus of Valsalva level is 53 mm, ascending part is 40 mm. Aortic valve: thin cusps, opening is normal, regurgitation grade 3. Tricuspid valve: the cusps are without features, regurgitation grade 3, ring diameter is 34 mm. Pulmonary artery has ring diameter of 26 mm. The pulmonary valve is without features, signs of pulmonary hypertension, the pressure is 42 mm Hg. The left atrium is 44 x 58 mm. The right atrium is 43 x 53 mm. Right ventricle: the size is 39 mm in diastole. The left ventricle: end-diastolic size is 67 mm, end-systolic size is 41 mm, end-diastolic volume is 231 ml, systolic volume is 74 ml. Ejection fraction is 68%. Posterior wall thickness is 9 mm in diastole. Interventricular septum is 9 mm. Atrial septal is without features. Separation of the pericardial leaflets behind the posterior wall of the left ventricle is 2-3 mm, behind the right atrium is 4 mm, over the anterior wall is 2 mm. In the ascending part and the aortic arch linear hyperechoic signals (intima) are located. Conclusion: aneurysm of the ascending aorta and the arch of the aorta, aortic valve regurgitation grade 3, dilation of the left ventricle, dilation of the left atrium, dilation of the right atrium, mitral valve insufficiency of 1 degree, tricuspid valve insufficiency of 1 degree, the symptoms of pulmonary hypertension, minor pericardial effusion.
Ultrasound examination of abdominal aorta (January 29, 2014) (Izhevsk) Visualization is extremely difficult due to tympania. The abdominal aorta is visualized in fragments, the diameter in the suprarenal department is 20.4 mm, in the infrarenal section - 19.6 mm, at suprarenal and infrarenal levels in the lumen of the abdominal aorta hyperechoic linear echo structure is visualized on the front-side wall, moving with the current blood, extending from the front wall by about 0.84 cm, with the blood flow between the portions of the echo structure and the walls of the aorta, the incidence of echo structure is not determined (gas in the intestinal canal). Dissection of the intima of the abdominal aorta beginning with the suprarenal department
is not excluded.
Multispiral computed tomography - aortography (January 30, 2014) (Izhevsk)
It is performed during bolus intravenous contrast of 0.6 mm slice thickness. Reactions to the contrast agent is not noticed. Mediastinum is not displaced, differentiated in its structure, the pericardium is thickened. Diameter of vessels: the pulmonary trunk - 32 mm, the right pulmonary artery - 23 mm, the left pulmonary artery - 21 mm, the superior vena cava - 24 x 15mm, the inferior vena cava - 31 x 22 mm. The ascending aorta at the level of the sinus of Valsalva is 60 mm, at the level of the pulmonary bifurcation - 39 mm, detachment of the intima from the sinus of Valsalva (true channel size of 47 x 38 mm, false - 43 x 15 mm) extending to the full length of the aorta to the bifurcation, with the transition to the mouth of the left common iliac artery is determined. Brachiocephalic trunk - 18 x 14 mm, moving away from the false and true channels, with the spread of intimal detachment of over 40 mm proximal brachiocephalic trunk. The left common carotid artery - 10 mm, departing from the true channel. The left subclavian artery - 14 mm, departing from the true channel. The aortic arch - 35 mm, the true channel dimensions - 35 x 20 mm, false - 24 x 15 mm. The descending aorta - 34 mm. Abdominal aorta at the level of diaphragm crura - 24 mm, the true channel dimensions - 22 x 13 mm, false - 24 x 12 mm. Celiac trunk diameter is 11 mm, blood supply from true channel. Superior mesenteric artery - 11 mm, blood supply from true channel. Aorta diameter on the level of renal arteries is 25 mm, the true channel dimensions - 24 x 11 mm, false - 24 x 13 mm. Right renal artery has a diameter of 6 mm on the mouth, moving away from the true channel. Left renal artery has a diameter of 6 mm on the mouth, moving away from the true channel. Aorta diameter on the level of bifurcation is 23 mm, the true channel dimensions - 17 x 9 mm, false - 18 x 14 mm. Right common iliac artery - 12 mm, blood supply from false channel. Left common iliac artery - 14 mm, blood supply from false channel.
Conclusion: dissecting aortic aneurism of thoracic and abdominal aorta (Figure 3).
Sensation 40 Ex: 1
ThorAngio 5.0 SPO C: OMNIPAQUE , Se: 6/5
Im: 23/56 M
Con A210.9 M
100.0 kV 322 0 mA Tilt: 0.0 0.4 s
Lin:DCM/Lin: W:300 L:40
Figure 4. Multispiral computed tomography - aortography
Ultrasound examination of abdomen organs (February 05, 2014) (Izhevsk) Conclusion: Diffuse changes of the pancreas.
Ultrasound examination of the kidneys (February 05, 2014) (Izhevsk) Conclusion: ultrasound picture corresponds to the age.
Ultrasound duplex scanning of brachiocephalic vessels (February 05, 2014) (Izhevsk)
In carotid arteries hemodynamically significant stenoses were not revealed.
The value of intima-media complex standardized sections: on the common carotid artery d = 0,5 mm, s = 0,5 mm, at the bifurcation of the common carotid artery on the left and right = 0.6 mm, differentiation into layers is not broken. Brachiocephalic trunk with signs of intimal abruption with transition into the common carotid artery for up to 3 cm. Internal carotid artery on the right has a C-shaped curve. The right vertebral artery diameter = 3.9 mm, the left vertebral artery diameter = 4.5 mm, S-shaped crimp of the right and left vertebral artery segments V1 and V2 (hemodynamically insignificant). Subclavian, jugular, vertebral veins are freely passable throughout, bloodstream is phased, the diameters are within normal limits.
Conclusion: echo signs of dissection of brachiocephalic trunk with the transition to the common carotid artery with hemodynamically insignificant angiopathy, C-shaped bend of the right internal carotid artery, S-shaped crimp of the right and left vertebral artery segments V1 and V2.
Ultrasound of lower limb veins (February 05, 2014)
the veins of the lower limbs are freely passable, compressible, blood flow is phased.
Doppler ultrasound of lower limb arteries (February 05, 2014)
Blood flow in the main arteries of the lower extremities, ischemia is not revealed.
Fibrogastroscopy (February 13, 2014)
Conclusion: Surface gastrobulbitis. Duodenal reflux.
The patient visited a dentist with extraction of carious teeth under local anesthesia, an allergist, a pulmonologist, ophthalmologist, neurologist, urologist.
The treatment included cefotaxime, diazepam, metoprolol succinate, amlodipine, indapamide.
During the treatment the patient's condition is stable, he does not show complaints actively. Physical activity is limited to bed rest.
Dynamics of the blood pressure was from 110/50 to 160/90 mm Hg, heart rate - from 70 to 84 beats per minute.
On February 05, 2014 telemedicine consultation with the Bakulev Scientific Center of Cardiovascular Surgery (Moscow) was held. The patient needs to be operated in a planned manner.
On February 23, 2014 the patient is sent to the Bakulev Scientific Center of Cardiovascular Surgery (Moscow) for the surgical treatment with the diagnosis:
Marfan syndrome. The dissecting aortic aneurysm of the thoracic and abdominal aorta (DeBakey type I) with transition to the brachiocephalic trunk, common carotid artery. Complete blockade of the right bundle branch block. Aortic valve insufficiency of 3-4 degree. Chronic heart failure of 2A degree, functional class 2 of NYHA. Arterial hypertension of 3 degree, stage III. Risk 4.
Venous congestion, vasomotor spasm of the arteries of the retina in both eyes. Mild myopia in both eyes. Subluxation of the lens of the right eye.
Encephalopathy of 1 degree (hypertensive, atherosclerotic) with soft neurological sign. Bronchial asthma, atopic form, mild course. Respiratory failure of 1 degree on the mixed type.
Allergic rhinitis. Allergic conjunctivitis. Sensitization to household allergens.
02/28/2014 the operation was performed to the patient.
In conclusion, it must be noted that dissecting aortic aneurysm is a life-threatening, difficult to diagnose pathology, because it can mimic other diseases. Such mimicry of this severe pathology is the cause of high mortality of patients. Aortic dissection is a diagnosis, which should not be lost from sight of a physician in the differential diagnosis of diseases associated with acute pain in the chest, abdomen and back. The earlier the disease is properly diagnosed, the better chance we have to save the patient, despite the high percentage of mortality in the acute period. We need consistency and continuity between primary care, diagnostic services, transportation stages, intensive care, cardiology and cardio surgery medicine sectors.
REFERENCES
1. ESC Guidelines for the diagnosis and treatment of diseases of the aorta in 2014
The Working Group on the diagnosis and treatment of diseases of the aorta of the European Society of Cardiology (ESC). Authors / working group members: Raimund Erbel * (Chairman) (Germany), Victor Aboyans * (Chairman) (France), Catherine Boileau (France), Eduardo Bossone (Italy), Roberto Di Bartolomeo (Italy), Holger Eggebrecht (Germany), Arturo Evangelista (Spain), Volkmar Falk (Switzerland), Herbert Frank (Austria), Oliver Gaemperli (Switzerland), Martin Grabenwöger (Austria), Axel Haverich (Germany), Bernard lung (France), Athanasios John Manolis (Greece), Folkert Meijboom (Netherlands), Christoph A. Nienaber (Germany), Marco Roffi (Switzerland), Hervé Rousseau (France), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Regula S. von Allmen (Switzerland), Christiaan J. M. Vrints (Belgium).- P. 28-38.
2. Hagan P.G., Nienaber C.A., Isselbacher E.M. et al. The international registry of acute aortic dissection (IRAD): new insights into an old disease // JAMA. - 2000. - Vol. 283. - P. 897-903.
3. Russian clinical guidelines. Section IV. Hereditary disorders of connective tissue. Diagnosis and treatment. Moscow, 2014, P. 224-225.
4. Belov YV, Komarov RN Theoretical and practical aspects of the classification of thoracoabdominal aortic aneurysms// Surgery. Journal of them. NI Pirogov. - 2007. №5 - P. 64-67.
ASSESSMENT OF MUCOGINGIVAL PATHOLOGY AMONG PATIENTS WITH FULL REMOVABLE ARTIFICIAL ORTHOPEDIC LIMBS
Abstract
168 patients using full removable artificial limbs less than for 2 years and having complaints were examined on periodontal reception. On the basis of complaints and dissatisfaction with artificial orthopedic limbs, the assessment of existence of mucogingival pathology is given.
Keywords
orthopedic rehabilitation, removable prosthetics, mucogingival pathology
AUTHOR
Natalya Vladimirovna Maksimova
PhD, Department of Surgical Stomatology, Ryazan Medical University after the Academician I.P. Pavlov of the Ministry of Health and Social Development of the Russian Federation, Ryazan, Russia. E-mail: [email protected]
Orthopedic rehabilitation of patients with full secondary edentia is one of the most difficult types of the stomatologic help [1, 4] in connection with loss of the majority of the anatomic-physiological reference points necessary for creation of a functional and stable design [2].
In clinical practice of orthopedic surgeons, who are engaged in removable types of prosthetics, there are cases of patients' dissatisfaction with the results of treatment [3, 6], which are shown in impossibility to use removable types of orthopedic artificial limbs in everyday life. According to A.I. Rybakov [5], up to 24% of patients with total absence of teeth do not use the made removable artificial limbs.
The most frequent reason of unsatisfactory use of removable artificial limbs is existence of clinically reasonable mucogingival pathology, which creates objective prerequisites to development of complications.
Unfortunately, it should be noted that prevention of these complications, which needs obligatory mucogingival surgery at stages of preprosthetic preparation, is observed in insufficient degree. Therefore there is an actual problem of preparation of prosthetic bed at stages of preparatory activities before orthopedic rehabilitation.
Research objective is to estimate existence of mucogingival pathology at the patients using full removable orthopedic artificial limbs.
Material and methods of the research. 168 patient aged from 64 till 85 years took part in the research. 90 women and 78 men had a full secondary edentia diagnosis; they have been using full removable artificial limbs within 2 years and showed complaints and had dissatisfaction with an orthopedic artificial limbs.
Clinical trial was conducted on the basis of dental clinic "Prime stomatology" in Ryazan. In relation to jaws, orthopedic artificial limbs were distributed as follows: 64 artificial limbs were on the lower jaw, 82 artificial limbs - on the top jaw and 22 full removable artificial limbs - on
