Aortic Aneurysm and Dissection in Giant Cell Arteritis

TO THE EDITOR:

The population review by Evans and colleagues [1] suggested an association between giant cell arteritis and aortic (thoracic and abdominal) aneurysms. The authors recommended that patients have an annual examination that includes palpation of the abdomen and a chest radiograph. Because polymyalgia rheumatica (with or without biopsy-proven giant cell arteritis) occurs in a population with many comorbid conditions, the true incidence of aortic disease has been difficult to assess. Regardless of statistical verification, however, a physical examination of the abdomen by any physician, especially rheumatologists who may see many associated vascular diseases, should always include palpation of the aorta.

The need for palpation of the aorta is shown by the following case report. A 76-year-old physician was in excellent health until late 1993, when he developed bilateral neck and shoulder pain, morning stiffness, and an erythrocyte sedimentation rate of 50 mm/h. When jaw claudication occurred and symptoms of pelvic girdle stiffness interfered with daily functions, he referred himself to a rheumatologist, who confirmed the suspected diagnosis of polymyalgia rheumatica. The patient began receiving prednisone in June 1994. In September 1994, after some improvement in joint symptoms, he suddenly collapsed and was found to have ruptured a previously undetected abdominal aortic aneurysm. Although the patient survived surgery, the graft became infected, and he died 4 months later. He never regained full consciousness.

Because this patient was my father, I took interest in reviewing all the physical examinations done before the rupture; to my dismay, I learned that none of his treating internists had completely examined the abdomen or palpated the aorta

Aortic aneurysms, both thoracic and abdominal. can now be repaired percutaneously using endoluminal grafts [2]. This advance greatly decreases the morbidity associated with repairing dissections and aneurysms (and, I hope, the morbidity and mortality associated with the disease process itself). As Evans and colleagues suggest, an abdominal examination is an important part of the evaluation of patients with polymyalgia rheumatica or giant cell arteritis. In the geriatric population, or in patients of any age, a complete examination of the abdomen should include the evaluation of the aorta.

• Copyright ©2004 by the American College of Physicians