Partially thrombosed aneurysm of the abdominal aorta: Unusual cause of chronic inflammation and resistance to recombinant human erythropoietin
A 72-year-old male with nephroangiosclerosis was on maintenance hemodialysis (three sessions per week) for 10 years. He was a chronic smoker and had dyslipidemia treated with diet alone. His medications included: furosemide 500 mg in non-dialysis day, oral folic acid and vitamin B12, and monthly 75-150 μg of methoxy-polyethylene-glycol epoetin-beta. Biological monitoring revealed episodic elevations of C-reactive protein (CRP) ranging from 1 mg/l to 60 mg/l associated with a decrease of hemoglobin (Hb) levels without any other obvious cause of resistance to rHuEPO []. Serum ferritin, intact parathyroid hormone and aluminum levels were within the normal ranges. The mean Kt/v was 1.15. The patient had no malnutrition and his native fistula showed no malfunction.\nPhysical examination found no evidence for any local or systemic cause of this inflammation. His vital signs were: Temperature 37°C, pulse 74 beats/min, blood pressure 128/68 mmHg and respiratory rate 20 breaths/min. Biological tests including liver parameters and serum protein electrophoresis were normal. Serology for hepatitis B virus showed negative hepatitis B surface (Hbs) antigen, positive anti-Hbs, and anti-hepatitis B core antibodies with no current biological or morphological signs of chronic hepatitis. Serology for syphilis, hepatitis C, and HIV viruses were negative. Chest radiography and radiography of the sinuses were normal. Sputum examination for acid-fast bacilli and tuberculin skin test was negative. The ear-nose-throat and stomatological examination were normal. Tumor markers were normal. Main laboratory tests are summarized in .\nTransthoracic echocardiogram, blood culture, abdominal and pelvic ultrasound, eso-gastric endoscopy, and colonoscopy showed no abnormalities. As part of a screening study of vascular calcifications in hemodialysis, our patient underwent a lateral abdominal X-ray, which demonstrated diffuse calcifications of the abdominal aorta and a large aneurysm extending from the second to the fourth lumbar vertebra []. Multislice spiral computed tomography-angiography with 3D-reconstruction showed a saccular dilatation of the infrarenal segment of the abdominal aorta measuring 70 mm in height, 41 mm of anteroposterior diameter and 40 mm in transverse diameter with diffuse calcification of both anterior and posterior wall of the aorta extending to the primitive iliac arteries []. There was no evidence of dissection or rupture. Cross sections showed a partial thrombosis of the aorta wall []. The diagnosis of CIS complicating a partially thrombosed aneurysm of the abdominal aorta was then made. Antiplatelet therapy by lysine acetylsalicylate 160 mg/day was introduced to prevent embolic complications. Follow-up over last 6 months showed regression of inflammation, improvement of Hb level, and reduction of rHuEPO doses [].