Methotrexate 15?mg/week was added as corticoid sparing agent and corticosteroids were tapered progressively. Outcome and follow-up After 6?months of ML 228 treatment, the patient is taking 7.5?mg/day of prednisolone and continues methotrexate. including vasculitis. Vasculitis can manifest with symptoms related to local vascular inflammation, or simply with fever and constitutional symptoms.3 Therefore, their diagnosis is dependent on careful clinical suspicion. The aorta can be affected by the inflammatory process in the course of a large vessel vasculitis, and in some cases, this can be the only location of disease. The most important diagnoses to consider are Takayasus arteritis (TA) and giant cell arteritis (GCA).3 We present a case of isolated aortitis that manifested with fever in a patient who presents no further symptoms or diagnostic criteria for TA or GCA. Case presentation A 49-year-old woman sought medical attention because of intermittent fever that lasted 2?weeks. She had no respiratory, neurological, gastrointestinal or urinary symptoms, and also denied arthralgia. She had a history of transient malar rash and gastro-oesophageal reflux treated with omeprazole. She lived in an urban area and worked in an office. She denied recent travel, animal contact or consumption of unpasteurised products. She had no significant family history. On examination, she presented a good general condition; she was eupnoeic and normotensive. She had no localised signs of infection, such as nuchal rigidity, ML 228 alterations in cardiopulmonary auscultation or in abdominal palpation, and no costovertebral angle tenderness or lymphadenopathy. Laboratory tests showed normocytic anaemia (haemoglobin (Hb) 9.6?g/dL, mean corpuscular volume 79.9?fL), increased inflammatory parameters with WASL 12?200 leucocytes/L with normal formula and sedimentation rate of 120?mm/h, C reactive protein (CRP) 196.8?mg/L. Renal function, coagulation, hepatic enzymology, lactate dehydrogenase and summary urine analyses were normal (table 1). Chest radiograph showed no pulmonary or mediastinal changes. Table?1 Baseline laboratory values Haemoglobin (11.5C15.510?g/L)9.6Mean corpuscular volume (78C96?fL)79.9Leucocytes (4.5C11.0109/L)12.20Neutrophils (40C75%)68.29Eosinophils (0.0C6.0%)0.41Basophils (0.0C1.0%)0.24Lymphocytes (15.0C45.0%)23.96Monocytes (2.0C11.0%)7.10Platelets (150C540109/L)499Sedimentation rate ( 20?mm/h)120C reactive protein ( 5.0?mg/L)196.8Urea (15.0C40.0?mg/dL)22Creatinine (0.51C0.95?mg/dL)0.80Sodium (136C145?mEq/L)139Potassium (3.50C5.10?mEq/L)4.1Chlorine (98C106?mEq/L)99Calcium (8.8C10.8?mg/dL)9.8Proteins (66C83?g/L)84.6Albumin (35C52?g/L)37.0Bilirubin (0.3C1.2?mg/dL)0.44Aspartate aminotransferase ( 35?U/L)17Alanine aminotransferase ( 35?U/L)16Creatine kinase ( 145?U/L)60Iron (60C180?g/dL)12Lactate dehydrogenase ( 247?U/L)182Ferritin (11C307?ng/mL)160Transferrin (2.00C3.60?g/L)1.93 Open in a separate window Investigations Blood cultures and urine culture were sterile. Serologies for HIV infection (fourth generation test), hepatitis virus, and were also negative. Investigation of anaemia revealed normal ferritin, no vitamin deficits, normal thyroid function and negative Coombs test. A transthoracic echocardiogram revealed no signs of endocarditis or valvular disease. As ML 228 there was no evidence of infection after the first stage of investigation, we directed our study to possible immunological and neoplastic causes. The patient had positive antinuclear antibody (ANA; 1/160, granular pattern) without specificity in an ELISA study, without complement consumption, negative antidouble stranded DNA, negative antiphospholipid antibodies, negative antineutrophil cytoplasmic antibody or negative rheumatoid factor. Electrophoresis of protein was normal and there was no proteinuria in 24?h urine collection. CT of the thorax and abdomen was performed, ML 228 which excluded the presence of abnormal lymph nodes or other signs of lymphoproliferative disease or tuberculosis. Since of an abnormally thickened aortic wall, the study was complemented with angio-CT, confirming regular concentric wall thickening of the entire aorta, from the aortic valve to the iliac bifurcation (figure 1). There was no involvement of the major branches of the aorta, and no stenosis ML 228 or aneurysmal dilatations. These findings were suggestive of aortitis. Open in a separate window Figure?1 Angio-CT of the aorta, coronal (left) and transversal (right) view: thoracic and abdominal aorta with regular continuous concentric thickening of the vascular wall (white arrows). Differential diagnosis The differential diagnoses of isolated aortitis include infectious and autoimmune aetiologies.3C5 Infectious aetiologies include acute bacterial infections, syphilis, tuberculosis.
