This post is adapted for the Health & Medical Case Studies created by the Master of Medical Biotechnology program of the University of Windsor. This work licensed under a Creative Commons Attribution-NonCommercial (CC BY-NC-ND) 4.0 International License.
35 Case 1-2010: A 68-year-old male with breathlessness
Lower respiratory tract infection and rapid expansion of an abdominal aortic aneurysm: a case report. Journal of Medical Case Reports,2010, 4(1). doi: 10.1186/1752-1947-4-333
Naylor, S., Gamie, Z., Vohra, R., Puppala, S., Kent, P., & Scott, D.
Case Summary 1
A 68-year-old Caucasian male was admitted with a contaminated lower respiratory tract infection (LRTI), increasing back pain and epigastric discomfort. This patient’s medical history includes consistent cigarette smoking for 20 years, a coronary artery bypass graft for ischemic heart disease, and an existing aortic aneurysm. Clinical examinations showed tender epigastrium and left bronchopneumonia. A computed tomography (CT) aortogram, CT thorax, and coronal CT angiogram were used to further investigate this patient’s condition and diagnosis.
Learning Objectives
- Investigating the clinical history of the patient and selecting appropriate examinations to identify this respiratory infection.
- Correlating the patient’s symptoms and the case study clinical examinations to narrow down the possible diagnosis.
- Familiarizing and defining new medical terminology associated with this patient’s condition.
- Extrapolating key lifestyle factors that have contributed to the respiratory infection and preventative measures that can be put in place to ensure the future health of the patient.
Clinical History 1
- Age: 68 years old
- Sex: Male
- Ethnicity: Caucasian
Medical History 1
- Has been previously diagnosed with infra-renal AAA which had been monitored for six-months.
- Maximum diameter was 4.9 cm, grown to 5.2 cm over one year.
- Most recent ultrasound scan was conducted two months before admission.
- Maximal diameter of the AAA was 5.4 cm.
- 20 years of cigarette smoking.
- Ischemic heart disease thus underwent coronary artery bypass graft in 1987.
Symptoms 1
- Shortness of breath
- Presumed community acquired LRTI (lower respiratory tract infection)
- Increasing back pain
- Epigastric discomfort
- 48-hours after admission, patient experienced pre-syncope with brief periods of hypertension
Examinations (Clinical Assays/Tests/Imaging) 1
Physical Examination 1
- Hemodynamically stable, however pyrexial and hypoxic.
Clinical Examinations 1
- Signs of tender epigastrium.
Blood Investigations 1
- Leukocytosis with neutrophilia: 15.03 x 109/L (Normal range: 2.5-7.5 x 109/L)4
- Confirmed non-leaking 5.6 cm AAA (abdominal aortic aneurysm) (figure 1, yellow arrow).
- Extensive lower lobe consolidation and collapse with hilar lymphadenopathy was observed (figure 2, yellow arrow).
- Due to symptoms of hypotension 48-hours after admission, a repeat CT aortogram was conducted revealing the increased size of the AAA to 7.0 cm (figure 3, yellow line). This would also reveal retroperitoneal fat stranding (figure 4, yellow line).
- No significant angulation (changes in angle formation) was shown in the neck of the aneurysm. The juxta-renal diameter (aneurysms adjacent to renal artery origins) had been 22.1 mm before increasing to 25.4 mm in its infra-renal (below the renal artery origins) segment (figure 4).
- These repeat CT scans revealed significant stenosis (narrowing) of the left common iliac artery.
Question & Answers Leading to Diagnosis:
Question 1: Considering the patient’s previous medical history and current symptoms, what diagnosis could we expect?
Question 2: From the patient’s respiratory symptoms, lab investigations and CT scans, what is the confirmatory diagnosis?
Question 3: The CT scans have shown AAA expansion and lower lobe consolidation, what biomarkers could be used to support this diagnosis? How can both diagnoses be correlated?
** For answers please check the next chapter.
Medical terminology/Abbreviations:
- Abdominal aortic aneurysm (AAA) – The enlargement of the lower area of the major vessel which supplies blood to the body.10
- Chemokines – A family of chemoattractant cytokines which are secreted by cells in response to the body’s immune system.11
- Computed tomography (CT) aortogram – A technique using CT scanning and an injection of contrast material into the blood vessels to examine and diagnose cardiovascular diseases. 12
- Computed tomography (CT) thorax – An imaging test to examine organs and chest using X-ray and computer technology. 13
- Coronal computed tomography (CT) angiogram – A technique using CT scanning and an injection of contrast material into the blood vessels to evaluate structure and patency of arteries suppling lower limbs and abdomen with blood. 14
- Coronary artery bypass graft – Surgery redirecting blood around a blocked artery of the heart. 15
- Cytokines – Group of glycoproteins, peptides and proteins secreted by cells in response to the immune system, they regulate and mediate immunity. 16
- Epigastric – Upper central region of the abdomen. 17
- Growth factor – Substance required for growth stimulation in living cells. 18
- Hypoxic – Condition where the areas of the body or the body does not have an adequate oxygen supply at the tissue level. 19
- Ischemic heart disease (or coronary heart/artery disease) – Disease with the heart is getting an inadequate supply of blood and oxygen due to narrowing of arteries. 20
- Lower respiratory tract infection (LRTI) or pneumonia – Infection that involves the lungs abscess and acute bronchitis. 21
- Pro-inflammatory biomarkers – Regulatory proteins that can be used to detect inflammation. 22
- Sepsis – Condition where the body’s response to an existing infection begins to damage it’s own tissues, this can be a potentially life-threatening. 23
- Stenosis – Narrowing of the diameter of bodily passages. 24
References
- Naylor, S., Gamie, Z., Vohra, R., Puppala, S., Kent, P., & Scott, D. (2010). Lower respiratory tract infection and rapid expansion of an abdominal aortic aneurysm: a case report. Journal Of Medical Case Reports, 4(1). doi: 10.1186/1752-1947-4-333
- Thoracic aortic aneurysm – Symptoms and causes. (2021). Retrieved 9 April 2021, from https://www.mayoclinic.org/diseases-conditions/thoracic-aortic-aneurysm/symptoms-causes/syc-20350188
- 3.0 Introduction – Tobacco in Australia. (2021). Retrieved 9 April 2021, from https://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-0-background
- Leukocyte Count (WBC): Reference Range, Interpretation, Collection and Panels. (2021). Retrieved 9 April 2021, from https://emedicine.medscape.com/article/2054452-overview
- Middleton, R. K., Lloyd, G. M., Bown, M. J., Cooper, N. J., London, N. J., & Sayers, R. D. (2007). The pro-inflammatory and chemotactic cytokine microenvironment of the abdominal aortic aneurysm wall: a protein array study. Journal of vascular surgery, 45(3), 574–580. https://doi.org/10.1016/j.jvs.2006.11.020
- Wallinder, J., Bergqvist, D., & Henriksson, A. E. (2009). Proinflammatory and anti-inflammatory cytokine balance in patients with abdominal aortic aneurysm and the impact of aneurysm size. Vascular and endovascular surgery, 43(3), 258–261. https://doi.org/10.1177/1538574408324617
- Gallagher, P. M., Lowe, G., Fitzgerald, T., Bella, A., Greene, C. M., McElvaney, N. G., & O’Neill, S. J. (2003). Association of IL-10 polymorphism with severity of illness in community acquired pneumonia. Thorax, 58(2), 154–156. https://doi.org/10.1136/thorax.58.2.154
- Monaco, M., Di Tommaso, L., Oliviero, U., Iannelli, G., & Stassano, P. (2008). A rapidly expanding descending thoracic aortic aneurysm: an unusual complication. Journal of cardiac surgery, 23(3), 260–261. https://doi.org/10.1111/j.1540-8191.2007.00525.x
- Mory, M., Hansmann, J., Allenberg, J. R., & Böckler, D. (2007). Images in vascular medicine. Rapid expansion of an inflammatory abdominal aortic aneurysm. Vascular medicine (London, England), 12(4), 381–382. https://doi.org/10.1177/1358863X07083276
- Abdominal aortic aneurysm – Symptoms and causes. (2021). Retrieved 9 April 2021, from https://www.mayoclinic.org/diseases-conditions/abdominal-aortic-aneurysm/symptoms-causes/syc-20350688
- Chemokines: Introduction | British Society for Immunology. (2021). Retrieved 9 April 2021, from https://www.immunology.org/public-information/bitesized-immunology/receptors-and-molecules/chemokines-introduction
- (ACR), R. (2021). CT Angiography (CTA). Retrieved 9 April 2021, from https://www.radiologyinfo.org/en/info/angioct
- Computed Tomography (CT) Scan of the Chest. (2021). Retrieved 9 April 2021, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/ct-scan-of-the-chest
- SWSLHD – Medical Imaging – Abdominal Aortagram. (2021). Retrieved 9 April 2021, from https://www.swslhd.health.nsw.gov.au/medicalImaging/serv_CT_Aortagram_Abdominal.html
- Coronary bypass surgery – Mayo Clinic. (2021). Retrieved 9 April 2021, from https://www.mayoclinic.org/tests-procedures/coronary-bypass-surgery/about/pac-20384589
- What are Cytokines. (2021). Retrieved 9 April 2021, from https://www.sinobiological.com/resource/cytokines/what-are-cytokines#:~:text=Cytokines%20are%20a%20large%20group,regulate%20immunity%2C%20inflammation%20and%20hematopoiesis.
- (2021). Retrieved 27 April 2021, from https://www.healthgrades.com/right-care/digestive-health/epigastric-pain
- Oxford Learner’s Dictionaries | Find definitions, translations, and grammar explanations at Oxford Learner’s Dictionaries. (2021). Retrieved 27 April 2021, from https://www.oxfordlearnersdictionaries.com/
- Samuel J., Franklin C. (2008) Hypoxemia and Hypoxia. In: Myers J.A., Millikan K.W., Saclarides T.J. (eds) Common Surgical Diseases. Springer, New York, NY. https://doi.org/10.1007/978-0-387-75246-4_97
- Institute of Medicine (US) Committee on Social Security Cardiovascular Disability Criteria. Cardiovascular Disability: Updating the Social Security Listings. Washington (DC): National Academies Press (US); 2010. 7, Ischemic Heart Disease. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209964/
- Therapeutic Guidelines Limited. (2014). Therapeutic guidelines. West Melbourne, Victoria.
- van den Berg, R., Jongbloed, E., de Schepper, E., Bierma-Zeinstra, S., Koes, B., & Luijsterburg, P. (2018). The association between pro-inflammatory biomarkers and nonspecific low back pain: a systematic review. The Spine Journal, 18(11), 2140-2151. doi: 10.1016/j.spinee.2018.06.349
- Sepsis – Symptoms and causes. (2021). Retrieved 27 April 2021, from https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214#:~:text=Sepsis%20is%20a%20potentially%20life,may%20progress%20to%20septic%20shock.
- Definition of STENOSIS. (2021). Retrieved 27 April 2021, from https://www.merriam-webster.com/dictionary/stenosis
Further Reading
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Infection that involves the lungs abscess and acute bronchitis.
upper central region of the abdomen
Surgery redirecting blood around a blocked artery of the heart.
Disease with the heart is getting an inadequate supply of blood and oxygen due to narrowing of arteries.
Abdominal Aortic Aneurysm - The enlargement of the lower area of the major vessel which supplies blood to the body.
Condition where the areas of the body or the body does not have an adequate oxygen supply at the tissue level.
A technique using CT scanning and an injection of contrast material into the blood vessels to examine and diagnose cardiovascular diseases.
In this case study, it represents the narrowing of blood flow and passage diameter.