Rapidly growing coronary artery aneurysm associated with pericarditis
A 61-year-old male with a history of diabetes, hypertension, and end-stage renal disease on hemodialysis had a fever accompanied with an elevated white blood cell count (11 300/μl), so he started antibiotics. Three days later, he complained of chest pain, and ECG revealed ST-elevation in II, III, and aVF (Fig. 1a). He was referred to the cardiology department of our hospital.
He underwent urgent coronary angiography (CAG). His middle right coronary artery had severe stenosis, and a bare metal stent was implanted. During the same CAG session, his left anterior descending showed two CAAs with a maximum diameter of 8 mm (Fig. 2a). After the procedure, his ECG started to show ST-elevation in almost all leads (Fig. 1b). Given the mild pericardial effusion on echocardiography (Fig. 1c and d), pericarditis was diagnosed.
After conservative therapy with antibiotics, the pericarditis resolved within 2 weeks. As follow-up, we performed CAG at day 19. The CAA had rapidly increased in size (Fig. 2b, maximum diameter from 8 to 20 mm). To avoid aneurysm rupture, the patient underwent coronary artery bypass and excision of the CAA. The pathology from a surgical sample showed severe acute and chronic inflammation with necrosis of the adventitia (Fig. 2c and d). The cause of pericarditis was unclear based on the findings of paired serum tests for viral infection. Blood and tissue cultures were both negative for bacteria.
CAA rapidly grew in size in association with pericarditis. A limited number of case reports concerning CAA with pericarditis are available 2,3. The interval between the initial symptom and CAA discovery varies from 1 day to 1 year. In most cases, Staphylococcus bacteria were found to be causative while systemic inflammatory disease has also been reported 4.