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A 55 year old normotensive male smoker with seropositive nodular erosive rheumatoid arthritis (rheumatoid factor 390, normal range 0–20 IU/ml), controlled on sulfasalazine and indometacin, had a thoracic aortic aneurysm detected on routine chest radiography. Computed tomography (CT), with spiral reconstruction, confirmed that this started immediately distal to the left subclavian artery and was 7 cm in diameter and 13 cm in length. Just above the diaphragm the aorta began to dilate again, and at the level of the renal hilum was 4.5 cm in diameter. The thoracic aneurysm was resected and replaced with a 32 mm knitted polyester graft impregnated with gelatin.
Histology of the resected aorta (haematoxylin and eosin stain, original magnification ×100) showed features consistent with rheumatoid vasculitis with a panmural aortitis and an inflammatory cell infiltrate comprising mainly plasma cells and lymphocytes. There was distortion and thinning of the elastic media and adventitial fibrosis. The vasa vasorum showed a dense perivascular cuff of lymphocytes with Russell bodies, which represent deposits of immune complexes (arrowed).
Vasculitis occurs in fewer than 1% of patients with rheumatoid arthritis and usually only in those with severe deforming rheumatoid arthritis and high titres of rheumatoid factor. Large vessel involvement with aortitis occurs in 5% of patients with rheumatoid vasculitis. Aneurysm formation secondary to rheumatoid vasculitis is extremely rare and then usually affects the aortic root and ascending aorta.
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