Motonobu Murai

Immunoglobulin G4―related coronary periarteritis in a patient presenting with myocardial ischemia

Recent studies suggest that the cardiovascular system might be a possible target of immunoglobulin G4-related disease. Here we present a 66-year-old man who was admitted to our hospital because of chest symptoms suggestive of acute coronary syndrome. Besides luminal narrowing of the coronary arteries, marked periarterial thickening around the coronary artery was observed by computed tomography coronary angiography. Serum immunoglobulin G4 levels of this patient were elevated (564 mg/dL). The patient underwent coronary bypass surgery. After incision of the pericardium, a glittery white-yellowish, elastic-hard periarterial mass surrounding the left circumflex artery could be seen. Histologic analysis of the biopsy specimen showed the formation of lymphoid follicles and the presence of immunoglobulin G4-positive plasma cells; therefore, the diagnosis was immunoglobulin G4-related coronary periarteritis accompanied by physiologically significant myocardial ischemia.

Aortic tumor or mobile thrombus: detection by multislice computed tomography.

To the Editor: We read with great interest the article by Loiselle et al. recently published in Echocardiography.1 The authors demonstrated the case with pedunculated, oval-shaped echogenic mass localized in the aortic arch detected by the transesophageal echocardiography, suggestive of mobile atheroma and/or thrombi. We also have recently experienced a case of a 70-year-old man who had pedunculated mobile mass that was detected by three-dimensional (3D) coronary computed tomography (CT) and transthoracic echocardiography. This aortic mass of 1.3 × 0.8 mm in size had irregular lobular structures, and was located at just distal to the right coronary ostium in the ascending aorta. He had undergone coronary artery bypass graft surgery for atherosclerotic coronary artery disease four years ago. He did not have significant neurologic symptoms or evidence of old cerebral infarction detected by brain MRI. Although aortic mass was found incidentally by coronary CT in this case, it is considered that mobile mass with relatively small size, as in our case, may not be easily detectable by chest CT if ECG synchronization is not performed. As Loiselle et al. pointed out, diagnosis of aortic mass may be rather difficult without histological assessment. In our case, MR imaging was not able to provide definitive information regarding the histological characteristics. Nevertheless, the pedunculated small mass, which was localized near the right coronary ostium, was attached to the aortic atheroma; therefore, it was considered to be more likely an aortic thrombus than aortic tumor. We initiated an anticoagulation therapy with warfarin. Although anticoagulation therapy for one month did not apparently change the size of the mass, the responsiveness to the anticoagulation therapy should be awaited for longer period to verify the throbus, as was discussed in the Loiselle et al.’s paper.1 We have to pay attention to abnormal intraaortic structures when CT coronary evaluation is performed, as 3D multislice coronary CT angiography would facilitate the detection of abnormal structures not only in the heart, but also in the thoracic aorta,2 lung, and other neighboring organs.