Bilateral Rasmüssen aneurysm in a patient with pulmonary tuberculosis: A case report

Abstract

We report the case of a 53-year-old male patient with Down syndrome and multiple comorbidities who presented with chest pain, dyspnea, hemoptysis, and fever. He had a history of type 2 diabetes, hypothyroidism, a nondocumented cardiopathy, and treated pulmonary tuberculosis. Radiological findings, including a chest CT scan, revealed bilateral apical cavitary lesions associated with bronchiolitis, consistent with active postprimary pulmonary tuberculosis, and a Rasmussen aneurysm in the both upper lobes. Unfortunately, the patient died from massive hemoptysis. This case highlights the importance of early recognition of vascular complications such as Rasmussen aneurysms in the setting of active tuberculosis.

Introduction

Tuberculosis can cause significant pulmonary damage, leading to complications like cavitary lesions and vascular involvement, including the formation of Rasmussen aneurysms. The latter is a rare but life-threatening complication that requires early identification and management. In this case, we describe a 53-year-old male with Down syndrome and a history of treated pulmonary tuberculosis who developed a bilateral Rasmussen aneurysm, which ultimately led to massive hemoptysis and death.

Case report

A 53-year-old male with Down syndrome was admitted to our hospital with a one-month history of progressive chest pain, fever, and general deterioration. Three days prior to admission, the patient developed dyspnea associated with mild hemoptysis, which prompted his presentation. He had a medical history of type 2 diabetes mellitus, hypothyroidism managed with levothyroxine, a nondocumented cardiopathy, and a history of pulmonary tuberculosis, for which he had completed a 6-month anti-tuberculosis regimen.

On clinical examination, the patient appeared febrile, with signs of respiratory distress and a reduced general condition. He had mild cyanosis and was tachypneic, but there was no significant fever. Physical examination revealed bilateral basal crackles and signs of respiratory effort. Laboratory results showed an elevated C-reactive protein (CRP), indicating inflammation, but there were no other significant abnormalities in the complete blood count or electrolytes.

A chest CT angiography was performed, revealing several key findings: bilateral upper lobe cavitary lesions with significant parenchymal destruction, communicating with adjacent bronchi, consistent with postprimary active tuberculosis. Additionally, vascular endocavitary lesions were observed, consistent with false aneurysms and suggestive of Rasmussen aneurysms. The scan also identified areas of bronchiolitis, particularly pronounced in the right upper lobe. The combination of these findings strongly indicated active pulmonary tuberculosis complicated by a Rasmussen aneurysm, a rare but severe complication of tuberculous cavities. Tragically, the patient experienced a sudden onset of massive hemoptysis, several hours after scan was performed, leading to rapid deterioration and subsequent death. Autopsy was not performed Fig. 1, Fig. 2, Fig. 3.

Fig. 1.

Axial chest CT angiography showing bilateral upper lobe cavitary lesions, with endocavitary false aneurysms, suggestive of a Rasmussen aneurysms.

Fig. 2.

Coronal chest CT angiography showing false aneurysms in both upper lobes.

Fig. 3.

Three-dimensional reconstruction of chest CT angiography showing false aneurysms.

Discussion

Tuberculosis (TB) remains a significant public health threat in the world. According to the World Health Organization (WHO), TB is the ninth leading cause of death worldwide and the leading cause of death from a single infectious agent, ranking above HIV/AIDS. In 2016, there were an estimated 1.3 million TB deaths among HIV-negative people (down from 1.7 million in 2000) and an additional 374,000 deaths among HIV-positive people (World Health Organization, 2017).

Rasmussen aneurysm is a rare complication of tuberculosis, where a pulmonary artery adjacent to a tuberculous cavity aneurysm may lead to life-threatening hemoptysis [1]. Pulmonary artery aneurysms are defined by a focal dilatation of a pulmonary artery involving all 3 layers of the vessel wall, whereas pseudoaneurysms do not involve all 3 layers, resulting in a higher risk of rupture [2]. It occurs due to a gradual weakening of the arterial wall adjacent to pulmonary cavitation [3]. Rasmussen's aneurysm is described in 5% of cavitary tuberculosis [4]. Another retrospective series of 189 patients utilizing multidetector CT reported a prevalence of 6.9% in patients with massive hemoptysis and tuberculosis [5]. Hemoptysis is a common presentation that can be fatal when massive, as occurred in our case. Life-threatening hemoptysis generally originates arterially, and this has a case fatality rate (CFR) of up to 80% if left untreated [6]. The imaging method of choice to evaluate this condition is CT pulmonary angiography, where the focal dilatation of the pulmonary artery branches can be visualized using intravenous contrast. However, due to the low incidence, the suspicion of Rasmussen aneurysm is often overlooked by radiologists [7]. Its management is frequently challenging, as the condition of the patients may deteriorate despite appropriate interventions. Endovascular management techniques like trans-arterial catheter embolization are the preferred management strategy. Embolization techniques can include glue embolization, coil packing, gel foam, detachable balloons, or stent grafts [8]. In Rasmussen's aneurysm, glue embolization is the preferred technique due to the fragility of the artery [9].

Conclusion

This case underscores the importance of early identification and management of complications associated with pulmonary tuberculosis in patients. Rasmussen aneurysm should be suspected in patients presenting with cavitary pulmonary lesions and hemoptysis, as it can be a life-threatening condition. Timely intervention, including imaging and endovascular procedures, is essential to prevent catastrophic outcomes such as massive hemoptysis.

Patient consent

Informed consent was obtained from the patient's next of kin included in this case report for the publication of their clinical details, images, and any potentially identifying information.