A Sleeping Giant

A CLINICAL PROBLEM-SOLVING article by Alanna Morris from Brigham and Women's Hospital, Boston.
A 71-year-old woman presented to her primary care doctor with abdominal pain and night sweats. Four weeks earlier, a headache, left maxillary sinus pressure, and intermittent night sweats had developed. Amoxicillin was prescribed for presumed sinusitis. Although her symptoms initially abated, after 1 week of treatment, new, diffuse abdominal pain developed, which was dull in character and persisted throughout the day. In addition, she had loose stools and anorexia; and worsening of her night sweats. During the 2 weeks before she saw her physician, she lost 4.5 kg (10 lb) in body weight and her headache recurred.
The patient was referred to the emergency room for further evaluation. She appeared to be in mild distress. She was febrile and tachycardic. Laboratory results were consistent with a systemic inflammatory response, possibly of rheumatologic origin.
The patient remained ill, with fever and abdominal pain. CT of the abdomen revealed abnormal intimal thickening of the thoracic and abdominal aorta that extended into the superior mesenteric artery and the proximal left common iliac artery. An MRI scan of the chest and upper abdomen confirmed diffuse intimal thickening and enhancement in the wall of the thoracic and abdominal aorta.
An interactive medical case related to this article is available at NEJM.org. [Original Article]