An 11-years-old boy presented with 7 days history of abdominal pain, precordial pain and intermittent hematemesis. The physical examination revealed appearance of anemia, precordial tenderness without other positive findings. Routine blood test was notable for Hb 60 g/L.
Contrast CT scan of the chest revealed a soft tissue dense mass close to the descending aorta (Figure 1 A and B). The mass and the adjacent artery were luminally connected and intensified substantially at the same time and to the same degree on the radiographic studies. The wall of the mass was slightly thickened and the inner surface of the wall was not smooth. The esophagus was deviated and became narrow due to compression (Figure 1 A). Axial maximum intensity projection (MIP) showed a linear metallic foreign body (Figure 1 C) and local airway moved forward and became flat. Volume rendering (VR) confirmed a rightside protruding mass adjacent to the beginning of the descending aorta (Figure 1 D). The gastroscopy showed ulceration of the esophageal mucosa (Figure 1 E).
Two days after admission, the boy suddenly became irritable and pale, with Hb 40 g/L. Bedside chest radiograph revealed left pleural effusion, left lung consolidation and atelectasis due to compression (Figure 1 F). The patient underwent urgent aortic angioplasty for the ruptured pseudoaneurysm. During surgery, pseudoaneurysm was found at the rear side of the beginning part of the descending aorta. The aortic wall was thickened and ulceration-prone, with a rupture of about 1.5 cm. A steel wire of about 2.0 cm long was found at the junction of the descending aorta and the pseudoaneurysm (Figure 1 G). Left hemothorax with a volume of about 500 ml was present and compression atelectasis occurred at left lung. It suggested that aneurysm formation of the descending aorta was related to foreign body (steel wire), which caused the perforation of the esophagus and damage of the descending aorta. Stump with edema and ulceration of the descending aorta was excised and sent for histopathology. The continuity was re-established with about 2.0 cm 20# Goretex graft. Residual wire was extracted.
In the postoperative period, the patient received 21 days antibiotic therapy with vancomycin and sulperazon, and his temperature returned to normal on the 14th postoperative day. He also made good cardiac recovery and extubation was performed on 1/st postoperative day. Chest X-ray on 6th postoperative day showed that left pleural effusion improved markedly (Panel H). Pathological examination of the resected specimen showed fibrinoid necrosis, massive haemorrhage and inflammatory cell infiltration (mainly neutrophils) of the intima, and a true degenerative aneurysm involving all three layers of the aorta. On 24th postoperative day, the patient was discharged without complication. At follow-up 1 month later, the patient recovered fully according to the gastroscopy.
Although the patient denied a history of swallowing any sharp and hard food or foreign body, such possibility could not be ruled out. Aortic pseudoaneurysm caused by foreign body is rare in children,1–3 and sometimes it can be misdiagnosed as cardiac diseases or gastric ulcer. Although rare, the possibility of false aortic aneurysm must be considered if patients are with pectoralgia accompanied by hematemesis. Contrast CT can help in diagnosis. If present, the patient should be sent to intensive care unit immediately because he can be in life-threatening condition at any time. The foreign body should also be closely monitored and surgical removal should be performed as soon as possible.
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2. Bullaboy CA, Derkac WM, Johnson DH, Jennings RJ. False aneurysm of the aorta secondary to an esophageal foreign body. Ann Thorac Surg 1985; 39: 275-276.
3. Mohanty AK, Flannery MT, Johnson BL, Brady PG. Clinical problem-solving. A sharp right turn. N Engl J Med 2006; 355: 500-505.