Clinical Snapshot
Colicky Costovertebral Angle Pain due to Symptomatic Aortic Ulcer
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A 72-year-old patient presented at our interdisciplinary emergency department with costovertebral angle pain that had started the evening before. The constellation of laboratory findings was suggestive of infection. Calculated empiric antibiotic therapy was initiated for suspected pyelonephritis. Over the hospital course, no microbial growth was detected. Since the cause of pain remained unknown, a computed tomography (CT) scan was obtained to confirm or rule out the likely diagnosis of symptomatic nephrolithiasis/urolithiasis. Instead, the CT scan revealed an abnormal contour bulge of the infrarenal aorta, extending dorsally into the body of the second lumbar vertebra . In a supplementary contrast-enhanced computed tomography, the bulge was identified as a penetrating aortic ulcer (PAU) of double the size of the aortic diameter, exerting pressure on the vertebral body (Figure 1). The symptoms were explained by the resulting atrophic lesion which had been present for weeks or months. Imaging did not reveal any morphological signs of spondylodiscitis. Maintaining the visceral arteries, the PAU was covered using a covered stent prosthesis which was placed percutaneously under local anesthesia (Figure 2). The symptoms improved in the further course. Thus, in order to ensure optimum diagnostic and therapeutic quality, it is necessary to re-evaluate potential alternative differential diagnoses again and again, even if the clinical diagnosis appears to be straightforward.
Franziska von Schimonsky, Behandlungsexzellenz des Bosch Health Campus, Robert-Bosch-Krankenhaus GmbH, Allgemeine Innere Medizin und Nephrologie, Franziska.vonSchimonsky@RBK.de
Dr. med. Laura Wiedemann, Prof. Dr. med. Alexander Maßmann, Behandlungsexzellenz des Bosch Health Campus, Robert-Bosch-Krankenhaus GmbH, Diagnostische & Interventionelle Radiologie und Nuklearmedizin
Conflict of interest statement: The authors declare no conflict of interest.
Translated from the original German by Ralf Thoene, M.D
Cite this as: von Schimonsky F, Wiedemann L, Maßmann A: Colicky costovertebral angle pain due to symptomatic aortic ulcer. Dtsch Arztebl Int 2024; 121: 546. DOI: 10.3238/arztebl.m2023.0224
