Volumen 6, Número 1 Editoriales Genética del Lupus eritematoso generalizado New Drugs for Rheumatoid Arthritis: The Industry Point of View Originales Hiperlaxitud ligamentosa en población escolar Daño en pacientes cubanos con lupus eritematoso sistémico Fibromialgia: percepción de pacientes sobre su enfermedad Actualización Consenso SER de terapias biológicas en AR Revisiones Estrategias terapéuticas en el síndrome antifosfolipídico Fármacos en el embarazo y contracepción en enfermedades reumáticas Artículo especial Gripe A: Recomendaciones SER Resonancia de raquis completo (págs. 49-52) Reumatol Clin. 2010;6(5):273–274 www.reumatologiaclinica.org Images in clinical rheumatology Chronic back pain as the first symptom in the rupture of an abdominal aortic aneurism: presentation of 2 cases Lumbalgia crónica como primer síntoma en la rotura de aneurisma aórtico abdominal: a propósito de 2 casos clínicos Rosalía Martínez Pérez,* José Luis Marenco De La Fuente, Sergio Rodríguez Montero, and Carmen Escudero Servicio de Reumatología, Hospital Universitario de Valme, Valme, Seville, Spain *Corresponding author. E-mail address: rosalia-82@hotmail.com (R. Martínez Pérez). 1699-258X/$ - see front matter © 2009 Elsevier España, S.L. All rights reserved. Introduction Abdominal aortic aneurysm 1 is a dangerous entity, with a prevalence of 2%-5% in the general population and mortality in case of rupture of 80%. Up to 91% of cases are accompanied by low back pain, so it is important to include abdominal aortic aneurysm as a differential diagnosis in chronic low back pain. There are no population screening diagnostic procedures for its prevention, and it is generally an incidental finding during the study of other diseases. We present 2 cases of chronic low back pain caused by underlying aneurysmal rupture. Case reports Case 1. The patient was a 54-year-old male, smoker, with a history of ischemic heart disease, arterial hypertension and dyslipidemia, without prior arteriopathy or chronic bronchitis. He had been studied a year earlier due to constitutional symptoms, anaemia and thrombocytopenia. Abdominal CT scan revealed splenomegaly and lymphadenopathy. A liver biopsy showed periportal granulomas and focal centrilobular necrosis. Smear testing was negative. A year later, the patient attended consultation due to a disabling low back pain of 8 months’ evolution. Lasegue sign was negative, with strength, reflexes, sensation and sphincter function preserved. On admission, he presented hypotension (100/60 mm Hg) and a haematocrit drop; the consequent nuclear resonance examination revealed aortic aneurysm, with a dissection of 8cm below the left renal artery and at 8 mm caudal to the right renal artery. Laboratory tests highlighted ACE of 101 IU/ml (No. value), and hypocalcaemia (10.9 mg/dl). The treatment was prosthetics and bifemoral bypass. He required admission to the ICU, with favourable haemodynamic evolution. Treatment with prednisone (60 mg/day) was started due to a suspected sarcoidosis with secondary abdominal aneurysm, with a favourable clinical response. Case 2. The patient was a 58 year-old-male, a smoker, with a history of arterial hypertension, severe chronic peripheral arterial disease with left forefoot amputation and ischemic heart disease (stent in circumflex artery). He was admitted due to low back pain with inflammatory characteristics (negative Lasegue sign and strength, reflexes, sensitivity and sphincter function preserved) and initially treated with diclofenac, metamizole and tramadol, with no clinical improvement. The patient also reported inguinal irradiation of 6 months’ duration, so he was admitted to urology. After ruling out a urological disease, he was referred to rheumatology for study. A decrease in haemoglobin (from 11.6 to 8.6 mg/dl) and hypotension (100/50 mm Hg) were observed. Suspicion of an underlying vascular disease led to an abdominal CT scan being performed, which showed an infrarenal abdominal aortic pseudoaneurysm with signs of recent bleeding (Figure). The treatment prescribed was aortoiliac endoprosthesis, as well as iliofemoral and femorofemoral bypass in the left common iliac artery. Despite administration of 10 blood concentrates, infusion of norepinephrine and fluid resuscitation, haemodynamic instability and renal metabolic deterioration led to death. Discussion Abdominal aortic aneurysms can cause chronic back pain with or without radiculopathy or myelopathy. Radicular symptoms are caused by nerve compression of the aneurysm, especially between L5 and S1. 2 Symptoms last from 2 weeks to 2 years 3 ; in our 2 cases, symptom duration was 7±1.4 months. We have found only 16 cases of abdominal aortic aneurysm associated with chronic low back pain described in the literature