Emphysematous change as a red flag sign preceding rapid progressive infectious aortic disease: two case reports

Abstract Background Infectious aortic disease is a rare and fatal disease, that requires the appropriate intervention. An accurate diagnosis should be promptly established. However, this is difficult because the clinical manifestations of this disease vary and are non-specific. Case presentation (CASE 1) An 87-year-old male, presenting with generalized malaise and weight loss, was admitted for further examination. A chest computed tomography (CT) showed mediastinal emphysema. Empirical intravenous antibiotics were administered to address the non-specific infectious findings in the laboratory data. The treatment was effective, and the patient fully recovered. However, he was in shock due to the impending rupture of a rapidly progressive thoracic infectious aneurysm several days later. An emergency total aortic arch replacement was performed, and the patient was discharged. (CASE 2) An 82-year-old male was admitted due to general malaise and anorexia. The patient underwent Y-graft replacement in the abdominal aorta. Abdominal CT revealed emphysematous changes adjacent to the abdominal aorta. The patient responded favorably to empirical treatment with intravenous antibiotics and was discharged 19 days after admission. Four days after discharge, he was admitted again due to epigastric pain. He suddenly went into a state of shock. After an episode of hematemesis, the patient went into cardiac arrest. Abdominal CT revealed an enlarged stomach and duodenum, filled with massive high-density contents proximal to the abdominal aorta. He died of hemorrhagic shock despite cardiopulmonary resuscitation. Conclusion Although emphysematous change is rare, it is a red flag sign during the early stage of infectious aortic disease. Thus, physicians should remain vigilant for this kind of critical sign.