Lymphoplasmacytic Response to Atheroma Mimicking Vasculitis
Ann D Treacy, Katsuya Norita, Peter J Ingram, Mary N Sheppard. National Heart and Lung Institute at the Royal Brompton Hospital, London, United Kingdom; Institute of Forensic Medicine, Belfast, United Kingdom
Background: Coronary artery atheroma accounts for the vast majority of sudden cardiac deaths whilst coronary artery vasculitis accounts for a rare number. We report a series of atheromatous coronary arteries with associated florid lymphoplasmacytic inflammation mimicking vasculitis.
Design: Three cases with mass like lesions surrounding atheromatous coronary arteries were referred from a single centre to the National Heart and Lung Institute at the Royal Brompton Hospital for expert pathology review. The cases were from males with mean age 74 years (range 55 – 91). In all cases coronial autopsies were carried out for sudden deaths in the community. Past medical histories of note were hypertension (N=2) and ischaemic heart disease (N=1), with one patient having a past history of aortic aneurysm repair.
Results: At autopsy, firm, white and whorled masses were described surrounding atheromatous coronary arteries ranging in size from 9-25mm in diameter. Each coronary artery had intimal atheroma ranging from moderate to severe. A thrombus was identified in one case. No gross infiltration of the myocardium was seen. No vascular abnormalities or lesions were identified elsewhere. Histological sections showed a mixed inflammatory infiltrate extending from the media into the adventitia, composed predominantly of plasma cells and lymphocytes with rare neutrophils and eosinophils. No giant cells or epithelioid cells were noted. No necrosis was present. There was focal infiltration of the myocardium by lymphoid aggregates. There was accompanying dense fibrosis accounting for 50% of the mass size. The presence of intimal circumferential atheroma was confirmed in all cases. Myocardial fibrosis was identified in one case. No inflammatory infiltrate was present in the myocardium. Slides from all three cases were stained with IgG and IgG4 by immunohistochemistry. The stained cells were counted in three high power fields from areas with the highest density of plasma cells using a 40x objective and 10x eyepiece of an Leica microscope. The proportion of IgG4 expressing plasma cells was greater than 50% of IgG-expressing cells in two of the three cases.
Conclusions: Atheroma may be associated with mild chronic inflammation present in the intima or associated with plaques. IgG4 related disease has been described in various organ sites, we report a series of IgG4 related coronary artery vascular lesions in association with atheroma.
Wednesday, March 6, 2013 9:30 AM
Poster Session V # 55, Wednesday Morning