Fever as a first manifestation of acute aortic dissection

We enjoyed the recently published article by Jansen Klomp and colleagues [1], concerning the pitfalls in the differential diagnosis of acute aortic dissection (AAD). In their cohort, the authors report a high percentage of initially missed diagnoses, increased to 31%. Atypical symptoms and signs disorientate physicians during diagnosis. We would like to focus on the importance of fever, an often overlooked sign, which may accompany AAD. Although rarely described among the classic manifestations of AAD, pyrexia is observed in one-third of cases, frequently as a first sign, especially in cases of painless dissections. Fever development may start with rigor, either simultaneously with AAD or preceding it by several days. Patients frequently present with pyrexia of unknown origin. It is not uncommon for fever accompanying painless AAD to be erroneously attributed to respiratory infections, leading to empirical treatment with antibiotics. Body temperature is often above 39 °C and left pleural effusion on chest X-ray is frequently seen. Left-sided effusions are due to irritation of the left pleura from its contact with the aorta, or even to leakage from the dissection per se [2]. Pericardial effusions are also frequent in this setting. Although the white cell count, erythrocyte sedimentation rate and C-reactive protein values are raised in febrile AAD, procalcitonin values remain normal, excluding an infective aetiology.