Mycotic aneurysm presenting as acute pyelonephritis

This report describes a 56-year-old man with a ruptured infected abdominal aortic aneurysm secondary to Salmonella bacteremia, initially presenting as acute pyelonephritis. Spike fever with severe back pain continued despite empiric antibiotic treatment at a local hospital. Hypotension with a sudden hemoglobin drop was observed on the second hospitalization day. Abdominal computed tomography to further examine the bleeding focus confirmed a rupture of the mycotic abdominal aortic aneurysm. This case was successfully treated through prompt surgical intervention and aggressive protracted antibiotic therapy. The case presented herein raises concerns about the uncommon but life-threatening mycotic aneurysm presented initially as acute pyelonephritis. Early diagnosis and appropriate surgical and antibiotic treatment of the Salmonella mycotic aortic aneurysm is crucial for a satisfactory outcome.     

MYCOTIC ANEURYSM PRESENTING AS ACUTE PYELONEPHRITIS

This report describes a 56-year-old man with a ruptured infected abdominal aortic aneurysm secondary to Salmonella bacteremia, initially presenting as acute pyelonephritis. Spike fever with severe back pain continued despite empiric antibiotic treatment at a local hospital. Hypotension with a sudden hemoglobin drop was observed on the second hospitalization day. Abdominal computed tomography to further examine the bleeding focus confirmed a rupture of the mycotic abdominal aortic aneurysm. This case was successfully treated through prompt surgical intervention and aggressive protracted antibiotic therapy. The case presented herein raises concerns about the uncommon but life-threatening mycotic aneurysm presented initially as acute pyelonephritis. Early diagnosis and appropriate surgical and antibiotic treatment of the Salmonella mycotic aortic aneurysm is crucial for a satisfactory outcome.     

Multiple mycotic arterial aneurysms involving the left anterior descending coronary artery following mitral and aortic valve endocarditis: A case report

We present a 57-year-old man with recent Streptococcus viridans endocarditis on mitral and aortic valves who had a mycotic aneurysm of the left anterior descending (LAD) coronary artery and associated superior mesenteric and cerebral artery aneurysms. The patient had preoperative renal failure and the infection was controlled with ceftriaxone. Mitral and aortic valve replacement were performed using tissue valves and the LAD aortic aneurysm was ligated and the patient had saphenous venous graft to the LAD. The postoperative course was complicated by pleural effusion and the patient had antibiotic therapy for 6 weeks postoperatively.     

Isolated gonococcal ascending aorta aneurysm

We present a very rare case of an acute septic infection and vegetative mycotic aneurysm caused by Neisseria gonorrhoeae in a 52-year old male. The aortic valve was bicuspid and calcified. He was successfully treated by the resection of the ascending aorta and the aortic valve with a replacement by separate prostheses, followed by 2 weeks of intravenous antibiotic therapy. The patient was followed up 18 months postoperatively with no signs of reinfection.     

Treatment of mycotic intracranial aneurysms

Two patients with mycotic intracranial aneurysms were successfully treated with only antibiotic therapy. One patient, who had subacute bacterial endocarditis, rheumatic valvular disease, and an abscessed tooth, sustained a subarachnoid hemorrhage from a ruptured right middle cerebral artery trifurcation aneurysm. The other patient, who had Turner's syndrome and probable congenital aortic stenosis, developed multiple neurological findings during an ipisode of acute bacterial endocarditis precipitated by an infected ingrown toenail; a false aneurysm of the distal left middle cerebral artery and two lesions involving the left superior cerebellar artery were found. A study of the literature shows that only 45 patients with mycotic intracranial aneurysms have received adequate antibiotic therapy and angiographic documentation. Statistically, there does not appear to be a clear-cut advantage to antibiotic plus surgical therpy over antibiotic alone. In fact, in 21 patients who underwent serial angiography, lesions were smaller in six and not visualized in 11. In four patients the aneurysms increased in size; in two others fresh lesions formed. The author proposes the following diagnostic and therapeutic regimen: 1) earliest possible diagnosis of the underlying disorder; 2) appropriate antibiotic therapy; 3) early four-vessel cerebral angiography and follow-up studies every 2 to 3 weeks; study; 5) definitive operation upon completion of antibiotic therapy if the lesion is larger or the same size; and 6) postoperative angiography to evaluate the effectiveness of treatment and to search for interim lesions.     

Rupture of an extended mycotic aneurysm of the descending thoracic aorta in a multiple myeloma patient undergoing anti-myeloma therapy

Infectious complications in patients with multiple myeloma remain the main cause of mortality because of disease-related immunodeficiency. A mycotic aortic aneurysm caused by Burkhoderia cepacia, which has been recognized as nosocomial pathogen in immunocompromised populations, is very rare and only few cases have been reported in the literature. We describe an unusual case of a ruptured mycotic aneurysm of the descending thoracic aorta with a DeBakey IIIb aortic dissection caused by Burkhoderia cepacia in a patient with active multiple myeloma during chemotherapy with anti-myeloma agents. Successful treatment of this mycotic aneurysm included appropriate antibiotic therapy and replacement of the aortic arch and the descending aorta for the extensive debridement of all infected aortas. This was followed by the wrapping of a prosthetic graft with a well-vascularized tissue flap of the greater omentum and of the latissimus dorsi muscle.     

Mediastinal rupture of a thoracoabdominal mycotic aneurysm caused by Salmonella typhimurium in an immunocompromised patient

A case is presented of rupture of a mycotic thoracoabdominal aneurysm caused by Salmonella typhimurium in a patient on immunosuppressive therapy following kidney transplantation. After initial medical treatment, surgery consisted of local debridement and implantation of an aortic prosthesis. Lifelong antibiotic treatment was prescribed because of the combination of immunosuppressive therapy, the history of recurrent S. typhimurium bacteremia and the presence of an aortic prosthesis.     

Unusual course of an abdominal aortic aneurysm in a patient treated with chemotherapy for gastric cancer

Most aortic aneurysms have a degenerative genesis and show a slow expansion over years. Only a few patients with a rapid progression of mycotic or inflammatory aneurysm during some weeks or months have been reported. We report a patient with a rapidly growing symptomatic infrarenal aneurysm with a maximal diameter of 53 mm, which developed over a 5-month period from a normal aorta and did not feature typical signs of degenerative, inflammatory, or mycotic aneurysm. The aneurysm was successfully treated by endovascular repair. A complete shrinking of the aneurysm sac was demonstrated during a few weeks postoperatively. Because the patient received chemotherapy with docetaxel, cisplatin, and 5-fluorouracil for metastatic gastric carcinoma 1 year before the aneurysm occurred, we postulate that chemotherapy induced a rapid expansion of the aorta in this patient.     

Valve replacement in a patient with infective endocarditis and ruptured mycotic cerebral aneurysm]

A 55-year-old man with a mild fever and sweating developed severe headache for the days before admission. Cerebral computed tomography and selected cerebral angiography on the day of admission revealed subarachnoid hemorrhage due to rupture of an aneurysm of a distal branch of the left middle cerebral artery. Detection of vegetation on the aortic valve by two dimensional echocardiography confirmed the diagnosis of infective endocarditis with a ruptured mycotic cerebral aneurysm. Because of rapid growth of the vegetation on the aortic valve and progression of heart failure despite antibiotic therapy, emergency cardiac surgery was performed. To prevent re-rupture of the aneurysm, the aortic valve was replaced with a bioprosthetic valve, and no anticoagulant was administered postoperatively. Repeated cerebral angiography revealed that the aneurysm was becoming progressively smaller during the next 9 months. No cerebrovascular accident occurred postoperatively. We believe that it is safe to treat a ruptured mycotic cerebral aneurysm without involvement of a hematoma mass in the brain conservatively, and that use of a bioprosthetic valve, if valve replacement is mandatory, and avoidance of anticoagulant therapy during the postoperative period are advisable in the treatment of a patient with infective endocarditis and a ruptured cerebral mycotic aneurysm.     

Infrarenal mycotic pseudoaneurysm. A late complication of coronary bypass surgery with proximal aortic dissection.

A 62-year-old man developed a mycotic infrarenal pseudoaneurysm at the re-entry site of a previous aortic dissection. The aortic dissection had occurred one year earlier while he was undergoing coronary bypass surgery. The patient was successfully treated with a Dacron bifurcation graft after the mycotic aneurysm had been sterilized. Causes and relationships of the mycotic pseudoaneurysm to aortic dissection and aortic balloon support are discussed.     

Simultaneous mitral valve replacement and bypass grafting for mycotic aneurysm of the femoral artery during the active phase of infective endocarditis: a case report.

A 52-year-old woman with a 3-week history of fever and cough was diagnosed as having bacterial endocarditis with vegetation and severe mitral valve insufficiency by echocardiography. Blood culture revealed Streptococcus mitis. After antibiotic treatment for 3 weeks, the patient noticed swelling with pain in her left groin. Computed tomography revealed an occluded aneurysm in the left common femoral artery. Simultaneous surgical treatments of mitral valve replacement and bypass grafting using a saphenous vein following resection of the mycotic femoral arterial aneurysm were performed. Pathohistological examination of surgical specimens revealed acute inflammatory findings, but no microorganisms were found, probably because of the preoperative antibiotic therapy. Her postoperative course was uneventful, and there was no recurrence of mycotic aneurysms in a period of 10 months after the operation. Prompt recognition and urgent simultaneous surgical treatments for mycotic aneurysms complicated with infective endocarditis were effective.     

Cardiac reoperation in a patient with osteogenesis imperfecta: a case report.

A case of a 40-year-old man with dehiscence of the prosthetic aortic valve and recurrence of mycotic aneurysm of the left ventricular outflow tract with osteogenesis imperfecta is presented. He had an operation of aortic valve replacement and direct closure of the mycotic aneurysm for infective endocarditis twenty-one months ago. We performed reoperation of prosthetic aortic valve, patch closure of the mycotic aneurysm and graft replacement of the ascending aorta. He was complicated with multiple fractures of bilateral scapla and dislocation of left shoulder one postoperative day. Fortunately, cardiac reoperation was performed successfully in this patient despite anticipated difficulties with tissue friability with osteogenesis imperfecta.     

Arteritis due to Salmonella with aneurysm formation: two cases.

Although arterial infection due to Salmonella is rare, it remains one of the most common causes of primary mycotic aneurysms. The presentation is one of sepsis, cultures positive for Salmonella and rapid expansion or rupture of the aneurysm. The authors' experience at Victoria Hospital, London, Ont., includes two cases of aneurysms infected with Salmonella--one aneurysm of the aorta and the other of the common femoral artery. Both patients were treated by excision of the aneurysm, extra-anatomic reconstruction in an area remote from the infected field and long-term administration of appropriate antibiotics. One patient was alive and well 36 months after resection. The other died of multiple organ failure 10 days after resection. From a review of the English and French literature since 1948, 64 cases of abdominal aortic aneurysms infected with Salmonella were found; half of the patients survived the perioperative period. The diagnosis of mycotic aneurysm must be considered in any patient with an aneurysm and culture specimens positive for Salmonella. The authors favour wide débridement of the infected aneurysm with extra-anatomic reconstruction. This view is supported by a review of the literature. The appropriate antibiotic therapy is bactericidal rather than bacteriostatic.     

Treatment of Mycotic Aneurysms with Involvement of the Abdominal Aorta: Single-centre Experience in 44 Consecutive Cases

ObjectiveTo review our management of mycotic aneurysms involving the abdominal aorta over the past 2 decades to assess the safety and efficacy of in-situ and extra-anatomic repair combined with antibiotic treatment.Materials and methodsFrom March 1990 to August 2008, 44 patients with a mycotic aneurysm involving the abdominal aorta were treated at our University Hospital. For all patients, we recorded the aetiology, clinical findings and anatomic location of the aneurysm, as well as bacteriology results, surgical and antibiotic therapy and morbidity and mortality.ResultsTwenty-one (47.7%) of the mycotic aneurysms had already ruptured at the time of surgery. Free rupture was present in nine patients (20.5%). Contained rupture was observed in 12 patients (27.3%).Urgent surgery was performed in 18 cases (40.9%). Revascularisation was achieved by in-situ reconstruction in 37 patients (84.1%), while extra-anatomic reconstruction was performed in six patients (13.6%). One patient (2.3%) was treated with a combined in-situ and extra-anatomic reconstruction. In one case (2.3%), endovascular aneurysm repair (EVAR) was performed.In-hospital mortality was 22.7%, 50% in the extra-anatomic reconstruction group and 18.9% in the in-situ repair group. One-third (33.3%) of our patients, who presented with a ruptured mycotic aneurysm died in the peri-operative period. This mortality was 13% in the patient-group presenting with an intact aneurysm.Of the 34 surviving patients, 12 patients (27.3% of surviving patients died after discharge from our hospital. In half of these patients, an acute cardiac event was to blame. Three patients (8%) showed re-infection after in-situ reconstruction.ConclusionManagement of mycotic aortic aneurysms remains a challenging problem. The results of surgery depend on many factors. In our experience, in-situ repair remains a feasible and safe treatment option for patients who are in good general condition at the time of surgery.     

Mycotic abdominal aortic aneurysm induced by immunotherapy with bacille Calmette-Guérin vaccine for malignancy

Successful surgical treatment of a mycotic abdominal aortic aneurysm infected with Mycobacterium bovis is described. The infecting organism can be traced to an intraneoplastic injection of bacille Calmette-Guérin (BCG) vaccine into a cutaneous malignant melanoma nodule 14 months before aneurysm detection (17 months before operation). Treatment consisted of aneurysm excision, in situ prosthetic graft placement, and antituberculous medications. This patient represents the first reported case of BCG-induced mycotic aortic aneurysm.     

Repair of Mycotic Aneurysms of the Aorta Involving the Aortic Valve

This report summarizes our successful management of 6 patients who underwent repair of mycotic aneurysms of the ascending aorta within a four-year period. Repairs have been successful despite involvement of as much as two-thirds of the circumference of the aortic valve annulus, involvement of the origin of the right coronary artery, and development of heart block. Three patients required surgical intervention because of hemodynamic decompensation before they had completed antibiotic therapy for endocarditis.In 3 patients, the aneurysm was buttressed with the valve skirt so that aneurysm repair and valve replacement were accomplished in continuity. In 2 patients, the aneurysm was repaired separately and the valve seated on the repair. In 1 patient, a large defect between the left and right coronary arteries was repaired with a woven Dacron patch secured to the valve skirt. The valve was seated to the left ventricle and the graft to the aorta. There were no operative or postoperative deaths. Our data suggest that mycotic aneurysms of the aortic annulus can be successfully repaired despite extensive damage.     

Mycotic aneurysm of the superior mesenteric artery: a delayed complication from a neglected septic embolus-a case report

Mycotic aneurysm formation in a visceral artery carries a significant risk of mortality and morbidity. The authors present a case of a symptomatic superior mesenteric artery aneurysm secondary to a septic embolus in a patient who had undergone aortic valve replacement. The patient initially presented with evidence of acute intestinal ischemia from a presumed embolic source. Although an extensive bowel resection was performed, an adequate search for the embolus was not carried out. Prompt diagnosis and removal of suspected septic emboli must be performed to avoid the formation of delayed mycotic aneurysms.     

Mycotic aneurysm of the suprarenal abdominal aorta.

We report on the successful treatment of a patient with a mycotic aneurysm of the suprarenal aorta. The aorta was resected and reconstructed using an in-situ polytetrafluoroethylene graft with a side arm branch to the left renal artery. The use of polytetrafluoroethylene graft for aortic reconstruction after suprarenal mycotic aneurysm resection has not been previously reported. The etiology, bacteriology, diagnosis, and principles of management of mycotic aneurysms of the suprarenal aorta are discussed.     

Endovascular treatment for a unusually large mycotic aneurysm manifesting as intracerebral hemorrhage - case report

A 62-year-old male presented with an unusually large mycotic aneurysm mimicking a saccular aneurysm manifesting as coma and hypotension. Computed tomography showed intracerebral and intraventricular hemorrhage. He was in septic shock due to acute infectious endocarditis. Cerebral angiography disclosed a large distal anterior cerebral artery aneurysm. The diagnosis was mycotic aneurysm based on the morphological features and associated endocarditis. The aneurysm and the parent artery were successfully occluded by endovascular embolization. High-dose antibiotic therapy in the following 6 weeks resulted in resolution of the infectious endocarditis. Early exclusion of ruptured mycotic aneurysm is mandatory because of the high risk of rerupture. Endovascular treatment is an effective alternative for mycotic aneurysms, especially if the patient's general condition is poor. Parent artery occlusion can be safely tolerated if the aneurysm is located distally.     

猪霍乱沙门菌所致人感染性动脉瘤的腔内治疗

目的 评价猪霍乱沙门菌所致人感染性动脉瘤的诊断治疗方法.方法 回顾性分析2000年1月至2008年12月收治的8例猪霍乱沙门菌感染性动脉瘤的诊断治疗方法及效果.结果 感染性腹主动脉瘤6例,胸主动脉瘤和胭动脉瘤各1例,均行人工血管内支架腔内修复术;放置直型人工血管内支架6例,分叉型人工血管内支架2例,手术成功率为100%,无围手术期30 d内死亡或并发症发生;所有患者均恢复满意,出院后口服抗菌药物,随访时间15～36个月,4例疗效满意,影像学及实验室检查无感染复发征象,3例感染复发行局部感染灶清创引流后痊愈,1例术后3个月因腹主动脉瘤破裂死亡.结论 猪霍乱沙门菌是侵袭性和毒力较强的菌株,对于猪霍乱沙门菌感染性动脉瘤,腔内修复、应用抗菌素并密切随访,是一种可供选择的治疗方式.