Suprarenal Clostridium septicum Aortitis with Rupture and Simultaneous Colon Cancer

We report a case of combined colon cancer and Clostridium septicum aortitis involving the suprarenal abdominal aorta with rupture. An 82-year-old male presented with fever, abdominal pain, and back pain associated with constipation. He was successfully treated by in situ aortic graft placement with polytetrafluroethylene and concomitant colon resection. Only 20 other cases of C. septicum mycotic aneurysm, aortitis, or aortic dissection have been reported. Concomitant surgical treatment for Clostridium aortitis or mycotic abdominal aortic aneurysm and colon cancer can be accomplished successfully in selected cases when the diagnosis of both conditions is made preoperatively.     

Mycotic aneurysm of the infrarenal abdominal aorta infected by Clostridium septicum: a case report of surgical management and review of the literature

We report a surgical case of mycotic aneurysm of the infrarenal abdominal aorta infected by Clostridium septicum. The patient was first treated with an in situ prosthetic graft replacement. When the infection recurred 5 weeks after the aortic surgery, the patient was successfully treated by transposition of rectus abdominis muscle flap around the graft. Only 19 cases of mycotic aneurysm or aortic dissection caused by Clostridium septicum have been reported. Ten of 12 patients who underwent vascular surgery survived, whereas all 7 patients who did not undergo surgery died. Surgical treatment should be undertaken since the surgical results seem satisfactory.     

Pneumococcal aortitis: a difficult preoperative diagnosis

Primary infections of the aorta are rare. We recently treated a patient who was given a diagnosis of noninfectious aortitis after an extensive work-up, but after clinical deterioration, was found to have a pneumococcal mycotic aneurysm at the time of surgery. The difficulty in distinguishing microbial aortitis from noninfectious chronic periaortitis is discussed as well as the need for frequent surveillance imaging of the aorta if immunosuppression is used to treat the latter entity. The infected aortoiliac segment was ultimately repaired with autologous femoral veins.     

Primary aortoduodenal fistula due to septic aortitis.

We report the second case of a primary aortoenteric fistula resulting from septic aortitis with a contained aortic leak into the retroperitoneum and finally erosion into the duodenum. An emergency laparotomy revealed a fistula between the third part of the duodenum and a decompressed sac (false aneurysm) arising from a nonaneurysmal, grossly infected pararenal aorta. The purpose of this report is to present this rare case in detail and to review primary aortoenteric fistulas reported in the English language literature. Most fistulas form in association with an abdominal aortic aneurysm and rarely are due to infection. Only 6% of patients presented with the classic triad of abdominal pain, a palpable mass, and gastrointestinal bleeding. Although 29% of patients presented with massive hemorrhage, adequate time usually existed for surgical treatment of these complications. A patient with ill-defined abdominal pain and fever who suddenly develops a palpable abdominal mass should have an emergency ultrasound or CT scan to exclude the possibility of an infected aortic aneurysm or a contained rupture of an infected nonaneurysmal aorta. If the symptoms are associated with bleeding and the patient is hemodynamically stable, emergent endoscopy should also be performed. If a primary aortoenteric fistula or an aortic pseudoaneurysm is confirmed, emergent surgery should be undertaken to avoid rupture into the bowel or retroperitoneum.     

Clostridium septicum: A usual suspect? Aortic rupture following right hemicolectomy: A case report

IntroductionThere is a known association between Clostridium Septicum, mycotic aneurysm and colon neoplasm.Case presentationWe report the case of a 90 year old female admitted with abdominal pain to the general surgery unit. Admission CT scan demonstrated a thick walled caecum and pericaecal inflammation suspicious for a perforated carcinoma. This was subsequently confirmed at colonoscopy with biopsy demonstrating a poorly differentiated adenocarcinoma. A laparoscopic right hemicolectomy was completed the following week after perioperative workup and intravenous antibiotic therapy. On the 9th postoperative day, fever and rising inflammatory markers prompted repeat abdominal CT scan which demonstrated a mycotic aneurysm of the upper abdominal aorta. After discussion with the vascular surgery and infectious diseases team, along the patient and family, the decision was made to palliate. The patient died at home from presumed spontaneous rupture two weeks after discharge.DiscussionMycotic aneurysm in colonic malignancy is a rare and often lethal complication. C. Septicum is causative in over 70% of cases with concomitant colonic malignancy.ConclusionMycotic aneurysm should be considered in any deteriorating patient with concomitant colonic malignancy.     

Once bitten, twice shy: an unusual case report of a mycotic aortic aneurysm

Primary mycotic aneurysms of the aorta are a rare, but potentially lethal condition comprising less than 1% of all aortic aneurysms. All age groups are affected but patients younger than 50 years are most susceptible. Organisms commonly implicated in aortitis and mycotic aortic aneurysms include Salmonella species and Staphylococcus aureus(1). We present the first case report of a primary aortic mycotic aneurysm caused by Capnocytophaga canimorsus, a commensal organism found in the mouth of dogs and cats and occasionally associated with serious human infections.     

Mycotic abdominal aortic aneurysm: a fatal sequel to concomitant prostatic and renal aspergillosis. Case report and review of the literature

We report the first case of aspergillus mycotic aneurysm as a sequel to concomitant prostatic and renal aspergillosis. The patient had undergone left nephrectomy and transurethral resection of prostate for aspergillus infection one year ago. He again presented with LUTS and backache and clinical examination showed visible pulsations in the epigastrium. CT-scan abdomen showed a pseudoaneurysm of the abdominal aorta. The aneurysm was repaired in situ with homografting and omental wrap. However, the patient succumbed to septicemia on the tenth postoperative day. Adjunctive surgery is usually essential as medical management alone has been unsatisfactory. It is imperative that these cases should be followed closely to detect the disease recurrence and complications at the earliest.     

Complicated chronic pancreatitis causing mycotic aortic aneurysm: in situ replacement with a cryopreserved aortic allograft

Mycotic aortic aneurysm, which resulted from infected pancreatic pseudocysts with retroperitoneal abscess, developed in a patient with chronic pancreatitis. The aorta was approached through median laparotomy. Necrotic material was debrided from the pancreatic pseudocysts, and the mycotic aneurysm was resected. The aorta was replaced in situ with a cryopreserved aortic allograft. This report discusses the rare complication of pancreatic pseudocysts, which affect the infrarenal abdominal aorta and cause a large mycotic aneurysm. This case suggests that the use of cryopreserved allografts is promising for in situ reconstruction, even in a grossly infected field.     

Cryptococcal aortitis presenting as a ruptured mycotic abdominal aortic aneurysm.

Mycotic processes occasionally complicate atherosclerotic aortic disease and usually require aggressive surgical therapy to control sepsis and prevent arterial rupture. Rarely, fungal organisms are responsible for primary infection of the abdominal aorta. We report the first case of Cryptococcal aortitis presenting as a ruptured abdominal aortic aneurysm. The surgical, pathologic, and microbiologic aspects of fungal aortitis are discussed.     

Mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer: report of a case

We report a case of mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer (PAU). An 81-year-old woman was admitted to a local hospital with fever and abdominal pain, and when her symptoms were not improved by antibiotics, she was referred to our department. Computed tomography (CT) and angiography showed a saccular aneurysm below the renal arteries, and an emergency laparotomy was performed because we suspected a mycotic abdominal aortic pseudoaneurysm. An abscess was found on the proximal side of the jejunum, caused by an aneurysm penetrating the serosa. We diagnosed a mycotic pseudoaneurysm after finding the anterior wall of the aorta penetrated by intense calcification. The pseudoaneurysm was resected with the abscess and the area was covered with a pedicled omental flap to prevent infection. An axillofemoral bypass was also done. The patient recovered well.     

Acceptable short-term results after endovascular repair of diseases of the thoracic aorta in high risk patients.

OBJECTIVE: To report our experience with endovascular stentgraft repair of diseases of the descending thoracic aorta in high risk patients. METHODS: Twenty-one procedures were performed in 20 patients (10 women), aged 22-81 years, for disease of the descending thoracic aorta with the Gore Excluder thoracic endoprosthesis (WL Gore) (n=11) and the Talent LPS Stent Graft System (Medtronic AVE) (n=10). All patients were considered high operative risk. Diagnoses included saccular aneurysm, aneurysm rupture, mycotic aneurysm, penetrating atherosclerotic ulcer, aortic dissection and aortitis. The access vessels were a tube graft of the (thoraco-) abdominal aorta (n=4), the common iliac (n=6) and the common femoral artery (n=11). Several patients needed major cardiovascular surgery for concomitant disease during the same stay. Computed tomography scan and chest X-ray was performed at 3 and 6 months and thereafter every sixth month postoperatively. RESULTS: Two patients died. One had a colon perforation 8 days postoperatively and died after 3.5 months, and the other with preoperative sepsis and a mycotic aneurysm died on day 11 from cardiac and renal failure. In one patient the stentgraft dislocated during release, and an additional stentgraft had to be implanted 1 week later to treat the proximal leak. In another patient the stentgraft could not be released from the introducer, and was pulled back to the aortic bifurcation and retrieved through laparotomy. Eighteen patients have been followed for 1-24 months, and no migration, wire fractures or endoleak have been seen. There were no neurologic complications. One patient treated for infected pseudoaneurysm had a chronic graft infection. CONCLUSION: In this small number of patients with high operative risk, short-term results of endovascular stentgraft repair of variable diseases of the descending aorta have been satisfactory. Stentgraft repair could be a valuable supplement to surgery for patients with complex multilevel or multiorgan disease.     

Endovascular stent-graft repair of a tuberculous mycotic aortic aneurysm

Mycobacterium tuberculosis is a rare cause of mycotic aortic aneurysms, which have been classically treated with a combination of antimycobacterial medical therapy and open surgery. Endovascular therapy has been gaining popularity as an alternative to open surgery for mycotic aneurysms. We report a case of a tuberculous mycotic aneurysm of the descending thoracic aorta that was successfully treated with endovascular stent-graft placement with complete resolution of the pseudoaneurysm at 1 year. We also review other cases in the previously published data to identify factors that may affect the outcome of endovascular treatment of tuberculous mycotic aneurysms.     

Molecular diagnosis of nonaneurysmal infectious aortitis

We report a 79-year-old patient who presented with a fever and abdominal pain. The patient was initially thought to have a retroperitoneal fibrosis or inflammatory abdominal aortitis in a normal-sized caliber aorta. Broad-range polymerase chain reaction (PCR) and DNA sequencing revealed the presence of Enterobacter. We finally diagnosed nonaneurysmal infectious aortitis, and we performed a successful surgical resection. Establishing a diagnosis of aortic infection before formation of an aneurysm is difficult. The molecular diagnostic technique was particularly useful in specifying the microbial species and diagnosis.     

Mycotic abdominal aortic aneurysm infected by <Emphasis Type="Italic">Vibrio mimicus</Emphasis>: Report of a case

This report describes a case of a mycotic aneurysm of the infrarenal abdominal aorta infected by Vibrio mimicus, which is the only such case ever reported in the literature. The 80-year-old male patient was first treated for gastroenteritis for 7 days. Two months later, he was admitted to the hospital and the aneurysm was diagnosed by three-dimensional computed tomography. The aneurysm was excised and the restoration was done using a 16-mm Dacron straight graft. The cultivation of the excised aneurysm and the inflammatory fluid was positive for V. mimicus. The postoperative period was free of complications and the patient has remained asymptomatic during the 4-year follow-up.     

Mycotic abdominal aneurysm requiring emergency operation due to sudden thrombotic obstruction: a case report

A 59-year-old man was admitted with history of low grade fever, general malaise and low back pain. Physical examination showed a pulsatile mass in the mid-abdomen. There were slight leucocytosis, elevated BSR and CRP. Abdominal ultrasonography, CT and MRI revealed an abdominal aneurysm within which there was an intimal flap and thrombus. Though blood culture was not positive, antibiotic therapy was initiated on the presumption of a mycotic abdominal aneurysm. Six days after admission, he complained of numbness in the lower extremities and both femoral pulsations were not palpable. Emergency surgery was undertaken. The aneurysm was adhered to the IVC and the ileum and there was a large thrombotic mass in it. Aneurysmectomy and Y-graft interposition were done uneventfully. Pathology revealed marked thickness of the aorta and infiltration of lots of inflammatory cells. The culture of aneurysmal wall was negative. This is the very rare case because of sudden thrombotic occlusion of the mycotic abdominal aneurysm. Several important features of this disease have been also discussed.     

Successful management of ruptured mycotic abdominal aortic aneurysm in a child

Mycotic aneurysm of the abdominal aorta is a serious disorder that generally carries a grave prognosis. A few survivors have been reported in adults but none in children. This report describes the successful management of ruptured mycotic abdominal aneurysm in a 10-year-old girl. The entire aneurysm was excised, and aortic continuity restored with low porosity bifurcated Dacron graft. With no macroscopic suppuration, we believe aortic continuity is a logical way to deal with this grave situation in children. Antibiotic cover was given pre and postoperatively for a total of six weeks. To our knowledge, this is the only surviving case in children in the literature. The pathogenesis and diagnosis of mycotic and infected aneurysm is discussed, and the literature has been reviewed.     

A case of contained ruptured aortitis due to Clostridium septicum infection in a patient with a colon malignancy

We discuss a case of contained ruptured aortitis due to Clostridium septicum infection in a 71-year-old man, who had undergone a right hemicolectomy and cholecystectomy to treat an ascending colon carcinoma. Computed tomography identified a juxtarenal abdominal aneurysm with gas formation in the right psoas muscle. Emergency abdominal exploration revealed a ruptured aortitis. After in situ graft replacement of the abdominal aorta, Clostridium septicum was identified in tissue culture. Antibiotic therapy with penicillin G was administered. The postoperative course was complicated by a retroperitoneal haematoma which necessitated surgical revision. The patient was discharged 2 months afterwards. At clinical monitoring at 6 months he is still doing well.     

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.     

Multiple peripheral pneumococcal mycotic aneurysms without aortic involvement: a unique case confirmed with the novel use of a molecular diagnostic technique

Mycotic aneurysms confer a high morbidity and mortality. Streptococcus pneumoniae aneurysms usually affect the aorta and are rare, although bacterial cultures from aneurysm tissue may be difficult following prior antimicrobial therapy. We report a unique case of mycotic femoral and popliteal artery aneurysms following pneumococcal pneumonia and meningitis, which were managed by resection, revascularization with autologous vein, and intravenous benzylpenicillin. Although blood and aneurysm sac cultures were negative, arterial wall S pneumoniae DNA was detected by polymerase chain reaction (PCR). Appropriate molecular diagnostic techniques can facilitate diagnosis and direct antimicrobial therapy; an important consideration with increasing antimicrobial resistance.     

Mycotic aneurysm of the thoracic aorta caused by extended-spectrum beta-lactamase-producing Escherichia coli

We report a case of successful treatment of a mycotic aneurysm of the thoracic aorta. A 65-year-old man with a dissecting aneurysm presented with urinary tract infection. He had a history of severe liver cirrhosis. Two weeks after admission, he had a high-grade fever and enhanced computed tomography (CT) demonstrated acute expansion of the distal aortic arch aneurysm. Because of the acute aneurysm expansion and elevated inflammatory response, we suspected a mycotic aortic aneurysm with possible impending rupture. Since conventional open chest surgery was considered to carry a high operative risk, the patient was managed with a combination of emergency endovascular treatment and antibiotic chemotherapy. Extended-spectrum beta-lactamase-producing Escherichia coli were identified from blood culture before treatment. After strict antibiotic therapy, the postoperative course was uneventful and the patient remained well 12 months later.