Management of aortic aneurysm infected with Salmonella

Brucella-infected abdominal aortic aneurysm: management strategies for an uncommon aneurysm

Objective

The occurrence of Brucella-induced abdominal aortic aneurysms is an exceedingly rare phenomenon, yet it stands as one of the most severe complications within this context. The combined utilization of serological testing and imaging diagnostics has been validated as an effective approach for the identification of Brucella-induced abdominal aortic aneurysms. Presently, the predominant therapeutic strategies encompass antibiotic treatment and surgical intervention. Nonetheless, ongoing controversies persist concerning the establishment of diagnostic criteria, the optimal timing and selection of antibiotic regimens, and the nuanced decision between open surgical procedures and endovascular interventions. Through a meticulous analysis of cases originating from our institution as well as a comprehensive review of previously documented instances, we aim to engage in a detailed discourse on the salient diagnostic and therapeutic facets surrounding Brucella-induced abdominal aortic aneurysms.

Methods

We conducted a retrospective summary of three cases involving Brucella-induced abdominal aortic aneurysms treated within our institution. Furthermore, we performed a comprehensive PubMed search, without imposing restrictions on language or publication year, to identify pertinent literature pertaining to Brucella-induced abdominal aortic aneurysms. The selection criteria primarily focused on case reports delineating occurrences of abdominal aortic aneurysms attributed to Brucella infection.

Results

We present three distinct cases of Brucella-induced abdominal aortic aneurysms managed at our institution, providing comprehensive insights into the employed diagnostic and therapeutic approaches. Additionally, over the past five decades, a total of 24 cases in 23 publications of Brucella-induced abdominal aortic aneurysms have been reported on PubMed. The earliest report dates back to 1976.

Conclusion

Our analysis suggests that Brucella-induced abdominal aortic aneurysm is characterized by a remarkably low incidence but is associated with a substantial risk of life-threatening complications. The integration of serological and imaging assessments assumes pivotal importance in facilitating prompt diagnosis of this condition. The prompt initiation of targeted antibiotic therapy is recommended, and the selection of appropriate surgical strategies should be guided by considerations including aneurysm dimensions and morphological attributes. The timely identification and intervention carry utmost significance in retarding disease advancement and ameliorating unfavorable clinical outcomes.

Primary Infected Aortic Aneurysm: Clinical Presentation, Pathogen, and Outcome

PURPOSE

Infected aneurysm of the aorta and adjacent arteries is rarely occurring and can be fatal without surgical intervention. Within the medical community, the most efficacious treatment strategy to address infected aortic aneurysm remains controversial. In this study, we have reviewed our treatment experience with 109 patients.

METHODS

We included in our study all consecutive patients treated for primary infected aortic aneurysm at our facility between 1995 and 2011. Aneurysm-related mortality was defined as the presence of in-hospital and late mortality related to infection or postoperative complications.

RESULTS

The median patient age was 72 years (range, 35-88), and 87 (80%) were male. Pathogen was isolated in 101 patients, and the most common microorganism identified was non-typhoid Salmonella in 61 (60%), followed by Staphylococcus aureus in 16 (16%) and Streptococci species in 7 (7%). Eighty-five (78%) patients underwent surgical treatment. Surgery included open repair with in-situ graft replacement in 77 (71%) and endovascular repair in 8 (7%). The aneurysm-related mortality rate was 67% in medically treated and 21% in surgically treated patients, with a median follow-up duration of 31.5 months (range 1-189). Additionally, risk factors for aneurysm-related mortality included old age, chronic lung disease, psoas muscle abscess, short duration of preoperative antibiotics, no operation, and probably endovascular repair.

CONCLUSIONS

Non-typhoid Salmonella was the most common pathogen found in our study group patients with infected aortic aneurysm. It appears that prolonged preoperative antibiotic treatment followed by open in-situ graft replacement remains the preferred and most effective treatment strategy.

KEY WORDS

Infected aortic aneurysm; Outcome; Pathogen; Surgery.

Treatment of infected abdominal aortic aneurysm caused by Salmonella

BACKGROUND

We reviewed the outcomes of patients treated for nontyphoidal Salmonella-infected abdominal aortic aneurysm (AAA) treatment at a single center.

METHODS

This was a retrospective chart review of 26 patients with nontyphoidal Salmonella-infected AAA. Four patients underwent medical therapy alone, while 22 patients underwent surgical therapy. Revascularization method selection was dependent on preoperative antibiotic response in the surgical therapy group.

RESULTS

The in-hospital mortality rate for the surgical therapy group was 14%, while the rate for the medical therapy group was 100%. Overall survival for the surgical therapy group was 82%, while the reinfection rate was 9%. In the surgical therapy group, 2 patients had periaortic abscesses and underwent in situ prosthetic graft replacement; none developed graft-related complications or died in the hospital. Kaplan-Meier analysis and log-rank testing revealed no significant differences in graft-related complication and overall survival rates between in situ prosthetic graft group and extra-anatomic bypass group. Salmonella choleraesuis had a higher antimicrobial resistance rate than other isolates. The predictors of survival were clinical presentation of abdominal pain and receiving surgical therapy.

CONCLUSIONS

If patients with Salmonella-infected AAAs have good responses to preoperative antibiotic therapy, in situ prosthetic graft replacement is a viable revascularization method, even in the situation of periaortic abscess presentation formation.

Salmonella mycotic thoracoabdominal aortic aneurysm associated with chronic lymphocytic leukemia

Non-typhoidal Salmonella infections typically cause self-limiting gastroenteritis. However, extraintestinal focal infections, including mycotic aneurysms of the aorta, can also occur. We present the case of a 71-year-old man with chronic lymphocytic leukemia (CLL) and a large type V thoracoabdominal mycotic aneurysm infected with Salmonella enteritidis, complicated by thoracolumbar spondylodiscitis, paravertebral collections, and epidural abscess. This is the first report of Salmonella aortitis in the setting of CLL, and the unusual extent of local infective invasion seen here with Salmonella enteritidis infection raises a suspicion of CLL-related immunosuppression as a direct predisposing factor. This case illustrates the need to consider the possibility of an immune defect, even in CLL patients with normal leukocyte counts. The underlying mechanisms are unclear, but are likely to involve defects in cell-mediated immunity, thought to be of particular importance in invasive infections with intracellular pathogens such as Salmonella spp.

Endovascular stent graft repair for a Salmonella-infected aneurysm of thoracic aorta

Thoracic endovascular aneurysm repair using stent graft has been reported as a feasible and effective treatment for aortic aneurysm. However, its application for treating infected aortic aneurysms is still controversial and less reported. We report a 74-year-old male diabetic patient diagnosed with Salmonella-infected aortic aneurysm, who was successfully treated with endovascular stent graft repair followed by a 2-month course of intravenous antibiotics and long-term oral antibiotic therapy. Sequential computed tomography scans demonstrated the shrinkage of the aneurysm and no evidence of relapse 11 months later.

Primary infected, ruptured abdominal aortic aneurysms: what we learned in 10 years

Primary infected, ruptured aortic aneurysms remain a rare and challenging clinical problem. Surgical treatment includes a range of options such as extra-anatomic bypass grafting and debridement with secutive in situ graft placement with autologous, bovine, and prosthetic grafts. Recently, endovascular treatment for infected abdominal aortic aneurysms has been reported with acceptable short-term survival. However, conclusive evidence based on randomized data with regard to optimal treatment is unavailable. We present 3 patients with a primary infected, ruptured abdominal aortic aneurysm that was treated with in situ graft placement and long-term antibiotic therapy. Our results, combined with a review of the literature, support in situ grafting as the treatment of choice.

Combined endovascular and open treatment for infected pseudoaneurysm of the thoracic aortic arch

Infected pseudoaneurysm of the aortic arch is a rare but life-threatening condition. The conventional treatment involves cardiopulmonary bypass, prolonged vascular clamping, and an extensive bypass procedure. We report a case of infected pseudoaneurysm involving the aortic arch. The patient underwent debranching of the supra-aortic arteries and bypass surgery, followed by stent grafting the next day. The patient had good recovery, and the 1-year follow-up computed tomography scan showed resolution of the infected pseudoaneurysm.

Bacteraemia due to ciprofloxacin-resistant Salmonella enterica serotype Choleraesuis in adult patients at a university hospital in Taiwan, 1996-2004

Eighty-one adult patients with Salmonella enterica serotype Choleraesuis (S. Choleraesuis) bacteraemia treated at a university hospital from 1996 to 2004 were evaluated. Multivariate analysis with a logistic regression model was used to characterize risk factors for primary bacteraemia and mycotic aneurysm and to determine the association of clinical characteristics of patients based on ciprofloxacin susceptibility of the causative organism. The incidence per 100,000 discharges was 0.76 in 1996 and 3.9 in 2004. The overall rate of ciprofloxacin resistance among these isolates was 59% (87 isolates) and the annual rate increased with time from 0% prior to 2000 to 80% in 2004. Among these patients, 48 (59%) had primary bacteraemia and 13 (16%) had secondary bacteraemia with mycotic aneurysm. Seventy (86%) patients had fever at presentation, 22 (27%) developed shock during hospitalization, and eight (10%) died of S. Choleraesuis bacteraemia. Patients with immunocompromised conditions had a higher risk of developing primary bacteraemia (OR 18.442, P < 0.001). Hypertension (OR 15.434, P = 0.002) and male gender (OR 7.422, P = 0.039) were associated with mycotic aneurysm. Patients with mycotic aneurysm were more frequently infected with ciprofloxacin-susceptible isolates (P = 0.028) and ciprofloxacin-susceptible isolates were also more frequently associated with recurrent infection than ciprofloxacin-resistant isolates (P = 0.038). The incidence of S. Choleraesuis bacteraemia has increased in the past 8 years, and this increase is associated with the upsurge of ciprofloxacin-resistant isolates.

Abdominal aortic mycotic aneurysm, psoas abscess, and aorto-bisiliac graft infection due to Salmonella typhimurium

Infections due to nontyphoidal Salmonella are common and their incidence has been increasing in the last few years. Here, we describe a patient with a rupture of abdominal aortic aneurysm associated with a psoas abscess due to Salmonella typhimurium. Early diagnosis, prompt surgical intervention, and active and prolonged antibiotic therapy are the gold standard for the management of this severe clinical situation.

Risk factors for bacteraemia and endovascular infection due to non-typhoid salmonella: a reappraisal

BACKGROUND

Endovascular infections are rare complications of non-typhoid salmonellosis. The diagnosis is frequently not established until the infection is advanced. It is important to identify high-risk patients and treat them as early as possible.

AIM

To identify risk factors for bacteraemia and endovascular infection in patients with non-typhoid salmonellosis.

DESIGN

Retrospective study.

SETTING

A single tertiary-care hospital in Taiwan.

METHODS

Data were collected by retrospective chart review. Log-logistic regression modelling was used to identify independent risk factors for bacteraemia and endovascular infection. We analysed the characteristics of patients with gastroenteritis vs. those with bacteraemia, and of bacteraemic patients with vs. without endovascular infection.

RESULTS

Between 1984 and 2004, there were 373 adult cases of non-typhoid salmonellosis. There were 76 intestinal Salmonella infections, 290 bloodstream infections (including 47 endovascular infections), and 7 extra-intestinal non-bacteraemic infections. The independent positive predictors of bacteraemia were systemic lupus erythematosus, liver cirrhosis, HIV infection, and solid organ cancers. The only independent positive predictor of endovascular infection was atherosclerosis. The independent negative predictors of endovascular infection were solid organ cancers and immunodeficiency.

DISCUSSION

Risk factors for atherosclerosis predisposed our patients with bacteraemia to endovascular infection. Although immunodeficiency predisposed patients to bacteraemia, it was associated with a low incidence of endovascular infection.

Influence of ciprofloxacin resistance on risk factors for endovascular infection in patients with infection due to group C nontyphoid salmonellae

From January 2000 through September 2004, a total of 54 patients with infection due to group C nontyphoid salmonellae were evaluated; 8 patients had gastroenteritis alone, and 46 patients had bacteremia. Of the 46 patients who had bacteremia, 12 had endovascular infection and 34 did not. The number of infections due to ciprofloxacin-resistant Salmonella organisms is increasing. Ciprofloxacin-resistant Salmonella organisms predisposed patients to acquire bacteremia, but they did not seem to predispose patients to acquire endovascular infection.