Clostridial mycotic aneurysm of the thoracoabdominal aorta--a case report

Mycotic Thoracic Aortic Aneurysm: Epidemiology, Pathophysiology, Diagnosis, and Management

Mycotic thoracic aortic aneurysm (MTAA) is an aneurysm of the aorta caused by infection of the vessel tissue through microbial inoculation of the diseased aortic endothelium. It is most commonly caused by bacteria. Rarely, it can be caused by fungi. However, viral aortic aneurysm has never been reported. Depending on the area and time period investigated, the infections organism discovered may vary significantly. Little is known about the natural history of MTAA due to its rarity. It is not known if they follow the same pattern as other TAAs. However, it is unclear whether MTAA follows a similar clinical course. The combination of clinical presentation, laboratory results, and radiographic results are used to make the diagnosis of MTAA. Treatment of MTAA is complex since patients frequently present at a late stage, frequently with fulminant sepsis, as well as concomitant complications such as aneurysm rupture. While medical treatment, including antibiotics, is recommended, surgery is still the mainstay of management. Surgery to treat MTAA is complicated and carries a high risk of morbidity and mortality and includes both open repairs and endovascular ones. In this review, we explore the etiology, pathogenesis, clinical presentations, diagnostic modalities as well as treatment management available for MTAA.

Clostridium septicum-infected aortic aneurysm or graft is a deadly diagnosis

BACKGROUND

Clostridium septicum is an anaerobic, motile, spore-forming, toxin-producing gram-positive bacillus that can lead to rapidly progressive gas gangrene due to the release of alpha toxin. Aortic aneurysm secondary to C. septicum infection is a rare condition with 60 cases reported in the literature; however, we have recently treated several patients with the condition in our large tertiary care and aortic center.

METHODS

Blood and tissue culture results collected between January 2005 and January 2018 and maintained in the microbiology laboratory database at the Cleveland Clinic were reviewed to identify those with C. septicum reported. Each was reviewed to determine radiographic or histopathologic correlation with aortic disease.

RESULTS

Seven cases of C. septicum aortitis were reviewed. Underlying malignant disease was found in four cases and a history of remote malignant disease in one case. The most common location for infection was the infrarenal abdominal aorta. Vascular surgery had previously been performed in three of the cases. Five of the seven patients underwent operative repair. All patients were treated with β-lactam antibiotics. The two patients who did not undergo an operation died, which is consistent with the 100% mortality described in the literature. Of the five patients who underwent an operation, there was only one documented survivor and one was lost to follow-up.

CONCLUSIONS

In the largest reported case series, only a small percentage of patients with C. septicum-infected aortic aneurysms survived >1 year. In the patients described, those who did not receive an operation had 100% mortality. Earlier recognition and prompt operation with appropriate antimicrobial therapy are needed to improve the outcome of patients diagnosed with this rare infection.

Clostridium septicum arthroplasty infection: beware of occult aortitis and malignancy

Introduction

The Clostridia species are responsible for life-threatening conditions such as tetanus, botulism and gas gangrene. Clostridium septicum is a rare cause of clinical infection, accounting for less than 1% of blood culture samples that test positive for Clostridia. However, C. septicum bacteraemia is associated with greater than 60% mortality and in over 80% of cases is associated with an underlying malignancy.

Case presentation

We present a review of the literature and the first case of an acute arthroplasty infection and concurrent infective aortitis caused by this organism in the absence of an identified underlying malignancy. Early diagnosis and multi-disciplinary input resulted in the patient surviving a rare and potentially fatal infective aortitis and septic arthritis.

Conclusion

This case demonstrates the importance of early systemic investigation to exclude occult infective aortitis in C. septicum infection. The key role of multi-disciplinary input into the management of this often fatal infection is also discussed along with the requirement to exclude occult gastrointestinal and haematological malignancy.

A rare case of Clostridium septicum aortitis with colon adenocarcinoma

Clostridium septicum aortitis is a rare, highly morbid condition typically accompanied by malignant disease, such as hematologic cancer or colon adenocarcinoma. Presenting symptoms commonly described include acute onset of abdominal pain, nausea, and fevers. Prompt diagnosis of infectious aortitis is critical to prevent deadly complications, such as sepsis and vascular catastrophe. The described management largely involves surgical resection of the infected aorta, débridement, and arterial revascularization through extra-anatomic bypass or aortic graft placement.

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature

BACKGROUND

Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates.

CASE PRESENTATION

A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death.

CONCLUSIONS

In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

A Rare Report of Infectious Emphysematous Aortitis Secondary to Clostridium septicum without Prior Vascular Intervention

The term “mycotic aneurysm” was first used by Osler in 1882 to describe a mushroom-shaped aneurysm in subacute bacterial endocarditis. Mycotic aneurysms account for only 2.6% of all aneurysms of the aorta. Rarer still are anaerobic infections secondary to organisms such as Clostridium septicum, which results in emphysematous aortitis. The vast majority of emphysematous aortic infections occur as a result of instrumentation; however, in this case we present an infection de novo. A 75-year-old male presented with a 2-week history of progressive fatigue and chest pain that then developed into constitutional symptoms. Chest radiograph demonstrated an obvious widened mediastinum. CT angiogram of his chest then confirmed this finding as well as significant periaortic gas and focal outpouching. Numerous diverticuli with inflammatory changes consistent with diverticulitis was observed on CT abdomen. Blood cultures returned positive for Clostridium septicum. Definitive treatment was discussed including debridement and graft insertion; however, patient decided on conservative management and was discharged on intravenous antibiotics. Unfortunately, as in most cases of emphysematous aortitis that do not undergo surgical management, the patient succumbed to his illness. The lesson provided will be the epidemiology of emphysematous aortitis, presentation, diagnosis, management, and prognosis through a case report.

Mycotic Carotid Artery Pseudoaneurysm Following Stenting

Carotid stenting is assuming an important role in the management of carotid disease. Surgeons although hesitant to embrace catheter treatment for the management of primary carotid artery disease, are more enthusiastic regarding it's use in the treatment of recurrent stenoses. This report suggests that caution should be exercised in the selection of patients to be treated with carotid stenting for recurrent disease.

Endovascular management of a mycotic group A streptococcal abdominal aortic dissection

Pyrexia of unknown origin can represent a great diagnostic difficulty to clinicians. We present a case of pyrexia with abdominal and back pain, in which blood cultures performed demonstrated group A haemolytic streptococcus. Having recently been abroad, the patient was investigated to find a source. CT scans performed subsequently demonstrated an inflammatory infrarenal abdominal aortic dissection. The patient was treated with intravenous antibiotics and underwent endovascular repair. This case details the unusual presentation of spontaneous abdominal aortic dissection and its management by endovascular means. Emphasis is placed on the often clandestine manner of presentation of this condition and the importance of awareness in the investigating clinician. This case presents a patient infected with group A haemolytic streptococcus, leading to aortitis and spontaneous dissection, previously unreported in the literature.

Clostridium septicum Aortitis of the Infrarenal Abdominal Aorta

Clostridium septicum aortitis is a rare infection that has a strong association with occult colonic malignancy. There is also emerging evidence to support the combination of medical and surgical management over medical management alone. To the best of our knowledge, we report the 40th known case of C. septicum aortitis.

A Case of Clostridium septicum Aortitis With Concomitant Adenocarcinoma of the Cecum

Clostridium septicum aortitis is a rare infection that is strongly associated with underlying adenocarcinoma of the colon. We report a case of a 73-year-old woman with peripheral vascular disease who presented after 4 weeks of severe abdominal pain. Abdominal computed tomography showed thickening of the cecal wall and gas in the aortic wall. Colonoscopy revealed a large ulcerated moderately differentiated adenocarcinoma in the cecum. Blood cultures grew Clostridium septicum. The patient was offered surgical intervention but refused; she was treated with antibiotics and discharged home where she died 1 week later.

Anaerobic bacteria as a cause of mycotic aneurysm of the aorta: microbiology and antimicrobial therapy

This review summarizes the microbiology, and antimicrobial management of mycotic aneurysm of the aorta (MAA) due to anaerobic bacteria. Anaerobic bacteria are an uncommon but important cause of MAA. Most cases of anaerobic MAA are caused anaerobic gram-negative bacilli (mostly B. fragilis group), Clostridium spp. (mostly Clostridium septicum, and Propionobacterium spp. (mostly P. acnes). Clostridial infection is frequently associated with gastrointestinal or hematologic malignancy. A review of all the reported cases is presented. Treatment of MAA involving anaerobic bacteria includes the use of antimicrobial effective against these organisms.

Clostridium septicum aortitis: Report of two cases and review of the literature

Clostridium septicum aortitis is a rare infection that has a strong association with occult colonic malignancy. To our knowledge, we report the 25th and 26th cases of C septicum aortitis in the English literature and make recommendations for its management. The first patient was a 75-year-old man who presented with abdominal pain. Computed tomography showed the presence of periaortic gas. He underwent aortic débridement and extra-anatomic bypass after blood cultures revealed C septicum. Four months after the initial presentation, he was readmitted with lethargy, found to have recurrent periaortic gas, and died. The second patient was a 76-year-old woman who presented with a 5-cm abdominal aortic aneurysm with surrounding retroperitoneal gas. She underwent emergency aortic ligation and retroperitoneal débridement. Her blood and intraoperative tissue cultures also grew C septicum. She had a prolonged postoperative course and ultimately died on hospital day 94. Both patients were found to have concurrent colon adenocarcinomas. C septicum aortitis is a lethal disease that necessitates prompt surgical intervention and appropriate antibiotic therapy. The strong association of C septicum with occult malignancy should prompt the astute clinician to undertake an exhaustive search for a neoplastic process.

Mycotic abdominal aortic aneurysm infected by Vibrio mimicus: 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.

Phenotyping Clostridium septicum infection: a surgeon's infectious disease

BACKGROUND

Clostridium septicum infection is associated with malignancy. Whether disease phenotype is affected by malignant status is not known. Surgical treatment is used frequently but its impact on survival has not been examined in a cohort >30 patients.

METHODS

A PubMed search of English language journal articles yielded 320 cases. Full information (infection location, cancer type, operative intervention, and survival) was available for 224 cases + 7 at our institution not previously reported.

RESULTS

Seventy-two percent of patients had malignancy or malady of the gastrointestinal (GI) or hematologic (HEME) organ systems. HEME survival was inferior to GI survival (35% versus 55%, P = 0.03). Overall, patients who underwent operation had improved survival (57% versus 26%; P < 0.0001) and this association was maintained within GI and HEME cohorts (P = 0.002 and 0.005, respectively). More GI than HEME patients underwent operation (81% versus 51%, P < 0.001). GI patients were more likely than HEME patients to experience infection of skin and soft tissues (SSTI, P = 0.006). Diabetics were more likely to experience SSTI than nondiabetics (77% versus 45%, P < 0.001).

CONCLUSIONS

C. septicum infectious phenotype varies with host milieu. The SSTI phenotype is more common in GI and diabetic patients. This recognition may aid in directing the search for occult malignancy, which must be performed given the >70% incidence of concomitant cancer. This infection is more fatal in HEME versus GI patients, perhaps due in part to less HEME group operative intervention. Primary surgical therapy should be considered in GI or HEME patients as operative intervention benefits both groups.

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.