Diagnosis and management of aortic mycotic aneurysms

Open versus endovascular repair of primary infected thoracic and abdominal aortic aneurysms

OBJECTIVE

Primary infected aortic aneurysms are life-threatening if not treated promptly, but still possess a high mortality rate following open repair. The goal of treatment is to prevent rupture and clear infection. An endovascular approach is accepted as a bridge to definitive open repair. Our study compares the outcomes of endovascular versus conventional open repair of infected aortic aneurysms.

METHOD

A single-center retrospective review was conducted of data from January 2012 to December 2021. Patients were categorized into three cohorts according to aortic involvement: thoracic aortic aneurysm (TAA), thoracoabdominal aortic aneurysm (TAAA), and abdominal aortic aneurysm (AAA). The primary endpoint was survival rate and the assessment of any associated factors.

RESULT

Ninety-nine patients presented with infected aortic aneurysms. Of the 56 patients who presented with infected TAA, 38 patients underwent thoracic endovascular aortic repair and 18 patients underwent open TAA repair. Forty patients presented with infected AAA, of which 21 patients underwent endovascular aortic repair and 19 patients underwent open repair. Three patients presented with infected TAAA and all underwent open repair. The mean age was 67 years (range 33-88); 74 patients (74.8%) were men and 71 patients (71.7%) had immune dysfunction. Mean follow-up time was 24 months in the endovascular repair group and 38 months in the open repair group. The probability survival rate in the endovascular repair group was 86%, 86%, 77% and 51% at 1 year, 2 years, 5 years and 10 years, respectively, and in the open repair group this was 81%, 81%, 76%, and 64% at 1 year, 2 years, 5 years and 10 years, respectively.

CONCLUTIONS

Endovascular repair for primary infected aortic aneurysms plays an important role in current practice as an alternate to open surgery or used as bridging to definitive open surgical repair. No significant difference was observed in either short- or long-term survival in patients with infected aortic aneurysm undergoing open or endovascular repairs.

Non-Anastomotic Axillofemoral Bypass Disruption After Blunt Trauma Treated by Endovascular Approach

Disruption in the non-anastomotic section of an axillofemoral bypass is a rare occurrence. In this report, we consider a patient who presented with a pseudoaneurysm in the non-anastomotic section of his axillofemoral bypass due to blunt trauma to the chest after a fall. Clinical presentation, management, treatment, and complications related to our case are discussed.

Endovascular treatment of a mycotic aneurysm in an immunocompromised child with acute leukemia-case report and review of the literature

Mycotic aneurysms are dilatations of an artery, a rare but severe complication arising from infectious obliteration of the vessel wall. Thoracic aneurysms often present with unspecific symptoms and multiple diagnostic and therapeutic challenges. In an advanced state, they have an increased risk of perforation and a high mortality rate. The surgical therapeutic approach has a high perioperative complication rate. In this study, we report a case of a thoracic mycotic aortic aneurysm in an immunocompromised pediatric patient caused by Klebsiella pneumoniae bacteremia. A combination of prompt antibacterial treatment and minimally invasive stent implantation showed a good outcome, avoiding possible severe surgical problems.

Staphylococcus aureus sepsis and hemoptysis as messengers of a rather impractically located mycotic aneurysm

BACKGROUND

Mycotic aortic aneurysms (MAA) arise due to infection of a pre-existent aneurysm or aneurysmal degeneration of an infected vascular wall. MAA of the thoracic aorta are relatively rare. Treatment is mainly guided by clinical experience as there are no large randomized trials available.

CASE PRESENTATION

A 79-year-old patient was hospitalized with staphylococcus aureus sepsis and MAA originating from the ostium of the left common carotid artery (CCA). Initial treatment consisted of high-dose antibiotics and blood pressure control. After 48 hours, a CT-angiography revealed rapid growth of the MAA with imminent rupture. Various treatment options were considered: a covered stent in the left CCA, a carotid-subclavian bypass with ligation of the left CCA ostium or arch replacement, or an extra-anatomical transposition of the supra-aortic vessels combined with a thoracic endoprosthesis. The last option was selected and, combined with six weeks of antibiotics, proved successful in controlling the impending rupture and treating the MAA.

CONCLUSIONS

Endovascular techniques are used if open surgery is refused, when surgical risks are prohibitively high (as definitive or palliative treatment), or as an emergency temporary treatment until definitive surgical treatment is feasible. Our high-risk patient underwent endovascular treatment for MAA as a definitive treatment. Endovascular treatment is increasingly becoming the treatment of choice due to the high morbidity and mortality of open surgical repair. Although the main concern using endovascular treatment is absence of debridement, recent studies show that combining endovascular treatment and long-term antibiotic therapy represents a potentially durable treatment and viable alternative to open surgical repair.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms

BACKGROUND

Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood.

METHODS

We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival.

RESULTS

Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72 years; range, 18-94 years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5 years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P = 0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P = 0.034) and preoperative serum albumin level <3 g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P = 0.033) were preoperative parameter that predicted persistent infection. A C-reactive protein level more than 5 mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P < 0.001) was observed in patients with persistent infection.

CONCLUSIONS

EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3 g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Therapeutic effectiveness of tuberculous aneurysm and risk factors for mortality: a systematic review

OBJECTIVE

This study aimed to determine the therapeutic effectiveness of tuberculous aortic aneurysms (TBAAs) and the risk factors for mortality.

METHODS

We reviewed all case reports of TBAAs treated with open surgery or endovascular aneurysm repair (EVAR) from online database in 1996-2021. Only thoracic and abdominal aortic aneurysms were included.

RESULTS

Eighty cases of open surgery and 42 cases of EVAR were included. The 2-year mortality and perioperative mortality rates of open surgery were 11.3% and 10.0%, respectively. Emergent open surgery had a significantly higher mortality (25.0%) than non-emergent open surgery (6.7%). In the EVAR group, 2-year mortality, perioperative mortality, and TBAA-related mortality were 16.7%, 4.8%, and 10.0%, respectively. Patients with typical tuberculosis (TB) symptoms before EVAR had a significantly higher TBAA-related mortality (35.0%) than patients with no typical TB symptoms before EVAR (0%). In the open surgery group, the rate of TB recurrence (2.7% vs 2.4%) and aneurysm recurrence (8.1% vs 7.3%) were quite close between preoperative anti-TB-treated and postoperative anti-TB-treated cases. However, in the EVAR group, TB recurrence (8.7% vs 0%) and aneurysm recurrence (12.5% vs 6.25%) were more common in postoperative anti-TB-treated cases.

CONCLUSION

Open surgery was accompanied by higher perioperative mortality, whereas EVAR was followed with higher TBAA-related mortality. Emergent surgical choices of open surgery may be associated with high perioperative mortality. Typical TB symptoms before EVAR are a significant risk factor for mortality after EVAR. Early anti-TB treatment should be administered if EVAR is the surgical option.

Cryopreserved venous allograft in the treatment of a mycotic abdominal aortic aneurysm caused by group B Streptococcus

We report a case of a mycotic abdominal aortic aneurysm caused by invasive group B streptococcus. Given the anatomical suitability with healthy segments of aortoiliac vessels, in situ repair was performed. A cryopreserved femoral vein graft was chosen because of risks of graft reinfection and negated the need for bilateral femoral vein harvest. The patient remained clinically well and the graft patent with no concerns at 6 months of follow-up. A review of literature on group B Streptococcus aortitis was performed.

Carotid-Axillary Bypass and Debridement for a Mycotic Aneurysm of the Left Subclavian Artery

Mycotic subclavian aneurysms are rare, and their presence typically mandates urgent repair due to the associated high risk of rupture and mortality. A multi-disciplinary team effort is of utmost importance in ensuring favorable results. In this case report, we present a 79-year-old male with a rapidly enlarging mycotic left subclavian artery aneurysm secondary to a retrosternal abscess and left sternoclavicular septic arthritis, who underwent aneurysmal exclusion, a left carotid-left axillary bypass and pectoralis muscle flap coverage with a good outcome.

WITHDRAWN: Endovascular Repair with Stent-Graft of Symptomatic Tuberculous Aortic Pseudoaneurysm

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Mycotic aneurysm secondary to melioidosis in China: A series of eight cases and a review of literature

Burkholderia pseudomallei is the causative agent of melioidosis, endemic in Southeast Asia and Northern Australia, and increasingly recognized in southern China, especially in Hainan Province. Mycotic aneurysm caused by B. pseudomallei is a rare but potentially severe illness with a high mortality rate. The clinical features of the mycotic aneurysm secondary to melioidosis have not been illustrated in China. Over a seven-year period (2013 to 2019), 159 patients with bacteremic melioidosis were retrospectively analyzed in Hainan province, China, of whom eight patients were confirmed to have mycotic aneurysm through the combination of imaging examination, pathologic examination and aneurysm tissue culture. We summarized these eight patients’ clinical characteristics, demographical features, treatments and outcomes. The susceptibilities to five commonly-used antibiotics for these eight B. pseudomallei isolates were also determined by E-test strips. Furthermore, the mycotic aneurysm cases secondary to melioidosis retrieved from the literature were also reviewed. Of the eight cases, six had abdominal mycotic aneurysms, one had a left iliac aneurysm, and the other one had an infectious mesenteric aneurysm. They were aged from 48 to 69 years old, and had the underlying risk factors of diabetes mellitus (2 patients), long-term smoking (4 patients), hypertension (6 patients), and soil and water contact history (6 patients), respectively. The positive arterial aneurysm imaging was observed in all patients via computed tomography (CT) or angiography. Eight B. pseudomallei isolates collected from both blood and mycotic aneurysm tissues remained 100% susceptible to imipenem and ceftazidime. After surgery combined with antibiotic administration, six patients survived, with a mortality rate of 25%. In melioidosis endemic areas, the mycotic aneurysm secondary to melioidosis might be underdiagnosed, and increased awareness of predisposing risk factors and clinical features of the mycotic aneurysm is required. Following a positive B. pseudomallei blood culture, the diagnosis of mycotic aneurysm should be under consideration in those with abdominal pain and/or hypertension. Imaging by CT or angiography is indispensable for its timely diagnosis and management.

Burkholderia pseudomallei has the potential to cause mycotic aneurysm, an infrequently-occurred complication of melioidosis, with a high mortality rate despite appropriate antibiotic therapy and vascular surgery. The comprehensive clinical features of mycotic aneurysm due to B. pseudomallaei have not been documented in the People’s Republic of China and might be underrecognized. Therefore, we described eight patients with mycotic aneurysm from 159 bacteremic melioidosis patients in Hainan, China, over a seven-year period (between 2013 to 2019). We summarized their clinical characteristics, demographical features, treatments and outcomes. To our knowledge, this is the first comprehensive report of mycotic aneurysm secondary to melioidosis in China. In summary, in melioidosis endemic areas, or for those returning from endemic areas, increased awareness of the risk factors is required for early diagnosis and management of mycotic aneurysm secondary to melioidosis.

Iliohepatic artery bypass for hepatic ischemia after repair of mycotic celiac artery aneurysm

An 81-year-old woman presented to our institution with a contained ruptured mycotic aortic aneurysm involving the takeoff of the celiac artery that required ligation of the celiac trunk, resulting in foregut ischemia and the need for revascularization. The technique of aortic reconstruction with delayed hepatic artery revascularization by a common iliac artery to hepatic artery bypass is described.

Streptococcus pneumoniae as a Cause of Mycotic and Infected Aneurysms in Patients without Respiratory Features: Challenging Diagnoses Aided by 16S PCR

BACKGROUND

Streptococcus pneumoniae is considered a rare cause of mycotic aneurysms. The microbiological diagnosis of mycotic aneurysms can be difficult, and many patients have negative blood culture results.

METHODS

We describe a series of four consecutive cases of mycotic aneurysms caused by S. pneumoniae with no respiratory features or extravascular septic foci. In two patients with negative blood culture results, 16S PCR was used for the diagnosis of S. pneumoniae infection.

RESULTS

Four men with mycotic aneurysms affecting the aorta, axillary, and popliteal arteries caused by S. pneumoniae presented to our center between 2015 and 2016. All were treated with at least one month of intravenous antibiotics, followed by at least 4 weeks of oral antibiotics. Two were additionally managed using endovascular surgical techniques, and one underwent an open surgical repair. The fourth patient presented with bilateral popliteal aneurysms, one of which ruptured and was managed using surgical ligation and bypass, whereas the other side subsequently ruptured and was repaired endovascularly. Three of the four patients are currently off antibiotics and considered cured, while one died of an unrelated cause.

CONCLUSIONS

S. pneumoniae should be considered a potential causative agent of mycotic aneurysms. Diagnosis can be confirmed using 16S PCR, especially in patients where peripheral blood cultures are uninformative.

Endovascular treatment of multiple tuberculous mycotic aneurysm: A case report

RATIONALE

We present a rare case of multiple tuberculous mycotic aneurysm. Multiple aneurysms caused by tuberculosis (TB) are difficult to treat. Here, we discuss a treatment modality using a microcore stent graft.

PATIENT CONCERNS

A 73-year-old man with pain in the back and on the right side of the chest associated with dry cough, presented with an inability to walk since 1-month.

DIAGNOSES

A diagnosis of multiple aneurysms caused by TB was made, based on computed tomography (CT) scan and positive T-spot and Xpert tests.

INTERVENTIONS

We administered the empirical anti-TB regimen (pyrazinamide, isoniazid, rifampicin, and ethambutol) and performed endovascular repair using microcore stent graft.

OUTCOMES

The post-operative hemodynamic analysis indicated that the patient's aneurysms no longer had a risk of rupture, and blood flow in the major branches of the aorta had been maintained. However, the patient could not survive due to a pulmonary infection acquired during recuperation at a local hospital.

LESSONS

For multiple tuberculous mycotic aneurysms, anti-TB therapy is inadequate and the microcore stent graft is a feasible option that can improve the hemodynamics in the aneurysms.

Miliary tuberculosis presenting as bilateral superficial femoral artery mycotic aneurysm in an immunocompetent patient

Mycotic tuberculous aneurysm is extremely rare. The aorta is the main affected artery however; iliac and less commonly femoral arteries can also be affected. In 75% of the cases a contagious focus leads to infection through erosion of the vessel wall; on the other hand direct seeding of the blood vessel wall via the vasa vasorum may occur in 25%. In a large number of patients it may be a manifestation of miliary tuberculosis. In this case report we describe an immunocompetent patient who presented with bilateral superficial femoral artery aneurysms, followed by bilateral testicular swellings and inferior mesenteric artery aneurysm, as a presentation of military tuberculosis. Early diagnosis of such patients is essential for initiation of both medical and surgical treatment in order to avoid catastrophic outcome of rupture and bleeding.

Successful total endovascular repair of a giant salmonella-infected painful thoraco-abdominal aortic pseudoaneurysm

Endovascular approach is now a safe and effective technique for the elective treatment of a thoraco-abdominal aneurysm. This technique has significantly reduced the morbi-mortality for elective surgery. Moreover, it can permit to treat patients with a high surgical risk who are not eligible for open surgery. The permanent availability of endovascular material opens the door for treating a complex emergency thoraco-abdominal aneurysm. Here, we present the case of an 81-year-old man who had a rapidly evolving salmonella-infected aortic thoraco-abdominal Type IV pseudoaneurysm. Total endovascular treatment using aortic endoprosthesis, chimneys for coeliac trunk and superior mesenteric artery and periscopes for renal arteries was performed and permitted to obtain the complete exclusion of the pseudoaneurysm. The patient was event free and discharged from hospital after a few days with an antibiotic treatment adapted for salmonella. He was still event free 10 months after surgery. Endovascular technique might be a viable option even for an emergency infected complex thoraco-abdominal aortic aneurysm. Secondary open surgery should be discussed under the benefit-risk balance.

Bone Deformities as a Complication of Giant Thoracic Aortic Aneurysm

The contained rupture of thoracic aortic aneurysm and related bone deformities is a rare condition. The diagnosis is critical due to potential and fatal complications. Radiologic evaluation is required to show the location, extension, and complications. Herein we present the X-ray radiography, ultrasonography, computed tomography, and magnetic resonance images of a giant dissected and contained rupture of the thoracic aortic aneurysm. The aneurysm destructed the adjacent vertebrae and rib, resulting in compression of dural sac and spinal cord, and obliteration of the neural foramina. Our case demonstrates a gigantic expansion of an aneurysm (14 cm) with chronic skeletal complications.

Miliary tuberculosis in a patient with tuberculous mycotic aneurysm of the abdominal aorta: Case report and review of the literature

The combination of miliary tuberculosis and tuberculous mycotic aneurysm has been described in the literature. We present the case of an 84-year-old man who was diagnosed with a mycotic aneurysm of the abdominal aorta and an adjacent soft tissue mass, after a 3- month history of fever. The patient underwent endovascular restoration of the aneurysm and was treated with broad-spectrum antibiotics. One and a half months later the fever relapsed and the chest CT scan revealed findings consistent with miliary tuberculosis and opacities of both upper lobes not present before, while the abdominal CT scan revealed an increase in the size of the para-aortic mass. Tuberculosis was documented by positive culture for M. tuberculosis of bronchial washing and by the CT-guided para-aortic mass biopsy. The patient received anti-TB treatment for 9 months leading to a spectacular improvement of his clinical condition and imaging findings. A review of the literature since 2008 revealed 28 more cases of tuberculous mycotic aneurysm. The treatment and outcome of all cases are described. Mycotic aneurysm of tuberculous etiology remains a reality and has a relatively good prognosis. Although miliary tuberculosis affects mortality even elderly patients may benefit from "aggressive" management and treatment.

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.

Deadly case of Pasteurella multocida aortitis and mycotic aneurysm following a cat bite

Animal bites are frequently encountered in the emergency department (ED). Aortitis leading to mycotic abdominal aortic aneurysm is a rare and potentially deadly complication of Pasteurella multocida (P. multocida) following an animal bite. We present the case of a 68-year-old male who presented to the ED after falling at home. He complained of weakness and abdominal pain. He was in septic shock and was treated empirically with broad-spectrum antibiotics and intravenous fluids. He reported previous antibiotic treatment of a cellulitis secondary to a cat bite injury to his right thumb four weeks prior. Abdominal ultrasound and subsequent computed tomography scan revealed a leaking mycotic abdominal aneurysm that was surgically repaired. Blood cultures and aortic wall tissue cultures grew P. multocida. Given how common animal bite presentations are in the ED, this case highlights the need to consider aortitis and mycotic abdominal aortic aneurysm in an unwell patient with an animal bite.

Rare Mycotic Aneurysm of the Mitral Valve without Aortic Valve Involvement

Mycotic aneurysms can be a rare, but serious complication of infectious endocarditis. We report the case of a 20-year-old woman who presented with fever and malaise from streptococcal bacteremia and found to have vegetation on the anterior leaflet of the mitral valve. On follow-up visit, the patient was noted to have a mycotic aneurysm of the anterior mitral valve without aortic involvement. Her clinical course was complicated by mitral valve chordal rupture, severe mitral regurgitation, and dyspnea from severe mitral regurgitation for which she underwent successful surgical repair of the mitral valve.

Bridging endovascular therapy and subsequent surgical repair for the treatment of infected aneurysms after percutaneous cardiac intervention

Bridging endovascular therapy, accompanied by a second stage open surgical repair was used to treat a rare case of infected aneurysms alongside external iliac artery after a percutaneous cardiac intervention. Because these aneurysms require early treatment, we suggest this approach, in order to avoid immediate, major surgery in a recently symptomatic cardiac and bacteremic patient receiving dual antiplatelet therapy. The approach seems to be safe and durable.

Extra-aortic mycotic aneurysm due to group A Streptococcus after pharyngitis

Mycotic aneurysms, especially outside the aorta, are uncommon, with group A Streptococcus a particularly rare cause. We report a case of extra-aortic mycotic aneurysm following a sore throat without demonstrable bacteremia where identification of the pathological organism was made by molecular diagnostic techniques after a standard laboratory culture was negative.

In situ aortobiiliac reconstruction of infected aneurysm using a single superficial femoral vein

OBJECTIVE

To demonstrate successful in situ aortoiliac reconstruction of an infected infrarenal aneurysm using one single superficial femoral vein (SFV).

METHODS

In situ reconstruction using the right SFV sutured in end-to-end anastomosis with the aorta and distally with the right common iliac artery and in end-to-side anastomosis with the left common iliac artery.

RESULTS

The operating time was less than reported for aortic in situ reconstruction with bilateral SFV harvesting. The duplex scan 3 months postoperatively showed permeability of the bypass without any anastomotic stenosis or pseudoaneurysm. The right common femoral, popliteal, and greater saphenous veins were patent without thrombus, and the patient did not complain about peripheral edema.

CONCLUSIONS

The use of only one instead of both the SFVs for aortobiiliac in situ reconstruction might be a way to reduce operating time and allow autogenous venous reconstruction even in patients with limited availability of venous material.

Spectrum of imaging findings in Salmonella infections

OBJECTIVE

Radiologic findings in Salmonella infections are not well described. In most patients, Salmonella infections produce mild and self-limiting clinical manifestations and therefore are treated empirically with antibiotics. Radiologic investigations are usually performed for patients with severe clinical manifestations or complications and for patients with unusual findings.

CONCLUSION

This pictorial essay illustrates various imaging findings in culture-proven cases of Salmonella infection, described broadly as common and uncommon manifestations.

[A case of Salmonella-infected thoracoabdominal aortic aneurysm making final diagnosis difficult]

We report a case of thoracoabdominal aortic aneurysm (TAAA) due to Salmonella Enteritidis making final diagnosis difficult. A 63-year-old man with a history of diabetes mellitus, hypertension, and cerebral infarction was seen elsewhere for a 40 degrees C fever, vomiting, and shaking on day 1 after onset. He was diagnosed with Salmonella bacteremia and hospitalized by us for intensive care. Computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound imaging did not, however, show critical findings of aneurysm, endocarditis, or osteomyelitis, and laboratory testing suggest significant inflammatory symptoms. He did not respond to antibiotics, but had an intermittent low fever during the first hospitalization. On day 48 after onset during the second hospitalization, abdominal CT showed an aneurysm -3 cm in diameter in the thoracoabdominal aorta above the renal artery- small enough to have been missed in earlier diagnosis. Surgery and TAAA graft replacement were done on day 64. Bacterial culture of the graft showed no Salmonella growth due to long-term in vivo antibiotic exposure. He recovered without significant complications, with oral ciprofloxacin antibiotic therapy continued to the present. This case indicates the importance of an early diagnosis through continuous blood culture and imaging for Salmonella sp blood stream infection.

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.

Mycotic aneurysm caused by Burkholderia pseudomallei: report of a Brazilian strain genetically related to Thai strains

Melioidosis, a severe infectious disease caused by Burkholderia pseudomallei that is prevalent in Southeast Asia and Northern Australia, has been sporadically reported in Brazil since 2003. We report a case of aortic aneurysm with blood culture positive for B. pseudomallei. The phylogenetic analysis of 16S ribosomal DNA showed this isolate to be evolutionarily grouped with the MSHR346 strains from Thailand.