Development of a mycotic aneurysm within 4 days

Subarachnoid Hemorrhage in Bacterial Meningitis Patients

INTRODUCTION

Subarachnoid hemorrhage (SAH) has been described as an uncommon complication of community-acquired bacterial meningitis. However, the incidence, clinical course, and outcome are unclear.

METHODS

We assessed the clinical characteristics, incidence, and clinical outcome of patients with SAH complicating bacterial meningitis in a prospective nationwide cohort study from 2006 to 2018 in the Netherlands. Patients were identified through the Netherlands Reference Laboratory for Bacterial Meningitis, which receives around 90% of CSF isolates of all Dutch patients with bacterial meningitis, or after direct report by the treating physician.

RESULTS

SAH was diagnosed in 22 of 2,306 episodes (0.9%), of which 7 (32%) were diagnosed upon admission and 15 (68%) during admission. All patients showed clinical deterioration before SAH was diagnosed: altered mental status in 18 of 22 patients (82%), focal neurological symptoms in 2 (9%) and, new-onset fever with severe tachycardia in 1 (5%). Acute onset of headache was not reported in any of the patients. Distribution of blood was diffuse in the subarachnoid space in 7 patients (32%), multifocal in 8 patients (36%), and focal in 7 patients (32%) of 22 patients. In 6 patients (27%), CT angiography, MR angiography, or digital subtraction angiography was performed, showing a mycotic aneurysm in 1 patient (5%) and vasculitis in 1 patient (5%). Presence of SAH in bacterial meningitis patients was associated with a poor prognosis assessed at discharge: 12 of 22 patients with SAH died (54%) compared to 361 of 2,257 (16%, p < 0.001) without SAH, and 19 of 22 had an unfavorable outcome (86%) compared to 831 of 2,257 (37%, p < 0.001).

CONCLUSION

SAH is an uncommon complication in bacterial meningitis and is associated with high case fatality and morbidity.

Management of Septic emboli in patients with infectious endocarditis

BACKGROUND AND AIM

Septic emboli (SE) associated with infectious endocarditis (IE) can result in splenic abscesses and infectious intracranial aneurysms (IIA). We investigated the impact of SE on patient outcomes following surgery for IE.

METHOD

From January-2000 to October-2015, all patients with surgical IE (n = 437) were evaluated for incidence and management of SE.

RESULTS

Overall SE was found in 46/437 (10.52%) patients (n = 17 spleen, 13 brain, and 16 both). No mortality was seen in the brain emboli groups, but in the splenic abscess group the in-hospital mortality was 8.69% (n = 4); and was associated with Age >35 (OR = 2.63, 1.65-4.20) and congestive heart failure (OR = 14.40, 1.23-168.50). Patients with splenic emboli had excellent mid-term outcome following discharge (100% survival at 4-years). Splenic emboli requiring splenectomy was predicted by a >20 mm valve vegetation (OR = 1.37, 1.056-1.77) and WBC >12000 cells/mm (OR = 5.58, 1.2-26.3). No patient with streptococcus-viridians infection had a nonviable spleen (OR = 0.67, 0.53-0.85). Postoperative acute-kidney-injury was higher in the splenectomy group (45.45% vs 9%) (p = 0.027). There were 6 patients with symptomatic IIAs that required coiling/clipping which was associated with age <30 years, (OR = 6.09, 1.10-33.55). Survival in patients with cerebral emboli decreased to 78% at 3-4 years. Patients with both splenic and brain emboli had a 92% survival rate at 1-year and 77% at 2-4 years.

CONCLUSION

Septic emboli is common in endocarditis patients. Patients with high preoperative WBC level and large valve vegetations require CT imaging of the spleen. Both spleen and brain interventions in the setting of IE can be performed safely with excellent early and mid-term outcomes.

Fungal Mycotic Aneurysm in a Case of Acute Lymphoblastic Leukemia

We report a case of a 15-year old boy who was managed as a case of B cell lymphoblastic leukaemia with the modified BFM 90 protocol. During the induction phase, he developed febrile neutropenia with sino-pulmonary fungal infection confirmed on histopathology. He developed left sided hemiparesis during in-hospital management of febrile neutropenia. Neuroimaging revealed 9.6 × 8.4 mm round well defined aneurysm arising from right cortical artery in distal middle cerebral artery territory. He underwent fronto-temporo-parietal craniectomy with evacuation of the hematoma and excision of the aneurysm. Histopathological examination of excised aneurysmal specimen grew same species of fungus as was cultured from nasal scraping. He recovered fully in next 6 months with minimal residual focal neurological deficits. Presently he is in maintenance phase chemotherapy. We presented this case to illustrate a rare complication of ALL therapy with mycotic aneurysm secondary to invasive fungal infection treated successfully.

Retrospective review of cerebral mycotic aneurysms in 26 patients: focus on treatment in strongly immunocompromised patients with a brief literature review

BACKGROUND AND PURPOSE

Cerebral mycotic aneurysms are a rare and deadly type of aneurysm that have no definitive treatment guidelines. Our purpose was to retrospectively review known or suspected cases of CMA in order to identify patient populations that may be associated with higher morbidity and mortality. We hope that the identification of patients with these risk factors will lead to early stratification upon presentation, and more urgent treatment of their CMAs. We also hoped to identify any benefit or complication that was specific to either the endovascular or neurosurgical repair of CMAs.

MATERIALS AND METHODS

A retrospective multi-institutional study was performed examining cases of CMA during a 15-year period. Patients were considered strongly immunocompromised if there were long-term severely immunocompromised states: AIDS, chemotherapy, or steroid immunosuppression. Patients were excluded if angiographic findings suggested an alternative diagnosis or if an infectious etiology was unknown. Antibiotics were considered "noninvasive treatment." Endovascular and neurosurgical repair were considered "invasive treatment." Data were recorded by reviewing electronic medical records and imaging reports.

RESULTS

Twenty-six patients with 40 CMAs were included. Three patients were considered strongly immunocompromised and presented with 4 CMAs, which demonstrated larger average size and more rapid growth; 3 of these patients' aneurysms were treated invasively in the acute period, with the one that was not ruptured causing death. Technical success (aneurysm occlusion without rupture or recanalization) and clinical success (no neurologic complication attributable to the intervention) were obtained equally endovascularly and neurosurgically. Clipping was aborted in favor of coiling for 1 patient. Anticoagulation needed reversal before 2 patients underwent craniotomy for clipping after valve replacement. For CMAs treated with antibiotics alone with angiographic follow-up (n=11), initial aneurysm size was unrelated to persistence and 64% completely regressed.

CONCLUSIONS

We recommend initial invasive treatment for CMAs in strongly immunocompromised patients. Testing for underlying immunocompromised states is warranted in patients with CMAs. Endovascular treatment is favored over neurosurgical treatment in patients requiring acute cardiac valve repair due to delays with anticoagulation reversal.

Diagnosis and management of mycotic aneurysms

We reviewed all papers most recently reported in the literature related to infected arterial aneurysms (IAAs) affecting the aorta and vascular beds other than the aorta. In this article, we report on vascular beds other than the aorta. As is the case for aortic IAAs, infected non-aortic aneurysms are rarely encountered. The majority of recent studies are limited to case reports and small series of unusual infected aneurysms. A comprehensive review of this entity was performed based on the available literature from January through December 2008 in all languages. Available reports were analyzed with respect to demographic features, type of presentation, methods of diagnosis and therapy, follow-up, and outcome (morbidity and mortality).