A curious case of a spontaneous infective native pseudoaneurysm of the internal carotid artery

We present a case of a 77-year-old patient who presented with a stroke. She subsequently became unwell and was found to have a spontaneous infective native carotid artery pseudoaneurysm. The patient was managed conservatively as per her wishes. Despite the rarity of this clinical diagnosis, clinicians should be aware of the pathophysiology of this entity and the available literature on management.

BCGitis with aortoiliac aneurysm involvement: Report of two cases and review of the literature

BCGitis is a rare complication after intravesical administration of Bacillus Calmette-Guérin for high-grade superficial bladder cancer and carcinoma in situ. May cause vascular involvement. We present 2 cases and a review of the literature of the case reports pubished on the 10 years prior to April of 2022, when this proyect was finished, which described a case of aortoiliac mycotic aneurysm after receiving this treatment. Of the 51 cases included (49 revised and 2 original), 100% were men, 82% were older than 65 years. The median latency period was 15 months (IQR 18). The most frequent location was the abdominal aorta, rupture occurred in 45,1% of patients. The most frequent symptom was abdominal or lumbar pain (61%), followed by general syndrome (49%). In 39,2% cases, it was associated with retroperitoneal abscesess. Attributable mortality was 13,6%. BCGitis should be included in the differential diagnosis in patients who have received BCG therapy and present vascular involvement, even years after being treated.

Coxiella Burnetii Endocarditis In A Patient With Mycotic Cerebral Aneurysms

Q fever is an ubiquitous zoonosis caused by Coxiella burnetii, an intracellular bacterium that can produce acute or chronic infections in humans. These forms are characterized by different evolution, serological profile and treatment that must be very long to achieve a cure in chronic forms. However, the serological profile for diagnosis and the real value of serology for predicting outcome are controversial, and management dilemmas for many patients with Q fever infection are continuously emerging. In this case report, we present a 20-year-old man from Nicaragua who worked as a farmer with a culture-negative infective endocarditis who presented with a mycotic aneurysm. The present report reviews the clinical presentation and diagnosis of Q fever IE.

Delayed formation and rupture of intracranial aneurysm following Abiotrophia defectiva endocarditis

Abiotrophia defectiva is a type of Streptococci and is a rare cause of infectious endocarditis. The progression and outcomes of infectious intracranial aneurysms (IIAs) associated with this species are unknown due to a limited number of reported cases. A woman in her 20s with a sudden headache had a subarachnoid haemorrhage on a head CT scan. Cerebral angiography showed an aneurysm on the right middle cerebral artery. She was diagnosed with infectious endocarditis caused by A. defectiva and underwent parent artery occlusion. Despite initiating targeted antibiotic therapy, a new IIA developed and ruptured 14 days postadmission. A second parent artery occlusion was performed on the new IIA. Following 6 weeks of continued antibiotic therapy, she underwent mitral valve repair and was discharged with no neurological symptoms. Endocarditis caused by A. defectiva can lead to the delayed formation of an IIA. Endovascular treatment was effective for repeated ruptured IIAs.

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.

The Association of Spondylitis and Aortic Aneurysm Disease

OBJECTIVES

The aim of this study is to assess any relation between spondylitis and aortic aneurysmal disease by reviewing the current literature.

METHODS

A systematic search was undertaken using MEDLINE, EMBASE and CENTRAL databases till May 2019, for articles reporting on patients suffering from spondylitis and aortic aneurysm.

RESULTS

The most involved aortic segment was infrarenal aorta (56.9%). The lumbar vertebrae were more frequently affected (79.7%). Commonest symptoms were back pain (79.1%), fever (33.7%) and lower limb pain (29.1%). 55.8% of cases were diagnosed using computed tomography. The pathology was attributed to infectious causes in 25.1% of cases. 53.4% of patients were treated only for the aneurysm, 27.9% for both pathologies, while two patients solely for the vertebral disease. Endovascular aneurysm repair was chosen in 12.8% of cases. The 30-day mortality was 8.1% (7/86); mostly from vascular complications.

CONCLUSIONS

A synchronous spondylitis and aortic aneurysm may share common etiopathology, when an infectious or inflammatory cause is presented. The lumbar vertebrae are more frequently affected. Low quality data do not allow safe conclusion to suggest the best treatment option.

Recurrent Stroke and Fatal Ruptured Mycotic Aneurysm Caused by Invasive Aspergillus fumigatus Infection

INTRODUCTION

Aspergillus species are ubiquitous fungi that may cause invasive infection, particularly in immunocompromised patients. Invasive aspergillosis most commonly affects the lungs but can also disseminate to the central nervous system (CNS). Manifestations of CNS aspergillosis include abscesses and, rarely, mycotic aneurysm leading to subarachnoid hemorrhage (SAH).

CASE PRESENTATION

A 48-year-old man undergoing treatment for squamous cell cancer of the larynx with chemotherapy and steroids presented with dysarthria and weakness. He was found to have both lung and CNS infection secondary to Aspergillus species. While receiving intravenous antifungal treatment after biopsy-proven Aspergillus infection, he developed a fatal SAH caused by a mycotic aneurysm.

DISCUSSION

Intracranial mycotic aneurysms are uncommon. However, mycotic aneurysm leading to a fatal SAH is a well-documented sequela of CNS aspergillosis. Mortality rates for CNS aspergillosis are extremely high.

CONCLUSION

In immunosuppressed patients with neutropenia or using chronic steroids who have concurrent pulmonary and CNS infection, there should be a low threshold to treat empirically for fungal infections prior to confirmation of diagnosis.

An unusual ischaemic presentation of thrombosed intracranial mycotic aneurysm with subsequent subarachnoid haemorrhage

We present an unusual case of acute ischaemic stroke secondary to thrombosed mycotic aneurysm with subsequent early aneurysmal rupture and subarachnoid haemorrhage, successfully treated with endovascular coil embolisation of the thrombosed segment. Imaging correlates are presented demonstrating successful endovascular management despite vessel occlusion precluding angiographic visualisation of the aneurysmal segment. Imaging and clinical follow-up is provided demonstrating durable occlusion and excellent clinical outcome with full functional recovery.

Mycotic Aneurysm of the Middle Cerebral Artery Leading to Subarachnoid Hemorrhage, as the Initial Presentation of Bartonella henselae Endocarditis

Bartonella species was first reported as a cause of endocarditis in 1993, currently it is thought to account for 3-4 percent of all diagnosed cases. Initial symptoms of Bartonella endocarditis are non-specific like weight loss, fever and fatigue. There are very few reported cases of Bartonella endocarditis causing mycotic aneurysm. We present a case of a 60-year-old male who presented with subarachnoid hemorrhage secondary to mycotic aneurysm. Due to high suspicion of endocarditis leading to mycotic aneurysm he underwent transesophageal echocardiography which showed mitral valve vegetations. His blood cultures were negative, he was eventually diagnosed with Bartonella henselae by elevated IgG titers greater than 1:800. Due to repeated mycotic aneurysms on antibiotics, he underwent surgical mitral valve replacement along with the full course of antibiotics and has been asymptomatic since.

When Less Invasive Causes Major Sequelae: A Dramatic Evolution of an Infected Common Femoral Artery Patch

Endarterectomy of the common and profunda femoris is currently performed for treatment of atherosclerotic lesions involving femoral bifurcation. Misperception of surgical risk in terms of morbidity and mortality has induced the trend to extend the indication for treatment to patients with mild symptoms at presentation, at the cost of unnecessary increased complication rate and mortality risk, which persists even after patient discharge. We report the case of a giant infected femoral pseudoaneurysm occurring in a 74-year-old patient, previously treated with femoral artery endarterectomy with prosthetic patch closure because of mild claudication. Surgically managed with en block resection and autologous vein reconstruction, his postoperatory course was further complicated by fatal sepsis. Complications for femoral artery endarterectomy, including infectious and fatal events, need a close follow-up of these patients to promptly diagnose and treat any event which may occur, preventing its evolution to more challenging and potentially life-threatening clinical scenario.

Infectious Aneurysm Caused by Citrobacter koseri in an Immunocompetent Patient

Citrobacter species can cause severe infection in immunocompetent patients. A 78-year-old man visited our hospital because he had had a fever lasting one day each month for the past 3 months. Antibiotics were initiated for suspected bronchial pneumonia, but the C-reactive protein level remained high. Contrast-enhanced computed tomography revealed saccular brachiocephalic artery aneurysm. Citrobacter koseri was isolated from a blood culture, and he was diagnosed with infectious brachiocephalic artery aneurysm. He underwent endovascular aneurysm repair after one month of intravenous cefepime and metronidazole. We herein report for the first time an immunocompetent patient with infectious aneurysm caused by C. koseri periodontal infection.

[Tuberculous mycotic aneurism of the aorta: a case report of haemoptysis.]

Mycotic aneurysm secondary to tuberculous infection (TB) of the aorta is a rare and life-threatening disease. We report a case report of a 78-year-old woman with a tuberculous mycotic aortic aneurysm (TBAA). Early diagnosis and a combination of surgical intervention (aortic reconstruction and extensive excision of the infected field) and prolonged antituberculous drug therapy provide long-term survival without evidence of recurrence after tuberculous aortic involvement.

Mycotic Aneurysm of the Abdominal Aorta due to Group B Streptococcus (GBS) Infection: A Case Report and Review of the Literature

We present a case report of an extremely rare infected abdominal aortic aneurysm (AAA) caused by group B streptococcus (GBS). A 66 years old, afebrile male patient with hypertension and history of chronic smoking presented with mild abdominal pain and discomfort. Physical examination revealed a pulsatile mass of 5 cm in diameter located at the periumbilical region. A computed tomography (CT) scan of the whole abdomen exhibited an outpouching lesion with intramural hematoma located at the infrarenal abdominal aorta, sized 5.1x3.7 cm in diameter, suggesting an abdominal aortic aneurysm. A transthoracic echocardiography demonstrated normal endocardium without vegetation. Surgical abdominal aortic aneurysm repair (aneurysmorrhaphy) was successfully done and intravenous amoxicillin/clavulanic acid was given. Tissue culture obtained from the aneurysm sac and para-aortic lymph nodes revealed group B streptococcus infection. Intravenous amoxicillin/clavulanic acid was continued for 14 days, and was transitioned to oral amoxicillin 3 grams/day. Currently, the patient has been followed-up for 20 months with neither recurrent infection nor post-operative complication. This is the first case report of infected abdominal aortic aneurysm due to GBS in Thailand.

Successful management of a giant unruptured mycotic coronary artery aneurysm after coronary angioplasty

Coronary artery stent infection has been reported with both bare metal stent and drug eluting stent and can present as mycotic coronary artery aneurysm, pseudoaneurysm, myocardial abscess, pericarditis or exudative effusion. Infection at the site of coronary stent implantation is rare and is believed to result typically from either direct stent contamination at the time of delivery or transient bacteraemia from access site. Introduction of drug-eluting stent (DES) has led to a marked reduction in the problem of in-stent restenosis across all patient subsets and lesions complexities. Recently, several case reports of pseudoaneurysm formation after DES implantation have been reported in the literature. We describe the successful surgical management of giant mycotic pseudoaneurysm of left anterior descending artery (LAD) presenting as fever of unknown origin. This report illustrates the importance of early detection and prompt management of these rare coronary pseudoaneurysms, which is a highly lethal condition.

Salmonella Aortic Aneurysm: Suggestions for Diagnosis and Therapy Based on Personal Experience

Infectious aneurysm is a rare event, especially after the introduction of antibiotic therapy. However, its early detection is very important for timely treatment with antibiotics and surgical intervention. This pathology may generally be due to mycotic endocarditis or septic embolization, prevailing in the preantibiotic era, and to aortitis, whose incidence is actually increasing, mainly in subjects with preexisting large-vessel atherosclerosis and intimal defects. This clinical entity is usually defined as microbial arteritis and recognizes Salmonella spp as the microorganism most frequently isolated from blood or vascular tissue cultures. The authors present the case of a 56-year-old man with a history of hypertension that some weeks before admission manifested as hyperpyrexia and episodic lumbar pain, associated with hepatosplenomegaly and with a pulsing mass in the periumbilical region. Abdominal computed tomography (CT) scan documented a voluminous infrarenal aortic aneurysm with a markedly reduced and irregular vessel wall. The patient underwent surgical excision of the aneurysm, during which marked periaortic inflammation phenomena, complete absence of the posterior aortic wall for a length of 5-6 cm, and the exposure of the correspondent vertebral bodies were observed. Histopathologic examination of the aneurysmal tissue showed atheromatous and thrombotic aspects and confirmed strong signs of inflammation. This case may suggest that the occurrence of microbial aortitis, especially from Salmonella spp, should be taken into account in the presence of a septic status associated with back, abdominal, or thoracic pain.

Mycotic bronchial artery aneurysmal rupture in the early stage of lung abscess: A case report

Symptomatic bronchial artery aneurysm warrants urgent intervention. It has a known association with pulmonary infection caused by Staphylococcus aureus. We hereby report an elderly lady with a ruptured left superior bronchial artery mycotic aneurysm. She was in the early stages of treatment for a left lung abscess. She had multiple episodes of haemoptysis following which she underwent a left lower lobectomy. Presentation of lung abscess with a concurrent ruptured mycotic aneurysm warrants early surgical intervention and can be curative as seen in this case.

Mycotic Aneurysm Caused by Bacteroides fragilis in an Elderly Immunosuppressed Patient

An 82-year-old Japanese man, who presented with a fever and abdominal pain, was admitted to our hospital. According to enhanced computed tomography images, the probable diagnosis was abdominal aortic mycotic aneurysm. Eight sets of blood cultures obtained from the patient were negative. Despite administering treatment with vancomycin and ceftriaxone, the aneurysm progressively enlarged. He underwent open debridement surgery and in situ replacement because of an aneurysmal rupture. Bacteroides fragilis was isolated from the tissue culture of the aortic wall. Metronidazole was administered and discontinued without any infection relapse. When faced with similar cases, rare pathogens should thus be considered as possible causes of mycotic aneurysms.

Infected Aortic Aneurysm Mimicking Anti-proteinase 3-Antineutrophil Cytoplasmic Antibody-associated Vasculitis

We herein report an unusual case of an infected descending aortic pseudoaneurysm with luminal pathognomonic oscillating vegetation with serological findings and clinical features mimicking anti-proteinase 3-antineutrophil cytoplasmic antibody-associated vasculitis. The positive blood cultures and imaging findings, including a pseudoaneurysm and vegetations in the aorta, suggested the presence of an infected aortic aneurysm. The patient was successfully treated with antibiotics and endovascular aortic repair. A precise diagnosis is crucial in order to avoid inappropriate therapy such as immunosuppressive treatment, which could result in life-threatening consequences in a patient with an infected aortic aneurysm.

Vascular complications and surgical interventions after world's largest Q fever outbreak

OBJECTIVE

Since chronic Q fever often develops insidiously, and symptoms are not always recognized at an early stage, complications are often present at the time of diagnosis. We describe complications associated with vascular chronic Q fever as found in the largest cohort of chronic Q fever patients so far.

METHODS

Patients with proven or probable chronic Q fever with a focus of infection in an aortic aneurysm or vascular graft were included in this study, using the Dutch national chronic Q fever database.

RESULTS

A total of 122 patients were diagnosed with vascular chronic Q fever between April 2008 and June 2012. The infection affected a vascular graft in 62 patients (50.8%) and an aneurysm in 53 patients (43.7%). Seven patients (5.7%) had a different vascular focus. Thirty-six patients (29.5%) presented with acute complications, and 35 of these patients (97.2%) underwent surgery. Following diagnosis and start of antibiotic treatment, 26 patients (21.3%) presented with a variety of complications requiring surgical treatment during a mean follow-up of 14.1 ± 9.1 months. The overall mortality rate was 23.7%. Among these patients, mortality was associated with chronic Q fever in 18 patients (62.1%).

CONCLUSIONS

The management of vascular infections with C. burnetii tends to be complicated. Diagnosis is often difficult due to asymptomatic presentation. Patients undergo challenging surgical corrections and long-term antibiotic treatment. Complication rates and mortality are high in this patient cohort.

Endovascular Treatment of Infected Brachial Pseudoaneurysm in an Intravenous Drug Abuser: A Case Report

We report the case of a 36-year-old male, admitted in the emergency room with a nonruptured brachial pseudoaneurysm after buprenorphine injection, with no signs of distal acute ischemia. After endovascular treatment with a nitinol covered stent associated with adapted antibiotherapy and 35 days of hospitalizations, the patient was discharged with good short results but stent need to be removed at 6 months for thrombosis and partial exposure through the wound.

[MYCOTIC ANEURYSM OF THE ASCENDING AORTA AND CEREBRAL INFARCTS IN A 17-MONTH OLD CHILD WITH KINGELLA KINGAE ENDOCARDITIS]

Endocarditis is an uncommon presentation of Kingella kingae infection in children. A previously healthy 17 month old child was referred to our emergency department for evaluation of fever lasting eleven days, aphthous stomatitis and a new systolic murmur. Within a few hours of admission, antibiotic therapy was initiated for a presumptive diagnosis of bacteremia and within 24 hours after admission, gram negative coccobacilli were growing in the blood culture. In addition, echocardiography demonstrated a mycotic aneurysm of the ascending aorta with a mobile vegetation. The presumptive diagnosis of Kingella kingae endocarditis was made. Further evaluation by MRI revealed frontal and occipital cerebral infarcts. Due to the presence of presumed septic emboli in conjunction with progressive left ventricular dysfunction, the child was urgently taken to the operating room where aggressive debridement of the infected tissue was performed and the aortic aneurysm was repaired. The patient had an uneventful post-operative course. This case emphasizes the need for a high index of suspicion when evaluating children with community acquired infection. In addition, it also demonstrates the importance of early diagnosis and appropriate treatment of K. kingae endocarditis.

Strategies to treat thoracic aortitis and infected aortic grafts

Infectious thoracic aortitis is a rare disease, especially since the incidence of syphilis and tuberculosis has dropped in western countries. However, the risk to develop an infectious aortitis and subsequent mycotic aneurysm formation is still present, particularly in case of associated endocarditis, sepsis, and in immunosuppressive disorders. Moreover, the number of surgical and endovascular thoracic aortic repairs is continuously increasing, and infective graft complications are observed more frequently. Several etiopathogenetic factors may play a role in thoracic aortic and prosthetic infections, including hematogenous seeding, local bacterial translocation, and iatrogenous contamination. Also, fistulization of the esophagus or the bronchial tree is commonly associated with these diseases, and it represents a critical event requiring a multidisciplinary management. Knowledge on underlying micro-organisms, antibiotic efficacy, risk factors, and prevention strategies has a key role in the management of this spectrum of infectious diseases involving the thoracic aorta. When the diagnosis of a mycotic aneurysm or a prosthetic graft infection is established, treatment is demanding, often including a number of surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for infectious diseases of the thoracic aorta are still burdened with very high morbidity and mortality. In this manuscript, we review the literature regarding the main issues related to thoracic infectious aortitis and aortic graft infections, and we report our personal series of patients surgically treated at our institution for these conditions from 1993 to 2014.

[Modern approaches to surgical treatment of post-injection vascular complications in intravenous drug addicts]

An ever-growing number of injection drug abusers causes great concern over specific post-injection complications involving major vessels, not uncommonly infected ones. The review is dedicated to the problem of vascular complications in drug abusers, clinical peculiarities of the nosology concerned, as well as a present-day view on diagnosis and policy of surgical treatment of infected false aneurysms in this cohort of patients. Surgical decision-making is based on a series of factors: baseline general condition of the patient, possibility of surgical care depending on the specific situation (scope and level of the infected area, phase of the course of the wound process, degree of ischaemia of the limb, choice of a plastic material), and probability of further injections of narcotic drugs. In treatment of such patients a promising trend includes endovascular and minimally invasive technologies, however assessing the remote results thereof requires accumulation of larger experience.

A rare but potentially lethal case of tuberculous aortic aneurysm presenting with repeated attacks of abdominal pain

Tuberculous aortic aneurysm is an extremely rare disease with a high mortality rate. The clinical features of this condition are highly variable, ranging from asymptomatic with or without constitutional symptoms, abdominal pain to frank rupture, bleeding and shock. We herein report the case of a 56-year-old man with a large tuberculous mycotic aneurysm in the abdominal aorta with an initial presentation of repeated attacks of abdominal pain lasting for several months. Due to the vague nature of the initial symptoms, tuberculous aortic aneurysms may take several months to diagnose. This case highlights the importance of having a high index of suspicion and providing timely surgery for this rare but potentially lethal disease.

Sphenoid Sinusitis Complicated by Pneumococcal Meningitis and an Infectious Aneurysm in the Intracavernous Carotid Artery

A 61-year-old Japanese woman presented with a headache and appetite loss lasting for nine days and was admitted to our hospital, where she was diagnosed with pneumococcal meningitis associated with acute sphenoid sinusitis. While the administration of meropenem and dexamethasone ameliorated the meningitis, right third and sixth nerve palsy suddenly developed 10 days after admission. CT angiography subsequently demonstrated an aneurysm in the cavernous portion of the right internal carotid artery. This is the first reported case of sphenoid sinusitis simultaneously complicated by both pneumococcal meningitis and an infectious aneurysm in the intracavernous carotid artery.

Infective Internal Iliac Artery Aneurysm Caused by Campylobacter fetus

A 67-year-old man with a persistent high fever was diagnosed to have an infective aneurysm in his left internal iliac artery. A blood culture detected a gram-negative spiral rod that was first identified as Campylobacter fetus subsp. venerealis based on a matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) analysis. However, the strain was finally confirmed to be Campylobacter fetus subsp. fetus based on a genetic analysis. The infection was successfully treated with emergency resection of the aneurysm, followed by 4 weeks of antibiotic therapy. Involvement of the peripheral artery is uncommon in cases of C. fetus-infective aneurysm. To figure out the epidemiology and pathogenicity of C. fetus infection, the accurate identification of the responsible organisms is essential.

Ruptured mycotic common femoral artery pseudoaneurysm: fatal pulmonary embolism after emergency stent-grafting in a drug abuser

The rupture of a mycotic femoral artery pseudoaneurysm in an intravenous drug abuser is a limb- and life-threatening condition that necessitates emergency intervention. Emergency stent-grafting appears to be a viable, minimally invasive alternative, or a bridge, to subsequent open surgery. Caution is required in cases of suspected concomitant deep vein thrombosis in order to minimize the possibility of massive pulmonary embolism during stent-grafting, perhaps by omitting stent-graft postdilation or by inserting an inferior vena cava filter first. We describe the emergency endovascular management, in a 60-year-old male intravenous drug abuser, of a ruptured mycotic femoral artery pseudoaneurysm, which was complicated by a fatal pulmonary embolism.

Mycotic Aneurysm of the Popliteal Artery Secondary to Enterococcus Endo-carditis : a Case Report

A mycotic popliteal aneurysm (MAAP) is a very rare condition [1]. We describe a 87-year-old Caucasian male who presented with a MAAP of the right leg due to an enterococcus mitral valve endocarditis. The aneurysm was excised and a reversed vein graft was interposed between the normal popliteal artery and the posterior tibial artery. A second vein graft was interposed between the first graft and the anterior tibial artery.

Mycotic aneurysm caused by Burkholderia pseudomallei in a previously healthy returning traveller

Burkholderia pseudomallei is a common cause of serious, difficult to treat infections in South-East Asia and Northern Australia, but is a rare imported pathogen in the USA and Europe. We report a case of a patient with a mycotic aneurysm caused by B. pseudomallei in a previously healthy returning traveller. The patient presented with 4 weeks of abdominal pain and intermittent fever after a brief vacation in Thailand. The aneurysm was excised and replaced by an autologous deep vein graft, and the patient was treated for 6 months with antibiotics adjusted according to postoperative renal impairment. Twenty-four months after surgery the patient is well and without relapse.

[Endovacular treatment of mycotic iliac aneurysm]

No gold standard exists in the treatment of mycotic aorto-iliac aneurysms. Surgical debridement and revascularization with bypass remain as the most definitive surgical solution, but also carry a relatively high risk of perioperative morbidity as compared to an endovascular approach. We present a case story with a mycotic a. iliac aneurysm treated successfully with an endoluminal covered stent graft. The patient had severe co-morbidity that ruled out open surgery.

Mycotic popliteal artery aneurysm

The name mycotic aneurysm was coined by Osler to describe aneurysms associated with bacterial endocarditis with an appearance of fresh fungal vegetations; however majority of them are caused by bacteria. Mycotic aneurysm (MA) is a rare complication of infective endocarditis (IE), seen in 3-15% of IE patients.

Infective endocarditis associated superior mesenteric artery pseudoaneurysm

BACKGROUND

Since William Osler first described mycotic aneurysms in the setting of endocarditis in 1885, few pseudoaneurysms (PAs) of the superior mesenteric artery (SMA) have been reported in the literature. We report 2 cases of SMA PA related to infective endocarditis that were managed with open surgery.

RESULTS

Here we report 2 cases of SMA PAs treated with different surgical techniques. A 59-year-old male with a history of intravenous drug use presented with abdominal pain and was found to have Streptococcus viridans endocarditis and an SMA PA. A laparotomy was performed, and proximal and distal control of the SMA PA was obtained. After ensuring that Doppler signals were still present in the distal mesentery and the entirety of the bowel was viable, the SMA was ligated proximal and distal to the PA. The patient recovered uneventfully. The second case is a 35-year-old female who presented with abdominal pain and was found to have Streptococcos gordonii endocarditis and an SMA PA for which the patient was initially observed. After several weeks, the patient's condition deteriorated and the patient underwent open ligation of the SMA, proximal and distal to the PA, with a bypass from the infrarenal abdominal aorta to a distal unnamed SMA branch and resection of 3 ft of ischemic small bowel. The patient continued to have recurrent bowel ischemia over the next several weeks and ultimately died.

CONCLUSIONS

SMA PAs associated with infective endocarditis are rare, but carry a high risk of rupture and associated morbidity and mortality. Delay in surgical management may increase this risk.

Concurrent Salmonella mycotic abdominal aneurysm and empyema thoracis: a rare coincidence

OBJECTIVE

To present a case of Salmonella bacteremia with a rare metastatic focus.

CLINICAL PRESENTATION AND INTERVENTION

A 61-year-old male presented with a suicide attempt after ingestion of half a bottle of toilet cleaner. He had a medical history of intravenous drug abuse and major depression. Persistent Salmonella enteritidis bacteremia occurred during his hospitalization, and a search for the primary source of infection disclosed a mycotic abdominal aortic aneurysm. A suppurative lesion was also noted over the left pleural space, and Salmonella empyema was confirmed after thoracentesis. He underwent video-assisted thoracoscopic surgery and endovascular repair of the abdominal aortic aneurysm and was placed on long-term antibiotics, without recurrence.

CONCLUSION

S. enteritidis involvement of the cardiovascular system is a rare coincidence and results in significant morbidity and mortality. In addition, the phenomenon of secondary metastatic infective foci involving the pleural space has an even lower frequency than that of cardiovascular involvement. Therefore, a high index of suspicion and prompt treatment from the treating physicians are strongly recommended.

Mycotic aortic aneurysm caused by haemophilus influenzae group F

BACKGROUND

Haemophilus influenzae is a rare cause of mycotic aortic aneurysm. We present a case of H. influenzae mycotic aortic aneurysm, which was complicated by prior endovascular stent-graft placement at another facility.

METHODS

A 58 year-old man was treated by endograft placement for a presumed penetrating aortic ulcer after having symptoms of abdominal pain and malaise for one month. He presented to our institution 11 days after endograft placement with septic physiology. Repeat computed tomography angiogram demonstrated an inflammatory mass around the distal aorta and right common iliac artery, which had an associated contained rupture.

RESULTS

The patient was treated using intravenous antibiotics, axillo-bifemoral bypass followed by endograft explantation and aortic and iliac ligation. Intraoperative cultures grew Haemophilus influenzae, serotype f.

CONCLUSIONS

Aortic endografts have been successfully used for treatment of selected mycotic aneurysms, generally after adequate treatment of the primary infection with intravenous antibiotics. This case demonstrates the unfavorable natural history of endograft placement in an unsuspected mycotic aneurysm. A high index of suspicion for possible aortic infection should be maintained for patients with systemic symptoms and unusual aortic pathology prior to choosing endovascular repair.