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• 71 y/o wm
• PMH of chr. pancreatitis, ETOH, tobacco abuse
• Went to OSH with chest tightness, fever
• MI was ruled out
• CT chest showed aortic irregularities

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• MRI showed marked enlargement with fluid
  collection of the descending aorta and transverse
  thoracic aorta
• OSH BC grew MSSA
• TTE from OSH -no vegetation, EF 50
• Cefazolin and rifampin were started and
• pt was transferred

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PE

• T 100.4 P 113 RR 14 BP 120/55
• On ventilator FiO2 40 PEEP 5 PO 98
• GA awake, followed commands
• HEENT- WNL
• Neck no JVP
• Chest- decreased BS at bases
• Heart tachycardia

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PE

• Abd distended, BS , tender upper quadrant
  bilat.
• Ext positive peripheral pulses, no signs of
  ischemia

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• WBC 21.7 Hb 13 Platelet 239,000
• BUN 27 Cr 1.0
• LFT WNL
• PT 13 PTT 26

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Hospital Course

• Pt underwent surgery on the day of admission

• Preop Dx
• -Ruptured mycotic pseudo aneurysm of
• the aortic arch and proximal
  descending
• thoracic aorta
• TEE intraoperative
• -no vegetation, EF 60, mild MR,
• descending aorta dilated approx. 30 mm

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Hospital Course

• Postop Dx same
• Procedure
• Replace transverse aortic arch and proximal
  descending thoracic aorta

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Hospital Course

• Continue with oxacillin and rifampin
• Added gentamycin for synergy
• C/S tissue from aorta grew MSSA
• Repeat BC negative
• Hospital course was complicated by acute renal
  failure and pancreatitis.
• Plan to c/w IV ATBs and Rifampin for total of 6
  weeks then PO ATBs life-long

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MYCOTIC ANEURYSM

• Localized, irreversible dilatation of an artery
  to at least one and one-half times its normal
  diameter
• Due to destruction of the vessel wall by an
  infection.
• May be a true or false aneurysm
• Involving all layers or only a part of the
  arterial wall.

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MYCOTIC ANEURYSM

• Following bacterial infection of a normal
  arterial wall or through secondary infection of a
  preexisting aneurysm
• Can occur anywhere in the body
• Routes of infection
• Septic emboli to the vasa vasorum
• Contiguous infective focus extending to the
  arterial wall
• Direct bact. inoculation from trauma , i.e.
  penetrating injury
• Bact. seeding of an existing intimal injury or
  plaque

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Predisposition

• Arterial trauma
• Self-induced, iatrogenic, or accidental trauma to
  the artery
• IDU was frequent, and usually involved the
  femoral vessels
• Complication of PTCA and femoral arterial
  angiography

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Predisposition

• Bact endocarditis the majority happened in the
  preantibiotic era
• Local or concurrent infection
• Impaired immunity , i.e. DM, alcoholism,
  corticosteroids, and malignancy
• Age- salmonella septicemia

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Microbiology

• Staphylococcus sp.
• Salmonella sp.
• Treponema pallidum rarely seen
• TB accounted for 41 cases in a literature review
  between 1945 and 1999- most often arose following
  the erosion of an infected contiguous LN into the
  aortic wall.

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Other organism

• Fungi e.g., Candida, Cryptococcus, Aspergillus
• Gram negative organisms e.g., Pseudomonas,
  Klebsiella, Campylobacter,Yersinia, and Brucella
• Gram positive organisms e.g., Streptococcus,
  Clostridium, and Corynbacterium
• Coxiella burnetti

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Clinical Manifestations

• Depend on the site of the aneurysm
• Classic painful,, pulsatile, and often a mass in
  a pt with systemic features of infection i.e.,
  fever
• Aorta involvement fever, back, abd pain
• In endocarditis- stroke, SAH

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• Local complication
• GI bleeding,
• Ischemia of a distal limb
• Dyphagia and hoarseness subclavian art
• Osteomyelitis of T, L spine- aorta
• Wrist drop- brachial art leads to nerve
  compression
• Rupture of aneurysm

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Diagnosis

• Imaging studies
• Blood culture positive 50-85
• Tissue culture positive up to 76
• Lab data- anemia, leukocytosis

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Imaging Studies

• US and CT with contrast
• Angiography- definitive diagnosis procedure
• MRI/MRA may be used in place of angiography
• Both angiography and MRI/MRA can detect
  extravasation and can help in planning for surgery

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Treatment

• Need early diagnosis
• Followed by prompt surgical and ATB therapy

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Surgery

• Depends on the site , availability of homologous
  graft material
• The best approach may be only able to determined
  at the time of the Sx
• Arterial ligation e.g., radial, brachial,
  external iliac and deep femoral
• In situ repair or reconstruction- suprarenal
  aortic aneurysms
• In situ bypass reconstruction infrarenal aortic
  aneurysms
• Embolization distal middle cerebral artery

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Antibiotic therapy

• 4-6 weeks of IV ATBs
• Initial ATBs - most probable infecting organism
  for the involved site
• Subsequent ATBs based on culture and sensitivity
• Consider longer duration if CRP, ESR, WBC not
  return to normal
• Life-long oral suppressive ATBs favor for
  organisms which are difficult to treat

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Outcome

• Mortality is high and depends on the artery
  involved, treatment received, and underlying
  conditions
• Some reports of aortic aneurysm showed MR 23-60
• Survival is higher for infrarenal AAA (96)
  compared to suprarenal (57)
• MR when medical surgical Tx (38) compared to
  medical Tx alone (96)
• Reinfection has occurred in 16

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Mycotic aneurysms of the thoracic aorta a
diagnostic challenge.

• Malouf JF - Am J Med - 15-OCT-2003 115(6)
  489-96
• Mayo Clinic
• 1976-2001
• 11 Pts with Dx of mycotic or infected thoraco
  aortic aneurysm
• Dx confirmed intraoperatively and postoperative
  histologic evaluation

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• Median age was 64 yrs ( range 30 to 87)
• 64 male
• Most pts had unexplained fever or uncontrolled
  sepsis
• 8 pts weregt 80 y/o
• At Dx, 5 pts had free or contained rupture of
  aneurysm
• 2 pts developed fistula

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• Time from admission to diagnosis ranged from 1-4
  days
• Time from diagnosis to surgery was 1-11 days
• Diagnosis was made at autopsy in 2 pts
• In the remaining, Dx was first suspected on CT in
  6 pts, TEE, TTE, echo, and angiography in 1 pt
  each
• Occasionally, more than one diagnostic imaging
  technique was used

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• Bacteriologic Dx was confirmed in all pts
• BC positive in 7 pts,
• tissue C/S positive in 7 pts
• BC negative in 4 pts
• S. aureus 5 pts
• E. coli 1 pts
• C. albicans 1 pts
• Histoplasma 1 pts
• Nontyphi Salmonella 2 pts ( 80, 85 y/o )

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• 9 pts had Sx
• One operative death
• Ruptured aneurysm intraoperatively in 3 pts
• Sx was debridement and resection of the infected
  segment
• 6 pts received life-long ATBs
• 8 operative survivors were alive at a mean F/U of
  19 months ( 2-60 months)
• None had recurrent infection

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• Prevalence of mycotic aneursym among all forms of
  aneurysms was 2.7
• Am J Pathol. 195531821-835
• Infection tends to occur at major branchings of
  the aorta, most frequently the femoral artery and
  abd aorta, followed by the thoracoabd and
  thoracic aorta
• Most pts had solitary lesion

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• CT is usually the initial imaging technique for
  
• the detection
• - Reproducible
• - Not time-consuming
• TEE is for R/O IE
• If TEE negative, should examine thoracic aorta
• TEE can miss aneurysm when
• Located at ascending aorta and proximal aortic
  arch
• Obscured by the interposed trachea

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• Aortography may be useful for
• excluding multiple aneurysms
• Outlining the relation of aneurysm to major
  branches of aorta
• Most of cases , aneurysm was made later while
  searching for a source of persistent fever
• Therefore, a high degree of awareness remains
  very important in early Dx

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• F/U by using imaging studies and markers of
  inflammation
• WBC tagged scan with gallium have been used to
  exclude infection in pts
• with h/o treated aneurysms
• Recurrent or persistent infection is the leading
  causes of death after successful surgery