Case Conference

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Case Conference

• Vipul Ganatra, MD

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Case 1

• 49 yr old AA male presents to the ER with lower
  abdominal pain and lower back pain.
• He was taking self-prescribed pain medications
  and prevacid.
• Also c/o night sweats, low grade fevers, nausea,
  and weight loss of 40 pounds over a period of one
  year.
• Also noticed SOB and loss of appetite.

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Case 1

• PMH
• Pulmonary TB in 1999 treated with
  INH/Rifampin/PZA/Ethambutol
• Hypertension
• GERD
• Perirectal abscess
• Balanitis

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Case 1

• MEDS
• Cipro
• Zosyn
• Vancomycin
• Esmolol
• Protonix
• NTG drip

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Case 1

• Gen A/O x 3
• Vitals 100.3- 106- 150/66
• Chest coarse breath sounds bilaterally
• Cardiac S1S2
• Abd Soft and non-distended. Palpable pulsatile
  mass present.

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Case 1

• Labs
• WBC 19.6, Hb 12.4, Plt cnt 267
• Cr 1.5, Alk phos 126, Tbili 1.7
• U/A Nitrite positive, 21-30 WBCs, TNTC bacteria
• Lactic acid 1.5
• Hepatitis B and C negative.
• HIV 1 2 antibody negative.

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• CT SCAN FINDINGS
• 1. Bilobed 6.3 x 5.3 cm, predominantly
  infrarenal, inflammatory
• aneurysm extending from the origin of the renal
  arteries to the bifurcation of the iliac
  arteries. Although there is no active
  extravasation, the appearance of the aorta is
  suggestive of severe instability. There is a
  focal outpouching in the inferior portion of the
  aneurysm which could represent a pseudoaneurysm
  or impending rupture.
• Enlarged prostate.
• 3. Numerous bilateral renal simple cysts, too
  small to characterize hypodensities and
  high-density cysts. These are probably benign.

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• CT SCAN FINDINGS
• The inferior mesenteric artery was not
  identified, which is suggestive of occlusion.
• 5. Fatty stranding around the aorta was felt to
  contain blood products.

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Case 1

• Patient was taken to the OR the next day in the
  morning and he underwent
• 1. Axillobifemoral bypass graft with 8
  millimeter PTFE.
• 2. Harvest of the right superficial femoral
  vein for use in aorto-visceral reconstruction.
• Aorta to superior mesenteric artery bypass with
  SFV.
• 4. Aorta left renal artery bypass with reversed
  saphenous vein.

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Case 1

• Resection of mycotic aortic aneurysm and
  bilateral common iliac artery aneurysm, from
  SMA to iliac artery bifurcations.
• Resection of the proximal left renal and
  superior mesenteric arteries for infection.
• Over sew of the right renal artery orifice.
• 8. Creation of an omental pedicle flap for
  placement into an infected aortic aneurysm
  cavity, s/p debridement.

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Case 1

• ID service was consulted as patient had h/o TB,
  culture of the aortic wall grew GNR and BC
  positive for GNR.
• ID recommended to continue Zosyn, Cipro and
  Vancomycin.
• Sputum to be checked for AFB x 3

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Case 1

• Blood culture done on the day of the surgery grew
  E. Coli. Urine culture grew many species.
• Later the aortic wall culture grew E. Coli and
  CoNS oxacillin resistant.
• His antibiotic was later changed to Meropenem and
  Zosyn and Cipro were discontinued.
• His creatinine went on rising and later he was
  put on CVVHD.

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Mycotic Aneurysm

• A mycotic aneurysm can develop either when a new
  aneurysm is produced by infection of the arterial
  wall or when a preexisting aneurysm becomes
  secondarily infected.
• The majority of mycotic aneurysms are caused by
  bacteria, despite the name which was coined by
  Osler to denote an appearance like "fresh fungus
  vegetations."

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Mycotic Aneurysm

• A mycotic aneurysm is defined as a 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.
• It may be a true or false aneurysm, involving all
  layers or only a portion of the arterial wall.

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Mycotic Aneurysm

• Mycotic aneurysms can arise following bacterial
  infection of a previously normal arterial wall or
  through secondary infection of a preexisting
  aneurysm.
• Mycotic aneurysms can occur anywhere in the body.
  In one series, 31 percent were abdominal aortic,
  38 percent femoral, 8 percent superior
  mesenteric, 5 percent carotid, 6 percent iliac,
  and 7 percent brachial.

Brown, SL et al J Vasc Surg 1984 1541
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Mycotic Aneurysm

• A number of routes account for infection of an
  arterial wall including
• Septic emboli to the vasa vasorum
• Contiguous infective focus extending to the
  arterial wall
• Direct bacterial inoculation at the time of
  trauma, such as a penetrating injury
• Bacteremic seeding of an existing intimal injury
  or atherosclerotic plaque

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Mycotic Aneurysm

• In one study by Hsu et al reviewed 48 patients
  with primary infected aortic aneurysms.
• 35 patients were infected with Salmonella species
  and 11 were infected with microorganisms other
  than salmonella species.
• Surgical debridement and insitu graft replacement
  performed in 35 patients, with an early mortality
  in 11.

Hsu et al. J Vasc Surg 2004 40 30-5
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Mycotic Aneurysm

• The authors concluded that with timely surgical
  intervention and prolonged antibiotic treatment,
  in situ graft replacement provides an excellent
  outcome in patients with primary infected aortic
  aneurysms and elective operation.
• Mortality is high in patients undergoing urgent
  operation.
• Advanced age, non-salmonella infection and no
  operation are major determinants of mortality.

Hsu et al. J Vasc Surg 2004 40 30-5.
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Mycotic Aneurysm

• Clinical Manifestations
• The classic presentation is that of a painful,
  pulsatile, and often enlarging mass in a patient
  with associated systemic features of infection
  such as fever.
• When the aneurysm involves the aorta, fever,
  back, and abdominal pain are common.

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Mycotic Aneurysm

• In some cases, a mycotic aneurysm can initially
  present with a local complication such as
• Gastrointestinal bleeding when an aortic mycotic
  aneurysm gives rise to an aorto-duodenal
  aneurysm. The third part of the duodenum overlies
  the infrarenal aorta.
• Ischemia of a distal limb
• Palpable neck mass (Pancoast's syndrome) due to a
  subclavian mycotic aneurysm
• Dysphagia and hoarseness due to subclavian artery
  mycotic aneurysm
•     

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Mycotic Aneurysm

• Osteomyelitis of the thoracic or lumbar spine due
  to aortic mycotic aneurysm
• Wrist drop due to brachial artery aneurysm
  leading to nerve compression
• Endobronchial mass due to mycotic pulmonary
  artery aneurysm
• Rupture of the aneurysm

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Mycotic Aneurysm

• Diagnosis
• General Labs Leukocytosis, anemia
• Cultures
• Imaging US, CT, Angiography, MRI

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Mycotic Aneurysm

• Treatment
• Surgery
• Antibiotic therapy
• Four to six weeks of parenteral antimicrobial
  therapy is recommended for the treatment of a
  mycotic aneurysm.
• A longer duration of treatment should be
  considered if biochemical parameters of
  inflammation (C reactive protein, erythrocyte
  sedimentation rate, and white cell count) do not
  return to normal.

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Mycotic Aneurysm

• The initial choice of therapy depends upon the
  most probable infecting organisms for the
  involved site. Subsequent decisions should be
  made after the organism(s) have been cultured and
  sensitivity testing performed.
• Some authors recommend that life-long oral
  suppressive antibiotics follow the intravenous
  course.

Brown SL et al J Vasc Surg 1984 1541.