Salmonella-related mycotic pseudoaneurysm

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Salmonella-related mycotic pseudoaneurysm

Author(s)

Bacel Nseir, MD

Anthony F. Cutrona, MD

A 74-year-old man is admitted to the hospital with a 7-day history of fever, rigors, chest pain, and general weakness. He underwent coronary artery bypass surgery 10 years ago.

High-resolution contrast-enhanced computed tomography of the chest shows an aneurysmal change near the mid-point of the descending aorta with a maximum diameter of 5 cm (Figure 1). Two sets of blood cultures done on admission identify Salmonella enteritidis, which was sensitive to ampicillin, sulfamethoxazole-trimethoprim (Bactrim), and ceftriaxone (Rocephin).

After 2 weeks of intravenous ceftriaxone 2 g/day, the patient undergoes excision of the mycotic pseudoaneurysm of the descending aorta, with placement of an aortic homograft. Biopsy of the excised aortic segment shows calcified fibroatheromatous plaques with no evidence of cystic medial degeneration or granulomas.

DISCUSSION

Mycotic aneurysm is a localized and irreversible dilatation of an artery due to destruction of the vessel wall by an infection. The dilatation is at least one and one-half times the normal diameter of the affected artery. It may be a true aneurysm or a pseudoaneurysm, involving all or some layers of the arterial wall. It is a rare but life-threatening condition.

A mycotic aneurysm can develop from septic embolization to the vasa vasorum, hematogenous seeding of an existing aneurysm, or extension from a contiguous site of infection.^1,2 Mycotic infections of the aorta show a preference for male patients already infected with S enteritidis or S typhimurium. ³ Predisposing factors include rheumatic deformity of the valves, a bicuspid valve, impaired immunity,⁴ self-induced or iatrogenic arterial trauma,^5,6 atherosclerotic deposits and calcification of the endovascular structure,⁷ and, in elderly patients, Salmonella septicemia.^8,9 Computed tomography is the most useful imaging modality.^10,11 Surgical interventions, in addition to parenteral antibiotic therapy for at least 6 weeks,^11,12 are required to:

Confirm the diagnosis
Reconstruct the arterial vasculature
Manage the complications of sepsis
Start preventive measures (ie, cholecystectomy).²

References

Carreras M, Larena JA, Tabernero G, Langara E, Pena JM. Evolution of salmonella aortitis towards the formation of abdominal aneurysm. Eur Radiol 1997; 7:54–56.
Cicconi V, Mannino S, Caminiti G, et al. Salmonella aortic aneurysm: suggestions for diagnosis and therapy based on personal experience. Angiology 2004; 55:701–705.
Schneider S, Krulls-Munch J, Knorig J. A mycotic aneurysm of the ascending aorta and aortic arch induced by Salmonella enteritidis. Z Kardiol 2004; 93:964–967.
Johnson JR, Ledgerwood AM, Lucas CE. Mycotic aneurysm. New concepts in therapy. Arch Surg 1983; 118:577–582.
Qureshi T, Hawrych AB, Hopkins NF. Mycotic aneurysm after percutaneous transluminal femoral artery angioplasty. J R Soc Med 1999; 92:255–256.
Samore MH, Wessolossky MA, Lewis SM, Shubrooks SJ, Karchmer AW. Frequency, risk factors, and outcome for bacteremia after percutaneous transluminal coronary angioplasty. Am J Cardiol 1997; 79:873–977.
Carnevalini M, Faccenna F, Gabrielli R, et al. Abdominal aortic mycotic aneurysm, psoas abscess, and aorto-bisiliac graft infection due to Salmonella typhimurium. J Infect Chemother 2005; 11:297–299.
Soravia-Dunand VA, Loo VG, Salit IE. Aortitis due to Salmonella: report of 10 cases and comprehensive review of the literature. Clin Infect Dis 1999; 29:862–868.
Malouf JF, Chandrasekaran K, Orszulak TA. Mycotic aneurysms of the thoracic aorta: a diagnostic challenge. Am J Med 2003; 115:489–496.
G ufler H, Buitrago-Tellez CH, Nesbitt E, Hauenstein KH. Mycotic aneurysm rupture of the descending aorta. Eur Radiol 1998; 8:295–297.
Lin CY, Hong GJ, Lee KC, Tsai CS. Successful treatment of Salmonella mycotic aneurysm of the descending thoracic aorta. Eur J Cardiothorac Surg 2003; 24:320–322.
Schoevaerdts D, Hanon F, Vanpee D, et al. Prolonged survival of an elderly woman with Salmonella dublin aortitis and conservative treatment. J Am Geriatr Soc 2003; 51:1326–1328.

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Author and Disclosure Information

Bacel Nseir, MD
Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, LA

Anthony F. Cutrona, MD
Chief, Division of Infectious Disease, Associate Professor of Internal Medicine, Northeastern Ohio Universities College of Medicine/Western Reserve Care System, Youngstown, OH

Address: Bacel Nseir, MD, Department of Infectious Diseases, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121; e-mail [email protected]

Issue

Cleveland Clinic Journal of Medicine - 76(5)

Publications

Cleveland Clinic Journal of Medicine

Topics

Infectious Diseases

Vascular

Page Number

315-316

Sections

The Clinical Picture

Author(s)

Bacel Nseir, MD

Anthony F. Cutrona, MD

Author(s)

Bacel Nseir, MD

Anthony F. Cutrona, MD

Author and Disclosure Information

Bacel Nseir, MD
Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, LA

Anthony F. Cutrona, MD
Chief, Division of Infectious Disease, Associate Professor of Internal Medicine, Northeastern Ohio Universities College of Medicine/Western Reserve Care System, Youngstown, OH

Address: Bacel Nseir, MD, Department of Infectious Diseases, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121; e-mail [email protected]

Author and Disclosure Information

Bacel Nseir, MD
Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, LA

Anthony F. Cutrona, MD
Chief, Division of Infectious Disease, Associate Professor of Internal Medicine, Northeastern Ohio Universities College of Medicine/Western Reserve Care System, Youngstown, OH

Address: Bacel Nseir, MD, Department of Infectious Diseases, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121; e-mail [email protected]

Article PDF

media_68285f7_315.pdf

Article PDF

media_68285f7_315.pdf

A 74-year-old man is admitted to the hospital with a 7-day history of fever, rigors, chest pain, and general weakness. He underwent coronary artery bypass surgery 10 years ago.

High-resolution contrast-enhanced computed tomography of the chest shows an aneurysmal change near the mid-point of the descending aorta with a maximum diameter of 5 cm (Figure 1). Two sets of blood cultures done on admission identify Salmonella enteritidis, which was sensitive to ampicillin, sulfamethoxazole-trimethoprim (Bactrim), and ceftriaxone (Rocephin).

After 2 weeks of intravenous ceftriaxone 2 g/day, the patient undergoes excision of the mycotic pseudoaneurysm of the descending aorta, with placement of an aortic homograft. Biopsy of the excised aortic segment shows calcified fibroatheromatous plaques with no evidence of cystic medial degeneration or granulomas.

DISCUSSION

Mycotic aneurysm is a localized and irreversible dilatation of an artery due to destruction of the vessel wall by an infection. The dilatation is at least one and one-half times the normal diameter of the affected artery. It may be a true aneurysm or a pseudoaneurysm, involving all or some layers of the arterial wall. It is a rare but life-threatening condition.

A mycotic aneurysm can develop from septic embolization to the vasa vasorum, hematogenous seeding of an existing aneurysm, or extension from a contiguous site of infection.^1,2 Mycotic infections of the aorta show a preference for male patients already infected with S enteritidis or S typhimurium. ³ Predisposing factors include rheumatic deformity of the valves, a bicuspid valve, impaired immunity,⁴ self-induced or iatrogenic arterial trauma,^5,6 atherosclerotic deposits and calcification of the endovascular structure,⁷ and, in elderly patients, Salmonella septicemia.^8,9 Computed tomography is the most useful imaging modality.^10,11 Surgical interventions, in addition to parenteral antibiotic therapy for at least 6 weeks,^11,12 are required to:

Confirm the diagnosis
Reconstruct the arterial vasculature
Manage the complications of sepsis
Start preventive measures (ie, cholecystectomy).²

A 74-year-old man is admitted to the hospital with a 7-day history of fever, rigors, chest pain, and general weakness. He underwent coronary artery bypass surgery 10 years ago.

High-resolution contrast-enhanced computed tomography of the chest shows an aneurysmal change near the mid-point of the descending aorta with a maximum diameter of 5 cm (Figure 1). Two sets of blood cultures done on admission identify Salmonella enteritidis, which was sensitive to ampicillin, sulfamethoxazole-trimethoprim (Bactrim), and ceftriaxone (Rocephin).

After 2 weeks of intravenous ceftriaxone 2 g/day, the patient undergoes excision of the mycotic pseudoaneurysm of the descending aorta, with placement of an aortic homograft. Biopsy of the excised aortic segment shows calcified fibroatheromatous plaques with no evidence of cystic medial degeneration or granulomas.

DISCUSSION

Mycotic aneurysm is a localized and irreversible dilatation of an artery due to destruction of the vessel wall by an infection. The dilatation is at least one and one-half times the normal diameter of the affected artery. It may be a true aneurysm or a pseudoaneurysm, involving all or some layers of the arterial wall. It is a rare but life-threatening condition.

A mycotic aneurysm can develop from septic embolization to the vasa vasorum, hematogenous seeding of an existing aneurysm, or extension from a contiguous site of infection.^1,2 Mycotic infections of the aorta show a preference for male patients already infected with S enteritidis or S typhimurium. ³ Predisposing factors include rheumatic deformity of the valves, a bicuspid valve, impaired immunity,⁴ self-induced or iatrogenic arterial trauma,^5,6 atherosclerotic deposits and calcification of the endovascular structure,⁷ and, in elderly patients, Salmonella septicemia.^8,9 Computed tomography is the most useful imaging modality.^10,11 Surgical interventions, in addition to parenteral antibiotic therapy for at least 6 weeks,^11,12 are required to:

Confirm the diagnosis
Reconstruct the arterial vasculature
Manage the complications of sepsis
Start preventive measures (ie, cholecystectomy).²

References

Carreras M, Larena JA, Tabernero G, Langara E, Pena JM. Evolution of salmonella aortitis towards the formation of abdominal aneurysm. Eur Radiol 1997; 7:54–56.
Cicconi V, Mannino S, Caminiti G, et al. Salmonella aortic aneurysm: suggestions for diagnosis and therapy based on personal experience. Angiology 2004; 55:701–705.
Schneider S, Krulls-Munch J, Knorig J. A mycotic aneurysm of the ascending aorta and aortic arch induced by Salmonella enteritidis. Z Kardiol 2004; 93:964–967.
Johnson JR, Ledgerwood AM, Lucas CE. Mycotic aneurysm. New concepts in therapy. Arch Surg 1983; 118:577–582.
Qureshi T, Hawrych AB, Hopkins NF. Mycotic aneurysm after percutaneous transluminal femoral artery angioplasty. J R Soc Med 1999; 92:255–256.
Samore MH, Wessolossky MA, Lewis SM, Shubrooks SJ, Karchmer AW. Frequency, risk factors, and outcome for bacteremia after percutaneous transluminal coronary angioplasty. Am J Cardiol 1997; 79:873–977.
Carnevalini M, Faccenna F, Gabrielli R, et al. Abdominal aortic mycotic aneurysm, psoas abscess, and aorto-bisiliac graft infection due to Salmonella typhimurium. J Infect Chemother 2005; 11:297–299.
Soravia-Dunand VA, Loo VG, Salit IE. Aortitis due to Salmonella: report of 10 cases and comprehensive review of the literature. Clin Infect Dis 1999; 29:862–868.
Malouf JF, Chandrasekaran K, Orszulak TA. Mycotic aneurysms of the thoracic aorta: a diagnostic challenge. Am J Med 2003; 115:489–496.
G ufler H, Buitrago-Tellez CH, Nesbitt E, Hauenstein KH. Mycotic aneurysm rupture of the descending aorta. Eur Radiol 1998; 8:295–297.
Lin CY, Hong GJ, Lee KC, Tsai CS. Successful treatment of Salmonella mycotic aneurysm of the descending thoracic aorta. Eur J Cardiothorac Surg 2003; 24:320–322.
Schoevaerdts D, Hanon F, Vanpee D, et al. Prolonged survival of an elderly woman with Salmonella dublin aortitis and conservative treatment. J Am Geriatr Soc 2003; 51:1326–1328.

References

Carreras M, Larena JA, Tabernero G, Langara E, Pena JM. Evolution of salmonella aortitis towards the formation of abdominal aneurysm. Eur Radiol 1997; 7:54–56.
Cicconi V, Mannino S, Caminiti G, et al. Salmonella aortic aneurysm: suggestions for diagnosis and therapy based on personal experience. Angiology 2004; 55:701–705.
Schneider S, Krulls-Munch J, Knorig J. A mycotic aneurysm of the ascending aorta and aortic arch induced by Salmonella enteritidis. Z Kardiol 2004; 93:964–967.
Johnson JR, Ledgerwood AM, Lucas CE. Mycotic aneurysm. New concepts in therapy. Arch Surg 1983; 118:577–582.
Qureshi T, Hawrych AB, Hopkins NF. Mycotic aneurysm after percutaneous transluminal femoral artery angioplasty. J R Soc Med 1999; 92:255–256.
Samore MH, Wessolossky MA, Lewis SM, Shubrooks SJ, Karchmer AW. Frequency, risk factors, and outcome for bacteremia after percutaneous transluminal coronary angioplasty. Am J Cardiol 1997; 79:873–977.
Carnevalini M, Faccenna F, Gabrielli R, et al. Abdominal aortic mycotic aneurysm, psoas abscess, and aorto-bisiliac graft infection due to Salmonella typhimurium. J Infect Chemother 2005; 11:297–299.
Soravia-Dunand VA, Loo VG, Salit IE. Aortitis due to Salmonella: report of 10 cases and comprehensive review of the literature. Clin Infect Dis 1999; 29:862–868.
Malouf JF, Chandrasekaran K, Orszulak TA. Mycotic aneurysms of the thoracic aorta: a diagnostic challenge. Am J Med 2003; 115:489–496.
G ufler H, Buitrago-Tellez CH, Nesbitt E, Hauenstein KH. Mycotic aneurysm rupture of the descending aorta. Eur Radiol 1998; 8:295–297.
Lin CY, Hong GJ, Lee KC, Tsai CS. Successful treatment of Salmonella mycotic aneurysm of the descending thoracic aorta. Eur J Cardiothorac Surg 2003; 24:320–322.
Schoevaerdts D, Hanon F, Vanpee D, et al. Prolonged survival of an elderly woman with Salmonella dublin aortitis and conservative treatment. J Am Geriatr Soc 2003; 51:1326–1328.