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Thoracic Mycotic Aneurysm
Barcikowski J, MS-III, St. Jean B, MD, Lancellotti G, MD
University of New England College of Osteopathic Medicine, Biddeford, ME
Introduction: A mycotic aneurysm is rare and represents 1-1.8% of all aortic aneurysms. It is
a life-threatening condition with high morbidity and mortality rates. The standard management
of infected aneurysms is surgical resection and debridement, with or without revascularization
procedures, followed by long-term antibiotic treatment. However, this conventional treatment
carries a high surgical morbidity and mortality rates. The use of endovascular aortic repair
may provide a good alternative for infected aneurysms.
Case: A 62 year-old male from Guatemala presented to the ED with black stool and
lightheadedness. His past medical history is significant for diabetes mellitus, TURP for
bladder outlet obstruction, hyperlipidemia, acute renal failure, hypertension, and a stroke in
2010. On admission, the patient reported experiencing weakness, abdominal pain and rectal
bleeding, but no nausea, vomiting, diarrhea, or constipation. Vital signs were significant for a
blood pressure of 87/48, respiratory rate of 12, and pulse rate of 105. Physical exam was
remarkable for right and left abdominal tenderness, maroon stool, and a positive guaiac
test. Lab studies showed WBC 17.1, hemoglobin 5.8, hematocrit 17.3, platelets 249. Sodium
was 124, potassium 4.3, chloride 93, bicarbonate 20 with anion gap of 11, glucose was
600. Lactic acid is 1.6. Chest x-ray showed no pulmonary infiltrates. Urinalysis showed white
blood cells. Gastroenterology was consulted to assess for a gastrointestinal bleed and they
recommended that he receive blood resuscitation, Protonix drip at 8 mg/hour after an 80, and
that he get an endoscopy to identify the source of bleeding once he was resuscitated. His
gastrointestinal bleed appeared to be stabilized by a transfusion of 2 units of packed red blood
cells. 48 hours after admission, the patient developed a fever of 38 degrees Celsius,
tachycardia, and an increased WBC of 16. Urine cultures showed Staphylococcus aureus,
Methicillin-sensitive Staphylococcus aureus, extended-spectrum beta-lactamase producing
Escherichia coli. The patient was given imipenem and oxacillin. He was transferred to ICU for
the treatment of sepsis. An abdominal/pelvic computed tomography scan with oral contrast
was performed to investigate his fever and abdominal pain. The scan showed a large
retrocardiac soft tissue structure per radiology. Interventional radiology and general surgery
were consulted to review the CT scan. It was recommended to obtain a chest CT Angiogram
to further investigate the esophageal mass and rule out an aortic leak. CTA showed a large
lower middle mediastinal mass measuring 8.2 cm by 6.7 cm and associated with a large lower
thoracic aortic pseudoaneursym secondary to a probable ruptured mycotic aneurysm. The
endoscopy the patient was supposed to receive was not performed for fear of rupturing the
pseudoaneurysm. As the patient was not stable enough to be transferred, he was taken
emergently to the Operating Room at our hospital for an endovascular stent repair. The
patient was returned to the ICU and was initially stabilized. Ultimately, the infected
pseudoaneursym will need to be drained and eventually be resected after bypass or he will
need life-time antibiotics.
Discussion: Mycotic aneurysms are a rare subdivision of aortic aneurysms. Current
management strategies are primarily based upon clinical experience guided by case studies.
The standard treatment of most mycotic aneurysms is surgical resection and debridement
followed by antibiotic therapy. During the past decade, endovascular repair of aortic
aneurysms has demonstrated satisfactory results and has the potential to become mainstay
alternative strategy for managing infected aortic aneurysms.