Management and Long-Term Outcomes of Patients With Infectious Intracranial Aneurysms.

BACKGROUND: Infectious intracranial aneurysms (IIAs) are rare complications of infective endocarditis (IE). Data on management and long-term outcomes remain limited. OBJECTIVE: To retrospectively study long-term outcomes of IIAs in patients treated medically or surgically. METHODS: Adult cases of IE and/or IIAs admitted to Emory or Grady Healthcare Systems between May 2015 and May 2020 were reviewed for demographic, clinical, and radiographic variables for up to 2 years. Primary outcome measure was 2-year survival. RESULTS: Among 1714 cases of IE, intracerebral hemorrhage occurred in 322 patients and IIAs in 17 patients. The presence of IIAs in IE was associated with higher odds of disposition to hospice/death (odds ratio = 6.9). Including non-IE patients, 24 patients had 38 IIAs mainly involving the distal middle cerebral artery and 16 were ruptured on admission. IIAs were predominantly treated with antibiotics as the primary approach. Open microsurgery was the primary approach for 5 aneurysms and was used as salvage in 7 IIAs. Endovascular management was the primary approach for 2 IIAs and used as salvage for 5 IIAs with antibiotic failure. Medical management had high rate of treatment failure (15/31) which predominantly occurred within 2 weeks of onset. The 2-year survival in this cohort was 70% (17/24). CONCLUSION: IIAs are rare complications of IE with a poor prognosis. Patients treated with antibiotics have higher risk of treatment failure requiring salvage surgical or endovascular intervention. Medical treatment failure occurred mostly within 2 weeks of onset and had a negative prognostic value emphasizing the need for close follow-up and early surgical or endovascular management.

Role of Recombinant Activated Factor VIIa (rFVIIa) in Bleeding Mycotic Aneurysm of the Abdominal Aorta.

Mycotic aortic aneurysm is an infective disease of the aorta with high mortality rate despite surgical repair. Recombinant activated factor VIIa (rFVIIa) is approved for the treatment of bleeding in hemophilia and used (off-labeled) in acute bleeding related to the trauma, cardiac surgery, and intracranial bleed. A 38-year female was admitted with abdominal pain, and was subsequently diagnosed with bleeding mycotic aneurysm of the abdominal aorta. She was given rFVIIa and the bleeding stopped successfully. We recommend further evaluation of the role of rFVIIa in bleeding mycotic abdominal aortic aneurysm, as it can bring a novel change in the management of this devastating disease. Key Words: Mycotic aortic aneurysm, Factor VIIa (rFVIIa), Abdominal aorta, Bleeding.

[Cerebral Blood Vessels and Infection].

Infectious intracranial aneurysms(IIAs)are rare cerebrovascular complications of systemic infections induced by microbial infiltration and degradation of the arterial vessel wall. Prospective or population-wide studies of the epidemiology, natural history, or management of IIAs have not been conducted. In this study, we present the epidemiological and angiographical features, management, and outcomes of IIAs based on published case series and retrospective studies. Most IIAs were small in size(< 5 mm), with aneurysms located in the middle cerebral artery followed by the posterior cerebral artery. Endovascular interventions for IIAs have increased since coils, liquid embolic materials, and microcatheter became more sophisticated, allowing them to reach more distal branches. Open surgery is still required in cases with large clots or in cases involving branches feeding the eloquent areas, which cannot be sacrificed. These multimodal approaches for managing IIAs have achieved satisfactory results. Septic cavernous sinus thrombosis is also a rare, life-threatening complication of head and neck infections. Several antibiotics and antivirals are used in combination with anticoagulants. However, no consensus has been reached because of a lack of randomized controlled trials and large population-based studies.

Mycotic abdominal aortic aneurysm in a patient with systemic lupus erythematosus: A case of critical antinomy.

Mycotic abdominal aortic aneurysms (MAAAs) are rare but life-threatening, and no standard therapy has yet been established. Effective surgery with intensive antimicrobial therapy is crucial; however, this can be fatal in immunocompromised patients. Only a few reports of MAAA with concomitant autoimmune disease exist; therefore, we were concerned about our lack of experience and knowledge about appropriate treatment. We report a 69-year-old male with an MAAA secondary to septic shock after spinal fusion surgery. He had also been on long-term oral immunosuppressants for systemic lupus erythematosus (SLE). After preoperative cephazolin, we performed debridement of infected tissue, graft replacement with a rifampicin-bonded prosthesis, and omentopexy. On the 52nd post-operative day, he was transferred back to the previous attending hospital under oral antibiotics and prednisolone. MAAA in patients with SLE should be treated with in situ replacement using an antimicrobial prosthetic or biological graft with thorough debridement and omentopexy, followed by antimicrobials and immunosuppressants, as needed.

A rare case of toxocariasis presenting with hypereosinophilic pericardial effusion and mycotic aneurysm.

Parasitic infections are the leading cause of hypereosinophilia in the paediatric population in tropical countries. We report an unusual case of Toxocara infection in an eight-year-old boy who presented with intermittent fever, hypereosinophilia complicated by massive pericardial effusion and a mycotic aneurysm. This child received treatment with four weeks of albendazole and steroids.

Mycotic aneurysm of the ascending aorta due to Escherichia coli: a case report.

Ascending aorta mycotic aneurysm is a rare entity. It is a life-threatening condition because of the possibility of aortic dissection, or rupture. Escherichia coli is recognised as an uncommon cause of aortic mycotic aneurysm. An 81-year-old woman with a history of Escherichia coli pyelonephritis 4 months previously, was admitted to our centre for a mycotic aneurysm of the ascending aorta caused by Escherichia coli. She was successfully treated by urgent in situ replacement of the ascending aorta with a cryopreserved homograft, combined with antibiotics. Although infrequent, Escherichia coli mycotic aneurysm should be suspected in older patients with atherosclerosis and who developed septicaemia. Prompt treatment with a combination of appropriate antibiotics and surgery is required.

Aneurisma infeccioso primário da aorta: série de casos e revisão da literatura / Primary infectious aortic aneurysm: a case series and review of the literature

Resumo Aneurismas infecciosos, anteriormente chamados de aneurismas micóticos, são raros; acometem com maior frequência a aorta de pacientes jovens e apresentam maior tendência à rotura do que aneurismas de outras etiologias. O formato sacular é o mais característico, e os agentes etiológicos mais comuns são Staphylococcus sp e Salmonella sp. A literatura fornece informações limitadas e imprecisas sobre a correta nomenclatura, diagnóstico e tratamento da doença. Os autores reuniram três casos cujos procedimentos diagnósticos e terapêuticos foram documentados. Além de relatar essa série de casos, realiza-se uma revisão sobre o tema, a fim de estabelecer estratégias diagnósticas e terapêuticas pertinentes.

Abstract Infectious aneurysms, formerly known as mycotic aneurysms, are rare, most often involve the aorta in young patients, and have a greater tendency to rupture than aneurysms of other etiologies. The most characteristic shape is saccular and the most common etiologic agents are Staphylococcus sp. and Salmonella sp. There is scant and imprecise information in the literature about correct nomenclature, diagnosis, and treatment. The authors present three cases in which diagnostic and therapeutic procedures were documented. In addition to reporting this case series, the authors also present a review of the subject, outlining pertinent diagnostic and therapeutic strategies.

Mycotic aortic aneurysm formation following intravesical BCG treatment for transitional cell carcinoma of the bladder.

Mycotic aneurysms are rare and if left untreated, can have devastating outcomes. In this case, a 72-year-old man presented to hospital with fevers, night sweats and abdominal pain. A CT scan revealed the development an infrarenal pseudoaneurysm over the course of 8 weeks, increasing from 2.8 cm to a 3.1 cm. The aneurysm was not present on a CT scan performed 6 months earlier. The patient underwent an emergency endovascular repair of the aortic aneurysm (EVAR) and was placed on broad-spectrum antibiotics. Intra-aortic blood cultures aspirated adjacent to the aneurysm and tissue biopsy confirmed tuberculosis bovis as the cause of the mycotic aneurysm. The patient had been treated with intravesical BCG for transitional cell carcinoma of the bladder several months prior. The patient was treated with an extended course of antituberculosis medication. He recovered well and was back to his baseline function within weeks.

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.

Candia albicans lumbar spondylodiscitis contiguous to infected abdominal aortic aneurysm in an intravenous drug user.

While the incidence of spondylodiscitis is rising because of longer life expectancy and the increasing use of immunosuppressant drug, indwelling devices and spinal surgeries, the fungal aetiology remains rare, sometimes affecting intravenous drug users. Candida spondylodiscitis is an extremely rare complication post aortic aneurysm repair. It is potentially fatal due to the risk of aneurysm rupture and septic complications. The growing problem of systemic diseases caused by Candida species reflects the enormous increase of patients at risk. The treatment of this complicated entity is challenging and often requiring a multidisciplinary team. We reported the rare case of Candida spondylodiscitis contiguous to infected aortic aneurysm in a 74-year-old male intravenous drug user, to the extent which the vertebral body bony destruction progressed to need one-stage posterior and anterior spinal fusion surgery with curettage. Our surgical intervention combined with prolonged course of antifungal therapy could successfully eradicate the infection and resolve the neurological deficits.

PET/CT in therapy control of infective native aortic aneurysms.

Infective native aortic aneurysms (INAA) are aneurysms arising from infection of the aortic wall. Treatment is demanding with 5-year survival rates between 53 and 55%. The aim of our study was to evaluate the usefulness of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in the long-term monitoring of patients with proven INAA. Fifty-three PET/CT were performed in 15 patients with INAA in this single-center retrospective cohort study and retrospective analysis of prospectively collected Vascular Graft Cohort Study (VASGRA) data. Median metabolic activity (as measured by maximum standardized uptake value, SUVmax) of the aneurysms at the initial PET/CT was high (6.8 (IQR 5.7-21.8)), and lower at the last PET/CT prior to the end of antimicrobial therapy (3.9 (IQR 2.7-6.8); n = 11) as well as in the first PET/CT after the end of the treatment (3.9 (IQR 3.0-4.4);n = 6). Compared to the course of C-reactive protein alone, PET/CT provided different (> 20% difference in trend) or altering (opposed trend) information on the course of disease in at least 14 comparisons (56%) in 11 patients (73%). The one-year and five-year freedom from all-cause lethality was 92% (95% confidence interval 57%-99%). As compared to the course of C-reactive protein, PET/CT provides different and occasionally altering information in therapy control of INAA.

Anaemia secondary to Escherichia coli mycotic aneurysm.

Mycotic aneurysms can pose a diagnostic dilemma due to their variable presentations. We present a case of a 93-year-old man initially presenting with fevers, intermittent chest pain and normocytic anaemia refractory to repeated blood transfusions. He received intravenous ceftriaxone as Escherichia coli grew in his blood cultures. His chest X-ray showed a widened mediastinum. A subsequent CT of the chest discovered a mycotic aneurysm at the descending thoracic aorta. He had a good outcome and was thriving after 1 year post endovascular repair.

Intracranial Mycotic Aneurysm in a Patient with Abdominal Actinomycosis.

Actinomycosis of the central nervous system is extremely rare. A 73-year-old woman with a history of abdominal actinomycosis presented with sudden-onset headache. Magnetic resonance imaging demonstrated a nodular lesion at the left precentral gyrus. A cerebral angiogram confirmed a fusiform aneurysm arising from the precentral branch of the left middle cerebral artery. High-resolution vessel wall imaging revealed circumferential wall enhancement of the aneurysm and multifocal enhancement of the M3 and M4 segments of both middle cerebral arteries. The patient had received a 4-week course of antibiotics, but follow-up angiography demonstrated no shrinkage or resolution of the aneurysm. Trapping combined with revascularization was successfully performed for refractory mycotic aneurysms.

Infected aortic aneurysm caused by Helicobacter cinaedi: case series and systematic review of the literature.

BACKGROUND: Helicobacter cinaedi is rarely identified as a cause of infected aneurysms; however, the number of reported cases has been increasing over several decades, especially in Japan. We report three cases of aortic aneurysm infected by H. cinaedi that were successfully treated using meropenem plus surgical stent graft replacement or intravascular stenting. Furthermore, we performed a systematic review of the literature regarding aortic aneurysm infected by H. cinaedi. CASE PRESENTATION: We present three rare cases of infected aneurysm caused by H. cinaedi in adults. Blood and tissue cultures and 16S rRNA gene sequencing were used for diagnosis. Two patients underwent urgent surgical stent graft replacement, and the other patient underwent intravascular stenting. All three cases were treated successfully with intravenous meropenem for 4 to 6 weeks. CONCLUSIONS: These cases suggest that although aneurysms infected by H. cinaedi are rare, clinicians should be aware of H. cinaedi as a potential causative pathogen, even in immunocompetent patients. Prolonged incubation periods for blood cultures are necessary for the accurate detection of H. cinaedi.

Mycotic aneurysm secondary to melioidosis in China: A series of eight cases and a review of literature.

Burkholderia pseudomallei is the causative agent of melioidosis, endemic in Southeast Asia and Northern Australia, and increasingly recognized in southern China, especially in Hainan Province. Mycotic aneurysm caused by B. pseudomallei is a rare but potentially severe illness with a high mortality rate. The clinical features of the mycotic aneurysm secondary to melioidosis have not been illustrated in China. Over a seven-year period (2013 to 2019), 159 patients with bacteremic melioidosis were retrospectively analyzed in Hainan province, China, of whom eight patients were confirmed to have mycotic aneurysm through the combination of imaging examination, pathologic examination and aneurysm tissue culture. We summarized these eight patients' clinical characteristics, demographical features, treatments and outcomes. The susceptibilities to five commonly-used antibiotics for these eight B. pseudomallei isolates were also determined by E-test strips. Furthermore, the mycotic aneurysm cases secondary to melioidosis retrieved from the literature were also reviewed. Of the eight cases, six had abdominal mycotic aneurysms, one had a left iliac aneurysm, and the other one had an infectious mesenteric aneurysm. They were aged from 48 to 69 years old, and had the underlying risk factors of diabetes mellitus (2 patients), long-term smoking (4 patients), hypertension (6 patients), and soil and water contact history (6 patients), respectively. The positive arterial aneurysm imaging was observed in all patients via computed tomography (CT) or angiography. Eight B. pseudomallei isolates collected from both blood and mycotic aneurysm tissues remained 100% susceptible to imipenem and ceftazidime. After surgery combined with antibiotic administration, six patients survived, with a mortality rate of 25%. In melioidosis endemic areas, the mycotic aneurysm secondary to melioidosis might be underdiagnosed, and increased awareness of predisposing risk factors and clinical features of the mycotic aneurysm is required. Following a positive B. pseudomallei blood culture, the diagnosis of mycotic aneurysm should be under consideration in those with abdominal pain and/or hypertension. Imaging by CT or angiography is indispensable for its timely diagnosis and management.

A mycotic aneurysm related to Salmonella Rissen infection: a case report.

BACKGROUND: Salmonella species commonly causes infection in humans and on occasion leads to serious complications, such as mycotic aneurysms. Here, we present the first case reported of a patient with a mycotic aneurysm likely secondary to Salmonella Rissen infection. CASE PRESENTATION: The patient presented with 4 weeks of lower back pain, chills and a single episode of diarrhoea 2 months prior during a 14-day trip to Hong Kong and Taiwan. Magnetic resonance imaging revealed an aneurysmal left internal iliac artery with adjacent left iliacus rim-enhancing collection. A stool culture was positive for Salmonella Rissen ST 469 EBG 66 on whole genome sequencing. The patient underwent an emergency bifurcated graft of his internal iliac aneurysm and was successfully treated with appropriate antibiotics. CONCLUSIONS: This case highlights the importance of considering the diagnosis of a mycotic aneurysm in an unusual presentation of back pain with features of infection.

Resection of a large mycotic aneurysm of the left anterior descending coronary artery.

A 50-year-old Indigenous woman, on home haemodialysis, was found to have a large mycotic aneurysm of the proximal left anterior descending coronary artery at the site of a previous drug-eluting stent. Blood cultures grew methicillin-sensitive S taphylococcus aureus bacteraemia. She underwent a complex operation involving resection of the mycotic aneurysm, removal of the stent and a coronary artery bypass graft to the distal left anterior descending (LAD) coronary artery using the left internal mammary artery. She had a complicated intensive care unit admission with pericardial tamponade on day 1 postoperatively requiring reopening and removal of clot and type 1 respiratory failure requiring reintubation on day 10 postoperatively. Once extubated, she developed prolonged hyperactive delirium and a significant decline in mobility. Over the course of a 6-week hospital admission, she received extensive multidisciplinary care and was discharged for rehabilitation to a peripheral hospital. She was discharged home after rehabilitation with ongoing follow-up with infectious diseases.

Infected aneurysm of the thoracic aorta probably caused by Bacillus cereus: a case report.

BACKGROUND: An infected aneurysm of the thoracic aorta is a rare clinical condition with significant morbidity and mortality. Patients with fast-growing aortic aneurysms show a high incidence of rupture. Gram-positive organisms, such as the Staphylococcus and Enterococcus species, are the most common cause of infection. CASE PRESENTATION: A 91-year-old man presented at our facility with high grade fever and tachypnea, which he had experienced for the previous two days. He had a history of end-stage renal disease and had been undergoing regular chest computed tomography (CT) follow-up for a left lower lung nodule. CT imaging with intravenous contrast media showed a thoracic aortic aneurysm with hemothorax. Rupture of the aneurysm was suspected. CT imaging performed a year ago showed a normal aorta. Blood samples showed a Bacillus cereus infection. The patient was successfully treated for a mycotic aortic aneurysm secondary to Bacillus cereus bacteremia. CONCLUSIONS: Here, we report a rare of an infected aneurysm of the thoracic aorta probably caused by Bacillus cereus. Although infected aneurysms have been described well before, an aneurysm infected with Bacillus cereus is rare. Bacillus cereus, a gram-positive spore-building bacterium, can produce biofilms, which attach to catheters. It has recently emerged as a new organism that can cause serious infection.

Successful Conservative Treatment of Mycotic Pulmonary Artery Aneurysms Caused by MRSA Bacteremia.

Mycotic pulmonary artery aneurysms (MPAAs) are rare and life-threatening with currently no recommended treatment strategies. In this report, we describe a successfully treated case of ventricular septal defect in an 11-month-old girl who developed bacteremia, infective endocarditis, and MPAA caused by methicillin-resistant Staphylococcus aureus (MRSA). We first started vancomycin, gentamycin, and panipenem-betamipron for infective endocarditis but switched to teicoplanin and arbekacin on day 3 after initiating treatment because bacteremia persisted, and vancomycin minimum inhibitory concentration was relatively high at 2 mg/L. Although we added clindamycin on day 5 and fosfomycin on day 7, MRSA bacteremia persisted, and we finally added daptomycin at 10 mg/kg per day on day 8, whereupon the bacteremia subsided within a day. Although the bacteremia subsided, the patient developed septic pulmonary embolisms and septic arthritis on her left knee. We continued daptomycin but switched the concomitant drug to linezolid, trimethoprim-sulfamethoxazole, and rifampicin on day 11. After several repeats of puncture and lavage of her knee joint, she became afebrile on day 16. Computed tomography scans taken on day 32 revealed right pulmonary artery MPAAs. She was treated with long-term multidrug therapy, and MPAAs were absent on subsequent computed tomography scans on day 184. Multidrug therapy mainly based on daptomycin could be a possible salvage therapy for refractory MRSA bacteremia with high vancomycin minimum inhibitory concentration. Conservative treatment should be selectively considered as a treatment option for clinically stable MPAA instead of surgical and endovascular treatment.