Primary and secondary arterial fistulas during chronic Q fever.

OBJECTIVE: After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever. METHODS: In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis. RESULTS: Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%). CONCLUSIONS: The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not.

Peritonitis as presentation of aorto-caval fistula with Salmonella choleraesuis-associated abdominal aortic aneurysm.

BACKGROUND: The majority of aorto-caval fistulae occur spontaneously, either as a result of rupture of an existing atherosclerotic abdominal aortic aneurysm into the vena cava or secondary to iatrogenic injuries during peripheral angiography or surgery. Aorto-caval fistula from an infected aortic aneurysm is a rare scenario, but potentially lethal. METHODS: Case report and review of the literature. CASE REPORT: A 63-year-old female with diabetes mellitus and liver cirrhosis was admitted for intractable abdominal pain with rebound tenderness. A computed tomography scan demonstrated an abdominal aortic aneurysm and ill-defined peri-aortic fluid with air density and evidence of a fistula between the aorta and the inferior vena cava. Salmonella cholerasuis had been isolated from a blood culture at a previous admission. Urgent endovascular exclusion of the aorto-caval fistula was carried out, and the infra-renal abdominal aneurysm was repaired using a Cook Zenith TX2 aortic stent graft. She received parenteral ceftriaxone for four weeks. CONCLUSIONS: This case shows acceptable short-term results after endovascular repair of a Salmonella-infected aorto-caval fistula.

Gastric variceal bleeding precipitated by a mycotic splenic arteriovenous fistula in a cirrhotic patient: radiological diagnosis and endovascular treatment.

Splenic arteriovenous fistula (SAVF) is an unusual cause of portal hypertension, and is rarely associated with an infective aetiology. It is often difficult to identify SAVF clinically, and thus, radiological modalities are invariably required for diagnosis and treatment. We herein describe a case of SAVF occurring in a patient with compensated cirrhosis as a sequel to salmonella gastroenteritis, and presenting with acute gastric variceal bleeding. Selective transcatheter embolisation of the splenic artery was effective in controlling bleeding.

Endovascular repair of a Streptococcus pneumonia-induced aortitis complicated by an iliacocaval fistula.

PURPOSE: To describe the successful endovascular treatment and follow-up of a patient with a Streptococcus pneumonia-induced right iliacocaval fistula. CASE REPORT: A 82-year-old man was diagnosed with a right iliacocaval fistula, as a result of Streptococcus pneumoniae infection of the distal aorta and proximal right common iliac artery. After antibiotic treatment, he was initially unsuccessfully treated with balloon expandable covered stents. Then, the fistula was excluded by an aortamonoiliac endograft to the left common iliac artery, and occluders in the distal and proximal right common iliac artery followed by a femoral-femoral crossover bypass. Postoperatively patient was treated with prolonged antibiotics. After a follow-up of 20 months, there are no signs of active infection, endoleak, or fistula, both clinically and on 2-deoxy-2-[F18]fluoro-D-glucose positron emission tomography/computed tomography. CONCLUSION: In selected patients, complicated infectious disease of the aorto-iliac tract may be treated successfully with an endograft and prolonged antibiotics.

[Vascular Aspergillus infection in two recipients of kidneys from the same donor]. / Infección vascular por Aspergillus en dos receptores de injertos renal del mismo donante.

We describe a clinical case of two patients who received a cadaveric renal graft from the same donor in a multi-organ extraction procedure. The donor was a 39-years-old woman who died of intracranial tumour. A benign ganglioma was shown in biopsy. The two recipients received the same immunosuppressive regimen. Induction comprised cyclosporin A, steroids and basiliximab while cyclosporin A and steroids were used in maintenance immunosuppression. The A patient was a 53-year-old woman with chronic renal failure due to chronic pyelonephritis. She had been undergoing periodic haemodialysis for five years. She was hospitalised for sciatic pain refractory to rest and analgesics 35 days after transplantation. Two days later, her graft function deteriorated. Ultrasonography ruled out a urinary tract obstruction. Cyclosporine levels was normal. It was interpreted as an acute rejection episode and was treated with boluses of methylprednisolone (500 mg for 3 days). At the same time, her right leg began to show paraesthesia, coldness and a decreased arterial pulse. A spinal magnetic nuclear resonance was performed. It showed an aneurysm of right common iliac artery (fig. 1). An arteriography confirmed the existence of a pseudoaneurysm and an arteriovenous fistula to inferior vena cava (fig. 2). The B recipient was a 56-year-old woman with chronic renal failure due to chronic pyelonephritis. She required haemodialysis for two years. In the 4th month after transplantation her graft function deteriorated. Graft biopsy did not show acute cellular rejection, so she was kept on immunosuppressive treatment. A second graft biopsy was taken and no changes with the previous one was observed. Renal function deteriorated and haemodialysis was required. During the 6th month she began to show paraesthesia, coldness and decreased arterial pulse in her right leg. Ultrasonography showed pyelocaliectasis with an adjacent solid-liquid mass, abdominal CT scan confirmed. Arteriography proved the presence of a pseudoaneurysm of the right common iliac artery (fig. 3). Transplantectomy and pseudoaneurysm resection was performed in the two cases. Culture analysis revealed fungi identified as Aspergillus in both pseudoaneurysms. Medical treatment was started immediately with liposomal amphotericin B. The clinical evolution of the two recipients were different. While recipient A died, B patient recovered, requiring haemodialysis.

Estenosis aórtica calcificada por endocarditis bacteriana experimental curada / Calcified aortic stenosis in experimental infectious endocarditis

Se estudia la participación de la endocarditis bacteriana en la génesis de estenosis aórtica calcificada. A nueve perros se les produjo fístula arterio-venosa femoral por el método de Lillehei y bacteriemia por inyección intravenosa de Streptococus mitis sensible, entre otros antibióticos, a la penicilina. Y se les inyectaron por vía intravenosa 10 ml diarios del cultivo de Streptococus mitis (1 X 10/10 bacterias) durante 15 días consecutivos. Los animales fueron sacrificados entre 28 y 102 días después de terminada la inoculación y tras haberles inyectado diariamente un millón de unidades y penicilina benzotínica. En un perro, se observó endocarditis bacteriana tanto en la mitral como en la aorta y en otros tres, entenosis aórtica calcificada con grandes depósitos calcéreos en el cuerpo y bordes valvulares. Estos mostraban una estenosis irregular y notable del orificio aórtico, de manera semejante a las observadas en el hombre