A case of Brucella aortitis associated with development of thoracic aortic aneurysm and aortobronchial fistula.

OBJECTIVES: The purpose of this case report is to document the occurrence of granulomatous aortitis complicated by formation of a saccular aneurysm and aortobronchial fistula due to Brucella infection. METHODS: A 65-year-old man with a history of feral swine hunting presented with hemoptysis and was found to have a saccular thoracic aortic aneurysm and associated aortobronchial fistula. The aneurysm underwent operative repair with closure of the aortobronchial fistula. RESULTS: Histopathological examination of the aneurysm wall revealed evidence of granulomatous aortitis. Cultures of the blood and aortic wall tissue were positive for Brucella suis. CONCLUSIONS: Although rare, Brucella infection should be considered in the differential diagnosis of aortic aneurysm with granulomatous aortitis.

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.

Marked cachexia in probable invasive pulmonary aspergillosis with bronchopleural fistula.

A 49-year-old man with a medical history of diabetes and heavy smoking was admitted to intensive care with severe bilateral pneumonia associated with marked cachexia. He developed a complex right-sided bronchopleural fistula and was transferred to our tertiary centre for consideration of surgical intervention.Despite escalation of antibiotic therapy, he did not improve and further investigations led to a diagnosis of invasive pulmonary aspergillosis. Definitive treatment plans required a right pneumonectomy; however, given the severity of cachexia, he remained unable to undergo such a large operation. This case demonstrates an atypical presentation of invasive pulmonary aspergillosis in a mildly immunodeficient individual. It highlights the challenges in assessment and management of critically ill patients' nutrition as well as optimal timing for surgical intervention.

Role of Endovascular Aortic Repair in the Treatment of Infected Aortic Aneurysms Complicated by Aortoenteric or Aortobronchial Fistulae.

BACKGROUND: The aim of this study was to compare outcomes and identify factors related to increased mortality of open surgical and endovascular aortic repair (EVAR) of primary mycotic aortic aneurysms complicated by aortoenteric fistula (AEF) or aortobronchial fistula (ABF). METHODS: Patients with primary mycotic aortic aneurysms complicated by an AEF or ABF treated by open surgery or endovascular repair between January 1993 and January 2014 were retrospectively reviewed. Outcomes were compared between the open surgery and endovascular groups, and a Cox's proportional hazard model was used to determine factors associated with mortality. RESULTS: A total of 29 patients included 14 received open surgery and 15 received endovascular repair. Positive initial bacterial blood culture results included Salmonella spp., oxacillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae. Mortality within 1 month of surgery was higher in the open surgery than in the endovascular group (43 vs. 7%, respectively, p = 0.035). Shock, additional surgery to repair gastrointestinal (GI) or airway pathology, and aneurysm rupture were associated with a higher risk of death. Compared with patients without resection surgery, the adjusted hazard ratio of death within 4 years in patients with resection for GI/bronchial disease was 0.25. Survival within 6 months was better in the endovascular group (p = 0.016). CONCLUSION: The results of this study showed that EVAR/thoracic EVAR (TEVAR) is feasible for the management of infected aortic aneurysms complicated by an AEF or ABF, and results in good short-term outcomes. However, EVAR/TEVAR did not benefit long-term survival compared with open surgery.

Aortobronchial and aortoenteric fistula.

Pathologic communication between the thoracic aorta and esophagus or tracheobronchial tree is a rare vascular condition and most commonly develops after open or endovascular aortic repair complicated by infection. Patients with aortoesophageal or tracheobronchial fistula often present with systemic infection and are at risk for major hemorrhage. Medical management is uniformly fatal. Expeditious definitive management requires operative repair by open repair or a combination of endovascular and open procedures. Appropriate antibiotic regimens are important for preventing graft reinfection.

HIV post-tuberculous broncho-oesophageal fistulas: A surgical solution.

We present a patient with HIV/AIDS with multiple tracheo-oesophageal fistulas probably due to previous tuberculosis. An Ivor-Lewis procedure was successfully undertaken following stringent pre-operative preparation. Surgical repair of persistent post-tuberculous tracheo-oesophageal fistulas may be safely undertaken in selected patients with HIV/ AIDS.

Venous-Airway Fistula With Aspergilloma: A Case of an Implanted Catheter Gone Bad.

The implanted venous access catheter is commonly used in the treatment of oncology patients. Although common long-term complications of these devices, such as infection and thrombosis, have been widely reported, venous-airway fistula due to port placement is an extremely rare and poorly understood complication. We report a case of a 56-year-old woman with pancreatic adenocarcinoma whose implanted catheter was complicated by the development of an azygo-bronchial fistula with a concomitant aspergilloma. Herein is the first reported case of successful venous-airway fistula closure obtained through silicone stenting.

[ANALYSIS OF MICROFLORA OF PLEURAL CAVITY IN PLEURAL EMPYEMA].

In the pleural empyema (PE) treatment, not depending on introduction of multiple operative procedures and the medicinal preparations application, some issues remain unsolved, including the infection agents verification, the most rapid bronchial fistula elimination and the lung volume restoration. The EP infection agents spectrum, their sensitivity to preparations were revealed, as well as the enhanced rate of the methicillin-resistant stamms (MRSA) and the microorganisms associations verification. A reduction of the infection agents sensitivity towards "simple" antibacterial preparations was established, so the physicians, treating PE, must prescribe "hard" antibiotics, what enhances its cost.

Aortoesophageal and aortobronchial fistula caused by Candida albicans after thoracic endovascular aortic repair.

Introduction: Endovascular stent-graft placement has emerged as a minimally invasive alternative to open surgery for the treatment of aortic aneurysms and dissections. There are few reports of stent graft infections and aortoenteric fistula after endovascular thoracic aortic aneurysm repair, and the first multicentric study (Italian survey) showed the incidence of about 2%. Case report: We presented a 69-year-old male patient admitted to our hospital 9 months after thoracic endovascular aortic repair, due to severe chest pain in the left hemithorax and arm refractory to analgesic therapy. Multislice computed tomography (MSCT) showed a collection between the stent graft and the esophagus with thin layers of gas while gastroendoscopy showed visible blood jet 28 cm from incisive teeth. Surgical treatment was performed in collaboration of two teams (esophageal and vascular surgical team). After explantation of the stent graft and in situ reconstruction by using Dacron graft subsequent esophagectomy and graft omentoplasty were made. After almost four weeks patient developed hemoptisia as a sign of aorto bronchial fistula. Treatment with implantation of another aortic cuff of 26 mm was performed. The patient was discharged to the regional center with negative blood culture, normal inflammatory parameters and respiratory function. Three months later the patient suffered deterioration with the severe weight loss and pneumonia caused by Candida albicans and unfortunately died. The survival time from the surgical treatment of aortoesophageal fistula was 4 months Conclusion: Even if endovascular repair of thoracic aortic diseases improves early results, risk of infection should not be forgotten. Postoperative respiratory deterioration and finally hemoptisia could be the symptoms of another fistula.

Vacuum-assisted closure device for the management of infected postpneumonectomy chest cavities.

BACKGROUND: Infected postpneumonectomy chest cavities may be related to chronic postpneumonectomy empyema or arise in rare situations of necrotizing pneumonia with complete lung destruction where pneumonectomy and pleural debridement are required. We evaluated the safety and efficacy of an intrathoracic vacuum-assisted closure device (VAC) for the treatment of infected postpneumonectomy chest cavities. METHOD: A retrospective single institution review of all patients with infected postpneumonectomy chest cavities treated by VAC between 2005 and 2013. Patients underwent surgical debridement of the thoracic cavity, muscle flap closure of the bronchial stump when a fistula was present, and repeated intrathoracic VAC dressings until granulation tissue covered the entire chest cavity. After this, the cavity was obliterated by a Clagett procedure and closed. RESULTS: Twenty-one patients (14 men and 7 women) underwent VAC treatment of their infected postpneumonectomy chest cavity. Twelve patients presented with a chronic postpneumonectomy empyema (10 of them with a bronchopleural fistula) and 9 patients with an empyema occurring in the context of necrotizing pneumonia treated by pneumonectomy. In-hospital mortality was 23%. The median duration of VAC therapy was 23 days (range, 4-61 days) and the median number of VAC changes per patient was 6 (range, 2-14 days). Infection control and successful chest cavity closure was achieved in all surviving patients. One adverse VAC treatment-related event was identified (5%). CONCLUSIONS: The intrathoracic VAC application is a safe and efficient treatment of infected postpneumonectomy chest cavities and allows the preservation of chest wall integrity.

Bronchomediastinal fistula caused by endobronchial aspergilloma.

RATIONALE: Endobronchial aspergilloma is a rare condition affecting immunocompromised patients. We present three cases resulting in airway fistulae. CASE PRESENTATIONS: A 68-year-old male with orthotopic heart transplantation presented with fatigue, cough, and dyspnea. A computerized tomography (CT) scan of the chest and bronchoscopy revealed an endobronchial right mainstem mass and airway fistula to the mediastinum. The mass was debrided and biopsy showed Aspergillus fumigatus. He was treated with antifungals and recovered. A 52-year-old male with acquired immunodeficiency syndrome presented with cough, dyspnea, and hypoxemia. Chest CT showed a bronchus intermedius mass and fistula to the mediastinum. Bronchoscopy revealed a necrotic endobronchial mass and pseudomembranes and confirmed the presence of a fistula. The mass was resected bronchoscopically and Aspergillus fumigatus was isolated. He was treated with antifungals and the fistula healed. A 63-year-old male with chronic lymphoid leukemia was admitted for dyspnea, cough, weakness, and dysphagia. Chest CT and bronchoscopy showed a mass causing obstruction of the subglottic trachea and a fistula to the mediastinum. Biopsy showed Aspergillus fumigatus and he was treated with antifungals. The sinus healed but the patient died of leukemia. MAIN RESULTS: Risk factors for airway aspergilloma include immune deficiency, mucosal damage, and ischemia. We report airway fistula formation as a complication of this infection, which has not been previously emphasized. CONCLUSIONS: Endobronchial aspergillomas may form fistulae to the mediastinum. Aggressive treatment with antifungals and bronchoscopic interventions are required.

Intrabronchial valves for treatment of alveolar-pleural fistula in a patient with Pneumocystis jirovecii pneumonia.

Alveolo-pleural fistula is a common complication of severe pulmonary infection. Some patients require long-term placement of chest tubes until spontaneous closure of the fistula takes place, whereas others require surgical intervention. We report a case of a patient with alveolo-pleural fistula secondary to Pneumocystis jirovecii pneumonia who was successfully treated with the use of intrabronchial unidirectional valves inserted using flexible bronchoscopy.

Intrathoracic vacuum-assisted management of persistent and infected pleural spaces.

PURPOSE: This study was designed to assess the use of the intrathoracic vacuum-assisted management of persistent and infected pleural spaces. DESCRIPTION: Five patients with a persistent and infected pleural space after pulmonary resection underwent intrathoracic vacuum-assisted management to reduce the duration and frequency of dressing changes and to accelerate the formation of granulation tissue and the obliteration of the pleural space. Three patients also underwent a pleural space filling procedure. EVALUATION: Resolution of the infection or complete obliteration of the pleural space, or both, was in all patients achieved using fewer dressing changes than with traditional methods. No major complications related to the vacuum-assisted management were reported. CONCLUSIONS: The use of intrathoracic vacuum-assisted management of a persistent and infected pleural space after lung resection may reduce the duration and frequency of dressing changes necessary to allow spontaneous chest closure or a space filling procedure. Its use may decrease patient discomfort and contribute to a faster resolution of the infectious process.

Successful surgical repair of an infectious thoracic aortic pseudoaneurysm accompanied by aortobronchopulmonary fistula and advanced hepatic dysfunction without assisted circulation.

The patient was a 59-year-old female. Because of massive hemoptysis, she was brought to our emergency center by ambulance. Thoracic computed tomography led to a diagnosis of an infectious thoracic aortic pseudoaneurysm accompanied by an aortobronchopulmonary fistula. Emergency surgery followed. Also noted was an advanced hepatic dysfunction, assessed as Child-Pugh score B, caused by an alcoholic liver disease. A localized affected area made it possible for us to perform an aneurysmectomy using a temporary bypass rather than assisted circulation. A patch plasty using expanded polytetrafluoroethylene completed the procedure. Streptococcus agalactiae (GBS) was detected in a sample obtained during the surgery from an abscess located in the aneurysm. The patient made satisfactory postoperative progress and left the hospital walking unaided on the 36th postoperative day.

Management of thoracic endograft infection.

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising, less invasive alternative to conventional open surgery for the treatment of thoracic aortic pathology. Most surveillance after TEVAR concentrates on the technical aspects of the procedure, including endoleak, device migration and endograft rupture; so far, the knowledge on endograft infectious complications is limited to anecdotal reports. Several etiopathogenetic factors may play a role in thoracic endograft infections (TEIs), including perioperative contamination, hematogenous seeding, and local bacterial translocation. Moreover, fistulization with the esophagus or the bronchial tree is a common mechanism of secondary TEI, and it represents a dramatic event requiring a multidisciplinary management. Risk factors assessment and prevention have a key role in avoiding the development of new TEIs. When a TEI is established, treatment is demanding, and includes several medical therapies associated with various surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for TEI are still burdened with very high morbidity and mortality. In this paper, we reviewed the English literature regarding the main strategies proposed for operative management of TEI, we reported and analyzed our personal series of 7 patients treated at our institution for TEI from 1999 to 2009, and we summarized results from the data collected during a recent Italian multicenter national survey, performed to investigate aortoesophageal and aortobronchial fistulae treated with TEVAR or developed following TEVAR.

Management of a thoracic endograft infection through an ascending to descending extra-anatomic aortic bypass and endograft explantation.

A 52-year-old man presented 33 months after thoracic aortic endovascular repair with hemoptysis and was found to have an aortobronchial fistula secondary to a mycotic aneurysm. The endograft infection was managed in a two-stage fashion. During the initial stage, the patient underwent an ascending-to-descending thoracic aortic bypass. Neither cardiopulmonary bypass, hypothermic circulatory arrest, nor aortic cross-clamping were used. During the same hospitalization, the patient underwent successful endograft explantation through a left thoracotomy. Imaging at 6 months demonstrated no anastomotic concerns and resolution of residual pulmonary inflammation. Thoracic aortic endograft infections necessitating endograft removal can potentially be successfully and safely managed without the need for cardiopulmonary bypass, hypothermic circulatory arrest, or interruption of aortic blood flow.