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.

Manejo de un aneurisma infeccioso / Treatment of infected aneurysm

Resumen Introducción: Los aneurismas infecciosos constituyen una patología poco frecuente y se caracterizan por presentar infección de la pared del vaso implicado. El mejor tratamiento no está definitivamente establecido. Objetivo: Describir un caso de aneurisma infeccioso con manejo endovascular. Caso clínico: Presentamos un paciente de sexo masculino de 75 años que ingresa por cuadro compatible con abdomen agudo y que en el posoperatorio se pesquisa un aneurisma infeccioso del tronco celíaco, el cual se trata mediante una endoprótesis y manejo antibiótico. Discusión: El manejo tradicional del aneurisma infeccioso es la cirugía abierta que incluye la extirpación o exclusión del aneurisma y de su tejido perivascular infectado, pero conlleva gran morbimortalidad. Conclusión: El aneurisma infeccioso puede ser manejado de forma mínimamente invasiva con técnica endovascular, con baja morbilidad inmediata, pero con resultados a largo plazo aun no concluyentes.

Introduction: Infectious aneurysms are a rare disease and are characterized by infection of the involved vessel wall. The best treatment is definitely not established. Aim: To describe a case of infectious aneurysm with endovascular management. Case report: We present a 75-year-old male patient admitted to a table compatible with acute abdomen and that an infectious aneurysm of the celiac trunk is investigated in the postoperative period, treated with an endoprosthesis and antibiotic management. Discussion: The traditional management of the infectious aneurysm is open surgery that includes the removal or exclusion of the aneurysm and its infected perivascular tissue, but it leads to great morbidity and mortality. Conclusion: The infectious aneurysm can be managed minimally invasively with endovascular technique, with immediate low morbidity, but with long-term results that are still inconclusive.

Mycotic aneurysm with aortoduodenal fistula

Firstly described in the 19th century by Sir William Osler, the mycotic aneurysm (MA) is a rare entity characterized by an abnormal arterial dilation, which is potentially fatal, and is associated with the infection of the vascular wall. Elderly patients are mostly involved, especially when risk factors like chronic diseases, immunosuppression, neoplasia, and arterial manipulation are associated. The authors report the case of a young male patient diagnosed with an aortic aneurysm of infectious origin in the presence of repeated negative blood cultures. The diagnostic hypothesis was raised when the patient was hospitalized for an inguinal hernia surgery. The diagnosis was confirmed based on imaging findings consistent with mycotic aneurism. The patient was treated with an endovascular prosthesis associated with a long-lasting antibiotic therapy. Five months later, the patient attended the emergency unit presenting an upper digestive hemorrhage and shock, from which he died. The autopsy revealed a huge aneurysm of the abdominal aorta with an aortoduodenal fistula. The histological examination of the arterial wall revealed a marked inflammatory process, extensive destruction of the arterial wall, and the presence of Gram-positive bacteria. This case highlights the atypical presentation of a MA associated with an aortoduodenal fistula. Besides the early age of the patient, no primary arterial disease could be found,and no source of infection was detected.

Aneurismas infecciosos: incidência, diagnóstico e tratamento / The infectious aneurysms: incidence, diagnosis and treatment

O objetivo deste trabalho é apresentar a revisão de literatura acerca dos novos parâmetros de incidência, diagnósticos e terapêuticos, dos aneurismas infecciosos. Foi realizada pesquisa no banco de dados Bireme e PubMed,com os termos: ?aneurysm?, ?mycotic? e ?infectious?, sendo usados para o estudo apenas artigos publicados entre 1997 e 2010. Grande parte dos artigos descreve uma alta incidência de múltiplos aneurismas e a localização preferencialmente proximal, quando associados à endocardite infecciosa, e distal, quando associados a outras infecções, também relatando a alta eficiência do tratamento endovascular, contudo uma alta mortalidade quando este é inviável. Novas técnicas diagnósticas são propostas e merecem mais estudos. A taxa de incidência e a alta taxa de mortalidade associada a casos em que a intervenção endovascular é inviável justificam exames direcionados ao diagnóstico precoce desses aneurismas em pacientes potenciais.

The objective of this paper is to present a literature review of incidence, diagnosis and treatment of infectious aneurysms. A search was carried out at the Bireme database and PubMed by the terms: ?aneurysm?, ?mycotic? and ?infectious?, being used to study only articles published between 1997 and 2010. Most of the articles describe a high incidence of multiple aneurysms, and proximal location when associated with infective endocarditis and distal when associated with other infections. It is reported a high efficiency in endovascular treatment, but a high mortality when unviable. New diagnostic techniques are proposed and deserve further study. The incidence and high mortality rate associated with cases in which endovascular intervention is not feasible, justify early diagnosis of these aneurysms in potential patients.

A giant syphilitic aneurysm in a young human immunodeficiency virus sero-positive individual.

A 35-year-old, human immunodeficiency virus sero-positive male presented with huge mediastinal mass for evaluation. After contrast enhanced computed tomography (CECT) angiogram, aneurysm of arch of aorta was diagnosed. The patient also proved to be co-infected with syphilis, which is the aetiological cause of aneurysm in this case. The present report highlights the need to suspect, diagnose and treat dual infections in individuals with high risk behaviour.

Aneurismas infecciosos / Infectious aneurysms

Los aneurismas micóticos de la circulación cerebral, son poco frecuentes y se asocian generalmente con endocarditis bacteriana. Se asocian a morbimortalidad elevada y su diagnóstico, auque se basa principalmente en datos clínicos además de algunas características angiográficas, tal como la localización y morfología, pueden ser un verdadero reto. Aunque muchos de estos aneurismas han presentado regresión con el manejo antibiótico, su comportamiento no es predecible en relación a su ruptura. Por tanto el objetivo del tratamiento, aunque difícil, debe ser la exclusión del aneurisma del árbol circulatorio ya sea mediante técnicas quirúrgicas o endovasculares.

Pseudo-aneurisma femoral micótico após onze anos de cateterismo / Mycotic femoral pseudoaneurysm after 11 years of catheterism

Relatamos o caso incomum de um alpinista de 52 anos que apresentava dor e edema em sua coxa direita, o que revelou ser um pseudoaneurisma micótico roto, sem histórico de trauma recente ou outra causa aparente. O paciente relatou uma história de infarto do miocárdio onze anos antes, com a realizacão de dois cateterismos femorais para cineangiocoronariografia. Ele negou qualquer episódio de febre ou diagnóstico de bacteremia naquele momento ou mais tarde, como também outra queixa durante esses onze anos. A raridade do caso, a aparência dessa complicacão extremamente tardia, juntamente com o tipo de atividade esportiva do paciente sugeriram-nos publicar o caso.

Endocarditis infecciosa: complicaciones neurológicas / Infectious endocarditis: neurologic complications

A pesar de los diferentes cambios que ha experimentado la Endocarditis Infecciosa (EI) con los años, los adelantos tecnológicos y la antibioterapia, las complicaciones neurológicas han continuado más o menos igual en el tiempo. Ellas se revisan extensamente en esta publicación, enfatizando la clínica, métodos de exploración y terapéutica actualizada.

Popliteal artery aneurysms masquerading as deep vein thrombosis

A 77 year old man with known ischaemic heart disease and p paroxysmal a trial fibrillation treated with a spirin and amiodarone, presented with progressive painful swelling of his left leg. He was also known to have a 5cm abdominal aortic aneurysm, which was under surveillance. On examination, he was tachycardic and pyrexial with a tender, swollen, erythenratous left leg. A deep venous thrombosis with overlying cellulitis was diagnosed and he was commenced on intra-venous antibiotics and therapeutic doses of subcutaneous Heparin. Blood cultures grew salmonella enteriditis phage type 4 sensitive to ciprofloxacillin, which was commenced. Subsequent C T scan confirmed a large false aneurysm of the popliteal artery with surrounding soft tissue suppuration and oedema. These findings were suggestive of ruptured popliteal artery, secondary to a salmonellosis-induced mycotic aneurysm rather than deep venous thrombosis. He was taken to theatre, and a reversed long saphenous vein femoro-popliteal bypass graft was performed with the graft tunnelled subcutaneously through uninfected tissue. The intervening popliteal artery with its mycotic portion was ligated proximal and distal to the area of sepsis. Necrotic tissue in the muscle compartments of the thigh and popliteal fossa was debrided and the wound left open. Salmonella was cultured from pus specimens obtained intra-operatively. The patient made a slow recovery on the intensive care unit and was discharged back to the ward on the tenth postoperative day with a clean healing wound and a functioning bypass graft

Giant splenic artery mycotic aneurysm presenting with massive hematemesis.

We report a 40-year-old man with rheumatic heart disease who presented with abdominal pain for three weeks and hematemesis for 24 hours. CT scan showed a large splenic artery aneurysm without evidence of pancreatitis. Mycotic aneurysm due to infective endocarditis was considered and confirmed by echocardiogram, which showed aortic and mitral valve regurgitation and vegetations. He was managed successfully with coil embolization of the aneurysm and antibiotics.

Endocarditis infecciosa: posibilidades y limitaciones en la fundamentación del diagnóstico / Infectious endocarditis: posibilities and limitations in diagnosis fundaments

Lejos de disminuir su frecuencia, la endocarditis infecciosa se está presentando en la actualidad en nuevos escenarios clínicos. Destaca su presentación en grupos etarios mayores y en relación a nuevas condiciones predisponentes, siendo hoy en día una patología frecuente en cualquier población hospitalaria. Los notables avances en los métodos de diagnóstico no han permitido aun reducir drásticamente las complicaciones de la enfermedad, determinantes de su todavía elevada morbimortalidad. La sistematización de los hallazgos clínicos y de laboratorio siguiendo los criterios de Duke, ha permitido ordenar y homogeneizar las distintas variables que apoyan el diagnóstico. Sin embargo, el amplio espectro de formas de su presentación clínica y las dificultades para contar con parámetros absolutamente específicos de la enfermedad, representan limitaciones a su reconocimiento oportuno. La forma de no retardar o equivocar el diagnóstico, con serias consecuencias en el pronóstico, es mantener siempre un alto índice de sospecha clínica que permita realizar a tiempo los exámenes adecuados para confirmar, rechazar o establecer el grado de certeza de la hipótesis diagnóstica

Aneurisma da artéria hepática: tratamento pela hepatectomia esquerda; relato de caso / Hepatic artery aneurysm: treatment by left hepatectomy; report of a case

É descrito um caso de aneurisma roto da artéria-hepática esquerda de 71 anos, do sexo feminino, com dor abdominal, emagrecimento e febre. O diagnóstico foi feito com uso de ultra-som com "doppler", tomografia computadorizada com contraste e angiografia do tronco celíaco e da artéria mesentérica superior. A rapidez no diagnóstico e a hepatectomia esquerda regrada levaram a um resultado satisfatório.