Fungal Mycotic Aneurysm of the Internal Carotid Artery Associated with Sphenoid Sinusitis in an Immunocompromised Patient: A Case Report and Review of the Literature.

In immunocompromised patients, invasive molds such as Aspergillus and Mucor can lead to locally aggressive angioinvasive infections that are often life-threatening. A particularly devastating complication is the development of a fungal mycotic aneurysm resulting from invasion of the arterial wall. Due to anatomic contiguity, the sphenoid sinus provides potential access for these fungi, which often colonize the respiratory sinuses, into the cavernous sinus and internal carotid artery (ICA), thus leading to the formation of ICA aneurysms. The ideal treatment of fungal ICA aneurysms includes a combination of surgical debridement and long-term effective antifungal therapy, but the role of endoscopic resection and the duration of antimicrobials are poorly defined. Here, we present the case of a 71-year-old immunocompromised patient who developed an ICA mycotic aneurysm, associated with a proven invasive fungal infection (presumptively Mucorales) of the sphenoid sinuses, as defined by EORTC/MSG criteria, and who survived after undergoing coil embolization with parent vessel sacrifice of the aneurysm in combination with liposomal amphotericin B. We also review the literature for published cases of invasive fungal sphenoid sinusitis associated with mycotic aneurysms of the ICA and provide a comparative analysis .

Gonococcal aneurysm of the ascending aorta: case report and review of Neisseria gonorrhoeae endovascular infections.

We present the case of a man with a bicuspid aortic valve who presented with persistent fever. Blood cultures yielded Neisseria gonorrhoeae, and the diagnosis of infected mycotic aneurysm was confirmed by detection of the bacterial genome in the aortic wall. The patient was cured with surgery and intravenous ceftriaxone.

Rothia aeria mitral valve endocarditis complicated by multiple mycotic aneurysms: laboratory identification expedited using MALDI-TOF MS.

Rothia aeria has only rarely been described as a human pathogen. We describe a case of Rothia aeria causing mitral valve endocarditis and multiple mycotic aneurysms, including cerebral mycotic aneurysms. In the case described, early identification of Rothia aeria was achieved using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS).

Extra-aortic mycotic aneurysm due to group A Streptococcus after pharyngitis.

Mycotic aneurysms, especially outside the aorta, are uncommon, with group A Streptococcus a particularly rare cause. We report a case of extra-aortic mycotic aneurysm following a sore throat without demonstrable bacteremia where identification of the pathological organism was made by molecular diagnostic techniques after a standard laboratory culture was negative.

Fucoidan interferes with Porphyromonas gingivalis-induced aneurysm enlargement by decreasing neutrophil activation.

PURPOSE: Neutrophils have been shown to be involved in all stages of human and experimental abdominal aortic aneurysm (AAA) development. The initial processes of neutrophil rolling and trapping in the intraluminal thrombus (ILT) are mediated mainly by P-selectin expressed by activated platelets. In the present study, we propose to evaluate the beneficial effect of fucoidan, a competitive binding agent of P-selectin, on aneurysmal growth in a rat model of aortic aneurysm with neutrophil enrichment of the ILT induced by repeated episodes of weak bacteremia. METHODS: Sixty Lewis rats with experimental AAAs, developed from decellularized aortic xenografts, were divided into four groups. Two groups were used as controls: group fucoidan control (FC) was treated with 200 mg of fucoidan (F) delivered by 2 mL, 4-week osmotic pumps placed intraperitoneally before closing the abdomen, and group C received saline instead of fucoidan. Two more groups were injected weekly with Porphyromonas gingivalis (P. gingivalis [Pg]): group F+Pg received 200 mg of intraperitoneal fucoidan and group Pg received saline. AAAs were harvested after 4 weeks and peripheral blood was sampled at that time. Cell-free DNA (cf-DNA) and myeloperoxydase (MPO) antigen concentrations were determined in plasma and in AAA-conditioned media. Histology and P-selectin immunostaining were performed on AAA tissue samples. RESULTS: Comparing rats injected with Pg, those receiving fucoidan presented reduced aneurysmal diameter. Histologic analysis of AAAs showed that fucoidan reduced the ILT thickness in Pg-injected rats, with fewer trapped neutrophils, and with signs of a healing process, as observed in control group C. Immunohistological analysis revealed a substantial decrease in P-selectin immunostaining at the luminal surface of aneurysms in fucoidan-treated rats compared to the other groups, suggesting an interaction between fucoidan and P-selectin. A significant decrease in MPO concentrations in both plasma and conditioned medium was induced by fucoidan treatment in Pg-injected rats, reflecting a pacification of the ILT biological activity. This effect was associated with a reduction in neutrophil activation and apoptosis, reflected by a significant decrease in cf-DNA concentration in both plasma and conditioned medium of fucoidan-treated rats. CONCLUSIONS: Our results suggest that fucoidan has a beneficial effect on experimental aneurysmal degeneration by decreasing neutrophil activation in the ILT enhanced by weak pathogen contamination. This effect seems to be related to its interaction with P-selectin, which may decrease the trapping of neutrophils into the ILT. Fucoidan could represent a therapeutic option in AAAs to decrease the neutrophil activation involved in the degenerative process of aneurysmal expansion and rupture.

Group B streptococcus mycotic aneurysm of the abdominal aorta: report of a case and review of the literature.

Mycotic aneurysm of the aorta is an uncommon condition, and Group B Streptococcus (GBS) is exceedingly rare in this setting. We present the first reported case of a GBS-infected abdominal aortic aneurysm (AAA) in North America. Key clinical and imaging findings and pathologic correlation are highlighted. A relevant review of the literature is discussed, which will bring the reader up to date with this specific disease entity.

Fatal mycotic aneurysms due to Scedosporium and Pseudallescheria infection.

Angioinvasive complications of Scedosporium infections are rare. We report two cases of mycotic aneurysm, following apparent localized infection, due to Scedosporium apiospermum and Pseudallescheria boydii. The thoracoabdominal aorta was affected in one patient, and cerebral vessels were affected in the other. Despite voriconazole therapy and surgical resection, the patients died. Previously reported cases are reviewed.

Surgical consideration of in situ prosthetic replacement for primary infected abdominal aortic aneurysms.

OBJECTIVES: To review our surgical experience of primary infected abdominal aortic aneurysms, with the aim of assessing the safety and durability of in situ prosthetic replacement. DESIGN: Retrospective study in a university hospital. MATERIALS AND METHODS: Thirty-four patients who underwent surgery for primary infected abdominal aortic aneurysms over the past 18 years were reviewed. Operative details and outcomes were recorded for analysis. RESULTS: There were six suprarenal and 28 infrarenal infections. Salmonellae (18 patients) were the most common pathogens. Thirty patients underwent in situ prosthetic replacement, two underwent extra-anatomic bypass and two underwent endovascular repair. The surgical mortality for overall patients was 18%, and for patients reconstructed in situ, 17%. Among the 30 patients reconstructed in situ, four patients who underwent concomitant gastrointestinal procedures (e.g., repair of the duodenal defect) died. By contrast, 25 of 26 patients without gastrointestinal involvement survived surgery. After a median follow-up period of 58 months, two discharged patients who underwent in situ reconstruction died of late graft infection. CONCLUSIONS: Our experience suggests that in situ prosthetic replacement can be performed safely with durable outcomes in the majority of patients with infected abdominal aortic aneurysms. Nevertheless, we advise caution when considering this technique with concomitant gastrointestinal procedures.

Superior mesenteric artery mycotic aneurysm in patients with left ventricular assist device support and intravenous drug abuse.

Mycotic aneurysm of the superior mesenteric artery (SMA) is one of the complications associated with infective endocarditis. However, there are no previous case reports in the literature describing mycotic SMA aneurysm after left ventricular assist device (LVAD) implantation. We describe the case of a 31-year-old male diagnosed with congestive heart failure due to nonischemic dilated cardiomyopathy who underwent LVAD implantation for bridge to heart transplantation. The postoperative course was uneventful, and the patient was maintained on anticoagulation and antiplatelet therapy. There were no signs of pump failure or device-related infections. However, 7 months post-LVAD support, the patient complained of abdominal symptoms (nausea and vomiting) with low-grade fever. Computed tomography identified an aneurysmal change of the SMA (2.2 × 1.8 cm). There was no evidence of thrombus or septic vegetation inside the heart. Aneurysm and segmental small bowel resection was performed. Pathological study revealed typical findings of mycotic aneurysm with significant infiltration of inflammatory cells. The patient, however, expired due to concurrent brain hemorrhage. Postmortem study indicated no sign of pump thrombus or septic emboli inside the pump or inflow/outflow conduit. This case report presents a rare mycotic aneurysm that developed in the SMA after chronic LVAD support.

Fatal rupture of pseudoaneurysm following angioplasty.

We report the sudden unexpected death from exsanguination of a 60-year-old white female who underwent balloon angioplasty of her right popliteal artery via a right common femoral arteriotomy 3 weeks before death. This resulted in a mycotic pseudoaneurysm of the right femoral artery that ruptured, causing fatal exsanguination. A pseudoaneurysm is an arterial wall defect in which part of the wall consists of fibrin and fibrous tissue, lacking components of the normal arterial wall, that is intima, media, and adventitia. Pseudoaneurysms result from traumatic arterial injury, infection, rupture of a true aneurysm, or surgery. A literature search revealed no reports with the patient dying unexpectedly outside the hospital. Immediate surgical intervention and antibiotic therapy are preferred treatments.

A clinicopathologic study of immunoglobulin G4-related sclerosing disease of the thoracic aorta.

OBJECTIVE: Immunoglobulin G4-related sclerosing disease (IgG4-SD) has recently been reported to occur in the cardiovascular system and manifest as inflammatory abdominal aortic aneurysm. Thoracic aortic lesions are often associated with aortitis in several divergent etiologies. Thus, this study was performed to review thoracic aortic lesions from the aspect of IgG4-SD and to elucidate the clinicopathologic characteristics of this subgroup in the thoracic aorta. METHODS: The study comprised 125 patients, including 71 with thoracic aortic aneurysm (TAA), 44 with aortic dissection, 7 with Takayasu aortitis, and 3 with infectious aortitis. IgG4-SD was identified by diffuse infiltration of numerous IgG4-positive plasmacytes by immunohistochemical examinations. Clinicopathologic features were compared between IgG4-related and IgG4-unrelated lesions. RESULTS: Among the 125 patients, IgG4-SD was found in 5 patients with TAA but was not detected in the other subgroups of thoracic aortic lesion. IgG4-related TAA included one case of lymphoplasmacytic aortitis, 1 case of inflammatory aneurysm, and three cases of atherosclerotic aneurysms. Patients with IgG4-related TAA showed clinicopathologic features similar to patients with IgG4-SD: male gender, old age, history of bronchial asthma and allergies, elevation of white blood cell counts, C-reactive protein levels, and IgG4 and IgE concentrations (in one patient); eosinophilic infiltration, obliterative phlebitis, lymph follicle formation, and perineural inflammation. In addition, compared with IgG4-unrelated TAA, IgG4-related TAA was characterized by clinically more frequency of involvement of the aortic arch (P = .002), saccular formation (P = .003), and fibrous adhesion to surrounding tissue (P < .001), and histopathologically thicker entire aortic wall and adventitia (P < .001 each). CONCLUSIONS: IgG4-SD is involved in 4% of all thoracic aortic lesions and uniformly presents in the form of an aneurysm with distinct histologic and clinicopathologic features. IgG4-SD represents one, albeit rare, etiology of TAA, especially those originating in the aortic arch.

Fatal mycotic aneurysm caused by Pseudallescheria boydii after near drowning.

Pseudallescheria boydii is a rare cause of mycotic infection. Factors predisposing to systemic infection include traumas, immunosuppression, and near drowning. We report a case of multiple aneurysms caused by this hyalohyphomycete, occurred after near drowning. The car driven by a 53-year-old woman plunged into a canal in The Netherlands. After a 20-min-long submersion, the woman was rescued. At hospital, a severe aspiration of muddy water and a mycotic pneumonia were diagnosed. Despite the immediate prescription of a long-term antimycotic therapy and the initial good response, the patient died 4 months later. The autopsy showed a mycotic aneurysm of the abdominal aorta and multiple ruptured mycotic aneurysms of the circle of Willis with fatal subarachnoid bleeding.

Cerebral aneurysms in children: are we talking about a single pathological entity?

PURPOSE: The objective of this article is to highlight the fact that cerebral aneurysms in children are heterogeneous unlike in the adult population. MATERIAL AND METHODS: This is a retrospective review of 17 children with intracranial aneurysms who were managed at a single institution from 2004 to 2009. RESULTS: The median age was 12 years (range 10 months-17 years). Sixty-five percent of the aneurysms were saccular and 24% were fusiform. There was one infectious and one distal lenticulostriate aneurysm. Patients with saccular aneurysms were predominantly male and presented more commonly with intracranial hemorrhage (91%). The fusiform aneurysms were dissecting in nature or chronic with intramural thrombus and mass effect. The treatment was dependent upon the type and location of the aneurysm. CONCLUSION: Pedriatic aneurysms are a heterogeneous group of intracranial arterial diseases with different etiologies, diverse morphology, and dissimilar clinical manifestations.

Intracranial infectious aneurysms: a comprehensive review.

Intracranial infectious aneurysms, or mycotic aneurysms, are rare infectious cerebrovascular lesions which arise through microbial infection of the cerebral arterial wall. Due to the rarity of these lesions, the variability in their clinical presentations, and the lack of population-based epidemiological data, there is no widely accepted management methodology. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-2009) using the following keywords (singly and in combination): "infectious," "mycotic," "cerebral aneurysm," and "intracranial aneurysm." We identified 27 published clinical series describing a total of 287 patients in the English literature that presented demographic and clinical data regarding presentation, treatment, and outcome of patients with mycotic aneurysms. We then synthesized the available data into a combined cohort to more closely estimate the true demographic and clinical characteristics of this disease. We follow by presenting a comprehensive review of mycotic aneurysms, highlighting current treatment paradigms. The literature supports the administration of antibiotics in conjunction with surgical or endovascular intervention depending on the character and location of the aneurysm, as well as the clinical status of the patient. Mycotic aneurysms comprise an important subtype of potentially life-threatening cerebrovascular lesions, and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatment.

[A rare cause of haematemesis with fatal gastrointestinal bleeding]. / Seltene Ursache einer Hämatemesis mit letalem Ausgang.

A 73-year-old man was admitted to the hospital due to severe hematemesis and collapse, severe anemia and inflammation. Two months ago, the patient had been treated with antibiotics due to septicemia with staphylococcus aureus. At that time CT scan had shown only thoracic arteriosclerosis. The subsequent high urgency upper endoscopy identified a circular mucosal defect in distal esophagus as bleeding origin. The patient died 10 hours after admission. Performing autopsy, a fistula between the thoracic aortic aneurysm and the distal esophagus was found in the background of severe arteriosclerosis. The rapid onset of an aneurysm with rupture after a bacterial infection is typical for a mycotic aneurysm.

Multiple mycotic aneurysms of the aortic root after aortic valve replacement.

A 74-year-old woman with severe aortic valve stenosis underwent aortic valve replacement with a pericardial bioprosthesis. Histological analysis of the excised valve showed dystrophic calcification associated with signs of healed infective endocarditis. Two months later, the patient died due to congestive heart failure. Autopsy revealed a bowel infarction and the presence of multiple mycotic aneurysms of the aortic root with mural thrombosis, which were unnoticed during the patient hospital stay and surgical window.

Acute enlargement, morphological changes, and rupture of intracranial infectious aneurysm in infective endocarditis. Serial imaging.

A 72-year-old man received a transcatheter aortic valve implantation (TAVI) 2 years ago for leakage of the degenerative bioprosthesis with Corevalve n°31 implantation, presented infective endocarditis (IE) (streptococcus sanguinis) of the bioprosthetic aortic valve. One month after antibiotic treatment was initiated, he presented a left-sided hemiplegia, a right frontal hematoma. MRI/contrast-enhanced magnetic resonance angiography (CE-MRA) revealed 2 infectious intracranial aneurysms (IIAs) of the right (10 mm) and left middle cerebral artery (MCA) (M2 segment, 5 mm). The right MCA IIA was treated within 1 day by glue-embolization. Seven days later, the patient acutely developed motor aphasia. CE-MRA showed significant enlargement (15 mm) and morphologic change of the ruptured left MCA IIA. This IIA was treated with Onyx-embolization. This case adds additional evidence that IIAs, during IE, can show rapid growth and morphological change over a 7 day course and emphasizes the imperative need of close imaging follow-up when IIAs are managed by antibiotic therapy.

Syphilitic aortitis: still a current common cause of aneurysm of the tubular portion of ascending aorta.

Aortic syphilis today is infrequently diagnosed clinically. Described herein are findings in 5 women who had resection of a fusiform aneurysm of the tubular portion of ascending aorta, and examination of the wall of the aneurysm disclosed classic features of aortic syphilis. The 5 patients were among 36 who had ascending aortic operations at Baylor University Medical Center in Dallas in 2018 and early 2019. Syphilitic aneurysm in each spared the sinus portion and involved diffusely the tubular portion of ascending aorta, beginning at the sinotubular junction. The aneurysmal wall was thicker than normal because of thickening of both intima and adventitia. The latter contained foci of lymphocytes and plasmacytes and thickened and narrowed vasa vasora. The media was disrupted by fibrous scars, which weakened the integrity of the aorta. Aortitis of the tubular portion of ascending aorta in syphilis is a diffuse process, but often is mistakenly called "atherosclerosis" which, when present in this portion of aorta, can be extensive but is focal. Aortic syphilis is important to diagnose so that patients can receive antibiotic therapy to delay, prevent, or treat neurosyphilis, a common accompaniment of aortic syphilis.