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ISSN: 2155-9880
Journal of Clinical & Experimental Cardiology
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Mycotic Aneurysm of the Abdominal Aorta Caused by Salmonella Non-Typhi Treated Surgically

Ben Jmaa Hela1*, Masmoudi Sayda1, Jmal Hassen1, Ben Jmaa Tarak2, Koubaa Makram2, Elleuch Sahar3, Souissi Iheb3, Ben Jmaa Mounir2, Karoui Abdelhamid3 and Frikha Imed1
1Department of Cardio-Vascular and Thoracic Surgery, Habib Bourguiba Hospital Sfax, Tunisia
2Department of infectious diseases, Hedi Chaker Hospital Sfax, Tunisia
3Department of anesthesiology, Habib Bourguiba Hospital Sfax, Tunisia
Corresponding Author : Ben Jmaa Hela
Department of Cardio-Vascular and Thoracic Surgery
Habib Bourguiba Hospital, 3029 Sfax, Tunisia
Tel: 0021696704740
E-mail: [email protected]
Received: February 01, 2016 Accepted: February 08, 2016 Published: February 18, 2016
Citation: Hela BJ, Sayda M, Hassen J, Tarak BJ, Makram K, et al. (2016) Mycotic Aneurysm of the Abdominal Aorta Caused by Salmonella Non-Typhi Treated Surgically. J Clin Exp Cardiolog 7:417. doi:10.4172/2155-9880.1000417
Copyright: © 2016 Hela BJ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Mycotic aneurysms are irreversible dilatation, localized in the artery due to the destruction of the wall by an infectious agent. We present the case of a 65 year old man treated for saccular aortic aneurysm, infra-renal secondary to infection with Salmonella Paratyphi B. After appropriate antibiotic therapy, the patient underwent resection with aneurysmal debridement followed by anatomical reconstruction with a prosthetic graft. He recovered well and quickly returned to normal functional status. The mycotic aortic disease is rare, but severe. However, improved diagnostic tools, appropriate antibiotic treatment, recent surgical techniques have reduced the high mortality associated with this pathology.

Abstract

Mycotic aneurysms are irreversible dilatation, localized in the artery due to the destruction of the wall by an infectious agent. We present the case of a 65 year old man treated for saccular aortic aneurysm, infra-renal secondary to infection with Salmonella Paratyphi B. After appropriate antibiotic therapy, the patient underwent resection with aneurysmal debridement followed by anatomical reconstruction with a prosthetic graft.

He recovered well and quickly returned to normal functional status.

The mycotic aortic disease is rare, but severe. However, improved diagnostic tools, appropriate antibiotic treatment, recent surgical techniques have reduced the high mortality associated with this pathology.
 
Keywords

Mycotic aneurysm; Abdominal aorta; Surgery
 
Introduction

The mycotic aortic aneurysm is a rare disease with an incidence of about 0.65% to 2% of all aortic aneurysms [1].

Pathogens include infectious organisms, the most common of which are Staphylococcus aureus, Salmonella and Streptococcus [2].

We report the case of a patient with a saccular aneurysm of the infra-renal aorta, due to a systemic infection with Salmonella Paratyphi B treated successfully with antibiotics and surgical resection.
 
Case Report

We report the case of a 65 year old man (a farmer), diabetic, admitted to the emergency department for fever and severe abdominal pain which started since 10 days. Biological tests have revealed leukocytosis 22,000/mm3, and blood cultures were positive for Salmonella paratyphi B.

The transthoracic echocardiography excluded endocarditis Abdominal CT scan revealed a small aneurysm of the antero-lateral wall of the aorta measuring 15 mm in diameter (Figure 1).

Antibiotic therapy was started with ceftriaxone (1.0 g every 12 h), and ofloxacin (400 mg every 12 h) for 6 weeks. The evolution was marked by the resolution of fever, abdominal pain, and bacteremia.

An abdominal CT scan performed after antibiotic therapy has revealed the progression and expansion of the aneurysm to 20 mm (Figure 2).

Because of the high risk of aneurysmal rupture, the patient underwent open surgery through a median laparotomy.

The intraoperative exploration revealed an inflammation and a saccular dilatation of the infra-renal aorta (Figure 3).

The aorta and the common iliac arteries were clamped and the aorta was opened. The aortic wall was atherosclerotic.

After resection of the aneurysm with debridement of the surrounding tissue, an anatomical reconstruction, with replacement of the damaged portion of the aorta with a synthetic graft, with implantation of the lower mesenteric artery into the prosthesis was performed (Figure 4).

Histopathological exam and cultures of a sample of the aortic wall were negative.

The postoperative course was uneventful. The patient had no abdominal pain, and the pulses of the two lower limbs were present.

The patient was discharged after 7 days.

He was seen at 1 month after the operation and he is fine.
 
Discussion

Mycotic aortic aneurysms can occur following a bacterial infection of a previously normal artery wall or secondary infection of a preexisting aneurysm [3].

Staphylococcus aureus and Salmonella typhi are the main microorganisms involved in the occurrence of mycotic aneurysms, especially in elderly diabetic patients, as was the case of our patient [4,5].

As a result of bacteremia, atheromatous lesions within the aneurysm can become infected, leading to necrosis and rupture of the aortic wall [6].

Most patients have non-specific symptoms like fever, back pain, and abdominal pain.

The biological manifestations are bacteremia, hyper leukocytosis, and elevated erythrocyte sedimentation rate [5]. A positive blood culture with radiological abnormalities of the aorta strongly suggests a bacterial disease [7].

The intensive antibiotic therapy is crucial and should be started as early as possible before surgery. The time required varies from 6 to 8 weeks [8].

Surgical treatment of mycotic aneurysms includes a resection of the aneurysmal sac with debridement of the infected tissue. The reconstruction can be extra-anatomic to avoid the use of grafts in a contaminated area [5,9]. However, the patency rate for axillo-femoral bypass is poor [10].

The anatomic aortic reconstruction using cryopreserved homograft or grafts showed excellent short and long-term results [11,12]. The advantage of homograft is to prevent recurrence of the infection, but they raise the problem of availability.

In our case, inflammation of surrounding tissue was important, but without local signs of infection, and for the unavailability of homograft, we used an anatomical reconstruction with a prosthetic Dacron graft impregnated with rifampicin. An implantation of the lower mesenteric artery in the prosthesis was performed.

The postoperative mortality rate of this type of aneurysm remains high, between 21% and 36% [13].

Experience with endovascular treatment of mycotic aneurysms is limited [14]. Therefore, it is still uncertain whether endovascular treatment or surgical prosthetic repair provides the best short and long-term results.

The main disadvantage of the endovascular treatment is that the infected tissue is not resected, which can facilitate the recurrence of the infection, and the infection of the stent graft [15].
 
Conclusion

Mycotic aneurysms of the aorta remain a severe life-threatening disease. The management is based on the resection of infected tissues, and vascular reconstruction using allografts; if they are unavailable by prosthetic graft, associated with an antibiotic therapy for a long period.
 
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Review summary

  1. John
    Posted on Aug 02 2016 at 5:12 pm
    The article reports an interesting and rare case that involves incidence of cardiovascular infection due to salmonella bacterimia. The article highlights the necessity of high degree of suspicion in clinical cases with background of diabetes with culture positive results. It is an interesting paper.
 

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