Surgical approach to a mycotic aneurysm of the pulmonary artery presenting with hemoptysis - A case report and a review of the literature

Mycotic pulmonary artery pseudoaneurysm following total arch replacement: a case report

BACKGROUND

Although the true prevalence and incidence are not clearly known, mycotic pulmonary artery aneurysm is a potentially devastating condition that leads to high mortality, over 60% if untreated. Among them, mycotic pulmonary artery pseudoaneurysm, which occurs in relatively central areas, has rarely been reported. We report an extremely rare case of a late complication with a mycotic pulmonary artery pseudoaneurysm, presumably due to infective endocarditis, in a 68-year-old woman 4 months after total arch replacement.

CASE PRESENTATION

A 68-year-old woman was referred to our department for 2 weeks with fever of unknown origin. She had a history of emergency total arch replacement for an acute type A aortic dissection 4 months earlier and chronic rheumatoid arthritis on monthly subcutaneous tocilizumab treatment for several years. Blood culture was positive for Enterococcus faecalis. Transthoracic and transesophageal echocardiography revealed a left ventricular ejection fraction of 58%, severe mitral regurgitation with a 15-mm diameter vegetation on the anterior mitral leaflet, and severe aortic insufficiency with string-like structures. Contrast computed tomography showed a focal saccular outpouching from the right pulmonary artery. On 18F-fluorodeoxyglucose (FDG) positron emission tomography, focal uptake of FDGs was observed along the same lesion of the pulmonary artery and ascending-arch graft. The patient eventually recovered after the surgical intervention of mitral and aortic valve replacement, re-total arch replacement, pulmonary artery repair, application of omental flap, and antibiotics without any evidence of re-infection after 1 year.

CONCLUSIONS

We report a successful surgical repair of mycotic pulmonary artery pseudoaneurysm 4 months after total arch replacement for acute type A aortic dissection. This report describes an effective treatment for an extremely rare postoperative condition.

Endovascular embolization with EVOH for the treatment of a Rasmussen aneurysm

First-line treatment of pulmonary artery aneurysms/pseudoaneurysms (PAA/PAPA) is percutaneous or endovascular embolization. The present case of a Rasmussen aneurysm, a PAPA caused by Tuberculosis (TB), was successfully treated with ethylene-vinyl alcohol (EVOH), a radiopaque liquid embolic agent with favorable characteristics. A 35-year-old man presented as a new patient with hemoptysis, and CT imaging revealed multiple cavitary lesions and a 2.1 cm aneurysm in the upper right lobe. Endovascular treatment was delivered and a complete lack of filling of the lesion was noted on post-treatment angiography. The patient's history includes risk factors and past TB infection. Despite the suspicious imaging, diagnostic tests were negative for active TB in this patient. He was then found to have MRSA bacteremia and a mediastinal lymph node positive for M. avium. The etiology of this aneurysm is suspicious for the superinfection of a chronic tuberculous cavity with M. avium, MRSA, or both.

A rare case of infective endocarditis in association with ventricular septal defect complicated by mycotic pulmonary artery aneurysm

We present a case of a 3-year-old child with mycotic aneurysm of left descending pulmonary artery secondary to infective endocarditis in the setting of ventricular septal defect. The case highlights the role of CT angiography in the diagnosis and characterization of the aneurysm and in demonstrating the extent of thrombo-embolic complications in distal pulmonary arteries and lung parenchyma.

A Case Report and Review of the Literature: Infectious Aneurysm Formation in the Pulmonary Arteries-A Rare but Perilous Sequela of Persisting Infection With Klebsiella pneumoniae

Septic aneurysms of the pulmonary artery are rare conditions, with few cases having been reported worldwide. They are assumed to result from septic emboli that cause a local inflammatory reaction of the arterial wall, ultimately leading to degenerative changes. We report the case of a 63-year-old female patient presenting with Klebsiella pneumoniae urosepsis and first diagnosis of diabetes mellitus, who developed a life-threatening infectious pulmonary artery aneurysm secondary to bacteremia with Klebsiella pneumoniae. The patient required a lobectomy due to pulmonary hemorrhage. We review the clinical hallmarks of Klebsiella pneumoniae related septic pulmonary embolic disease and summarize currently known risk factors for the development of infectious aneurysmatic disease including diabetes mellitus and other states of immunosuppression. The featured case aims to increase the awareness for this seldom but life-threatening complication of infectious diseases such as Klebsiella pneumoniae urosepsis.

Mycotic Pulmonary Aneurysm Managed With Covered Stent

Mycotic aneurysms are vascular dilations caused by fungal or bacterial infections. The involvement of the pulmonary artery or its branches is extremely rare with only a few cases reported in the literature posing a diagnostic challenge. We present the case of a young adult patient with acute myeloid leukemia undergoing chemotherapy, who presented with febrile neutropenia, recurrent bacteremia due to Pseudomona Aeruginosa and Klebsiella Pneumonie and hemoptysis. The management was unconventional, opting for the placement of a covered endovascular stent, being the first successful case with this reported technique. Rapid detection of this pathology and individualization in the management of each patient is essential because of high risk of mortality due to sepsis and rupture of the aneurysm.

Paediatric haemoptysis from multiple pulmonary artery aneurysms

The case of multiple peripheral pulmonary artery aneurysms in children presenting with haemoptysis following an episode of bacterial endocarditis is presented. They are extremely rare and clinically non-specific but critical because early diagnosis is crucial for preventing sudden death from their rupture. Computed tomography pulmonary angiography remains the investigation of choice. Despite no consensus recommendation on the management, a multidisciplinary team should plan the beneficial approach with minimal procedure-related morbidity and mortality to improve survival. This case report aimed to emphasize the recognition of this rare cause of haemoptysis in children.

Mycotic aneurysms of pulmonary artery secondary to pulmonary valve endocarditis in a child

We present the case of a 7-year-old child with mycotic aneurysms of bilateral lower lobe pulmonary arteries secondary to pulmonary valve endocarditis. The child underwent pulmonary vegetectomy with ventricular septal defect closure and left lower lobe pulmonary lobectomy via midline sternotomy.

Multiple pulmonary artery mycotic aneurysms and septic emboli in a patient with tricuspid valve vegetation and infective endocarditis

Mycotic pulmonary artery aneurysms are rare infectious aneurysmal dilatations of the pulmonary arteries in patients with risk factors of intravenous drug use, endocarditis, or congenital heart disease. Timely diagnosis is crucial given high mortality rate associated with this condition. We present a rare case of a 24-year old male with history of intravenous drug use who presented with fever, hypoxia, and bacteremia. The patient was subsequently diagnosed with infective endocarditis with septic vegetations of the tricuspid valve. Computed tomography angiogram demonstrated multiple bilateral mycotic pulmonary artery aneurysms and associated pulmonary septic emboli in this patient with infective endocarditis. Treatment options for mycotic pulmonary artery aneurysms are variable and include conservative management, endovascular coil intervention, or surgical resections. Presence of hemoptysis and increasing aneurysm size may warrant aggressive intervention.