Non-aneurysmal infectious aortitis: a case report

Infectious Aortitis: Case Report and Literature Review

Aortitis is the inflammation of the aorta secondary to either infectious or non-infectious etiologies. Infectious aortitis is a rare but potentially life-threatening condition. It is more common among older patients with preexisting pathology. Clinical presentation is variable, therefore, a high index of suspicion is required for timely diagnosis and management. We report a case of aortitis which was complicated with the development of a saccular abdominal aortic aneurysm. A 76-year-old male presented to the Emergency Department with two days of right lower quadrant abdominal pain. Clinical evaluation and imaging studies revealed abdominal aortitis, which progressed to a saccular abdominal aortic aneurysm. We highlight a unique presentation of infectious aortitis to raise awareness among physicians. We also reviewed the available literature on infectious aortitis to illustrate the importance of early diagnosis and appropriate treatment to improve the patients' outcomes.

Aortoenteric fistula secondary to an Inflammatory Abdominal Aortic Aneurysm

Primary aortoenteric fistulas are rare, with the annual incidence of such fistulas estimated to be 0.007 per million. The most common predisposing conditions for primary aortoenteric fistulas are atherosclerotic abdominal aortic aneurysms or penetrating atherosclerotic ulcers. We illustrate a rare case of an inflammatory aortic aneurysm causing a primary aortic fistula, with a direct fistulous jet from the aorta to the bowel with resultant catastrophic bleeding. In contrast to atherosclerotic aneurysms, most inflammatory aneurysms are symptomatic and show dense perianeurysmal fibrosis and periaortic wall thickening. A direct jet of contrast extravasation from the aorta into a bowel loop, while rarely seen, remains the most specific sign of a primary aorta-enteric fistula. A comprehensive literature review of the clinical presentation, imaging features, and differential diagnosis of a primary aortoenteric fistula are also discussed.

Conservative treatment of non-aneurysmal infectious aortitis: a case report and review of the literature

BACKGROUND

 Non-aneurysmal infectious aortitis is a rare clinical entity with most often lethal complications when surgical intervention is delayed.

OBJECTIVES

 This report describes the case of a non-aneurysmal infectious aortitis complicated with a penetrating aortic ulcer in an elderly woman, caused by a methicillin-sensitive Staphylococcus aureus. Surgery was deemed contra-indicated and treatment was limited to the administration of intravenous vancomycin (2 grams daily), followed by flucloxacillin (6 times 2 grams daily). She remains well after one year.

METHODS

The Internet databases Medline and Embase were searched. Articles were selected based on relevanceof abstract, article type and impact of the journal.

RESULTS

 A literature review addresses current insights in the pathogenesis, diagnosis, and treatment of non-aneurysmal infectious aortitis.

Fulminant Infectious Aortitis With Ascending Aortic Rupture

Infectious aortitis is associated with a high rate of acute aortic adverse events. However, the nonspecificity of symptoms and low sensitivity of blood cultures may delay early recognition of this condition. A 77-year-old man was incidentally found to have aortitis. His disease took a fulminant course and was complicated by dissection and rupture only 4 days after the diagnosis. Serial computed tomographic angiography provided valuable information about the development of aortitis into dissection and rupture. Postdissection histologic analysis revealed gram-positive cocci in the aortic wall.

Staphylococcus aureus aortitis and retroperitoneal fibrosis: A case report and literature review

An infected aortic aneurysm is a process with high mortality rate. Survival is dependent on an early diagnosis and surgical management. This case report details a rare presentation of aortitis with persistent methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, which initially presented as retroperitoneal fibrosis and was ultimately fatal.

Inflammatory diseases of the aorta: Part 2: Infectious aortitis

Infectious aortitis is a rare but life-threatening disease. Due to impending local and systemic complications, prompt diagnosis and initiation of effective causal treatment are essential for patient survival. Differentiating infectious aortitis from other aortic diseases, in particular non-infectious aortitis, is of great importance. This article discusses the various causes, diagnostic tools, and therapeutic strategies for infectious aortitis.

A Case Report on the Successful Treatment of Streptococcus pneumoniae-Induced Infectious Abdominal Aortic Aneurysm Initially Presenting with Meningitis

Infectious abdominal aortic aneurysms often present with abdominal and lower back pain, but prolonged fever may be the only symptom. Infectious abdominal aortic aneurysms initially presenting with meningitis are extremely rare; there are no reports of their successful treatment. Cases with Streptococcus pneumoniae as the causative bacteria are even rarer with a higher mortality rate than those caused by other bacteria. We present the case of a 65-year-old man with lower limb weakness and back pain. Examination revealed fever and neck stiffness. Cerebrospinal fluid showed leukocytosis and low glucose levels. The patient was diagnosed with meningitis and bacteremia caused by Streptococcus pneumoniae and treated with antibiotics. Fever, inflammatory response, and neurologic findings showed improvement. However, abdominal computed tomography revealed an aneurysm not present on admission. Antibiotics were continued, and a rifampicin soaked artificial vascular graft was implanted. Tissue cultures showed no bacteria, and histological findings indicated inflammation with high leukocyte levels. There were no postoperative complications or neurologic abnormalities. Physical examination, blood tests, and computed tomography confirmed there was no relapse over the following 13 months. This is the first reported case of survival of a patient with an infectious abdominal aortic aneurysm initially presenting with meningitis caused by Streptococcus pneumoniae.

Escherichia coli primary aortitis presenting as sequelae of incompletely treated urinary tract infection

We report a rare case of nonaneurysmal infectious aortitis (IA) with the causative microorganism being Escherichia coli. The patient was a 78-year-old man who presented with a 3-week history of abdominal pain, fevers, and anorexia after treatment for a urinary tract infection. The patient had positive blood cultures and a computed tomography scan that had signs of IA. He was treated with intravenous antibiotics and extra-anatomic revascularization with excision and debridement of the infected aortic segment with a good outcome. IA is an uncommon condition with a high mortality rate; however, if diagnosed early, it can be successfully treated.

Clinical pathologic conference: A 65-year-old male with left-sided chest pain. A case of an unexpected occupational hazard

The authors present a case of a 65-year-old male who presented four times to the emergency department (ED) with left-sided chest pain. On the first three visits, the patient was admitted with a different diagnosis related to his chest pain. On the final visit, an abnormality on an imaging study performed in the ED led to the ultimate diagnostic test revealing the cause of the patient's symptoms. The patient's clinical presentation and ultimate clinical course are summarized, and a discussion of the differential diagnoses of his condition is presented.

Infectious aortitis: a rare cause of chest pain in a child

Infectious aortitis (IA) is a life-threatening bacterial infection that occurs almost exclusively in adults. Only 1 case of IA had been previously reported in a child. We present a case of IA that occurred in a 6.5-year-old previously healthy girl who was seen in our emergency department because of fever and chest pain of immediate onset. She underwent a thorough evaluation but died of aortic rupture before the correct diagnosis was established. The etiology, clinical presentation, diagnosis, and treatment of IA are discussed.

Acute Infectious Pseudoaneurysm of the Descending Thoracic Aorta and Review of Infectious Aortitis

Thoracic aortic wall disruptions may occur secondary to trauma, surgical interventions, infection, or autoimmune or idiopathic inflammatory disorders. Such vessel wall disruption can lead to aortic dissections, aneurysm development, or more commonly, pseudoaneurysm (PSA) formation. Although aortic wall infections as an antecedent to mycotic aneurysms have been recognized since the 17th century, there has been a temporal evolution in the development of this disease. Prior to the antibiotic era they were commonly associated with endocarditis or syphilis. More recently, however, they are associated with infection of a damaged atherosclerotic area of the aorta and secondary hematogenous or contiguous seeding. We report the first case of the rapid development of a pseudoaneurysm in the descending thoracic aorta attributable to an infection of a contiguous esophageal duplication cyst by a diagnostic esophageal ultrasound (EUS) fine-needle aspiration. A literature review of mycotic thoracic aortic aneurysms and pseudoaneurysms is also presented.

Early diagnosis of nonaneurysmal infectious thoracic aortitis using transesophageal echocardiogram in a patient with purulent meningitis

Infectious thoracic aortitis is a rare entity in the antibiotic era and usually appears in patients with prior aortic disease and/or associated infective endocarditis. Infected nonaneurysmal aorta will likely progress to mycotic aneurysm if left untreated. In most of the reports, infectious thoracic aortitis presents with a mycotic aneurysm. We report the case of a patient with a nonaneurysmal infectious thoracic aortitis, probably secondary to purulent meningitis, early diagnosed by transesophageal echocardiogram.

Infectious thoracic aortitis: a literature review

Infectious thoracic aortitis (IA) remains a rare disease, especially after the appearance of antibiotics. However, if left untreated it is always lethal. It usually affects patients with atherosclerotic aortic disease and/or infective endocarditis. Mycotic aneurysm is the most common form of presentation, although a few reports of nonaneurysmal infectious thoracic aortitis have also been described. Various microorganisms have been associated with infectious thoracic aortitis, most commonly Staphylococcal, Enterococcus, Streptococcus, and Salmonella species. It is extremely important to establish an early diagnosis of IA, because this condition is potentially life-threatening. However, diagnosis is frequently delayed since clinical manifestations are usually nonspecific. Antibiotherapy in combination with complete surgical excision of the infected aorta is the best choice of treatment.