Unilateral lower limb hypertrophic osteoarthropathy due to aortic graft infection and aortoenteric fistula

Graft Infection Masquerading as Rheumatologic Disease: a Rare Case of Aortobifemoral Graft Infection Presenting as Hypertrophic Osteoarthropathy

BACKGROUND

Prosthetic vascular graft procedures are a common treatment modality for peripheral vascular disease. A relatively common complication is graft infection, occurring at a rate of 0.5-5%. When they occur, graft infections are associated with significant morbidity and mortality. Vascular graft infections also represent a diagnostic and therapeutic challenge for the physician METHODS: Here, we report a case where the rare finding of secondary hypertrophic osteoarthropathy was an important indication of underlying aortic graft infection that was initially misdiagnosed. A review of the literature revealed 34 cases of vascular graft infection associated with hypertrophic osteoarthropathy.

RESULTS

The mean interval from surgery to time of infection was approximately 5 years. Mortality was 35%. When combined with hypertrophic osteoarthropathy, vascular graft infection was complicated by an aortoenteric fistula in 53% of the cases.

CONCLUSION

The complexity of this case highlights the challenges physicians face in order to diagnose and treat this condition.

Hypertrophic Osteoarthropathy Secondary to Vascular Prosthesis Infection

An infected vascular graft is an uncommon association in hypertrophic osteoarthropathy (HOA) but is important because of potential catastrophic complications. Here we describe 3 new patients with HOA secondary to vascular prosthesis infection and review the other 23 patients described in the English literature with this clinical syndrome. The finding of symptoms and signs of localized HOA in patients with arterial prosthesis may be the presenting manifestation of graft sepsis. In most patients the graft is located at the aorta or aortic bifurcation. The initial symptoms are fever, joint pain mainly involving the knees and ankles, clubbing, and in some cases intestinal bleeding. Recurrent abscesses and bacteremia arising in spite of appropriate antimicrobial therapy are prominent infectious signs. Another characteristic feature is the wide variety of bacteria isolated from a single patient. When a polymicrobial enteric flora is isolated from the blood or other tissue, an intestinal origin of infection can be readily suspected. Gallium or leukocyte scans are useful for detecting an abscess around the vascular prosthesis. In some cases, the detection of gas around the graft demonstrated by computed tomography is highly suggestive of prosthesis infection. Mechanisms involved in the pathogenesis of HOA associated with aortic graft infection are unknown. Treatment consists of intravenous antibiotics and surgical replacement of the infected graft. The prognosis of arterial prosthesis infection depends greatly on early diagnosis and treatment before the onset of life-threatening complications. Knowledge of this rare association may lead to an early diagnosis and appropriate management of this serious and often fatal complication.

Periostitis and hypertrophic osteoarthropathy: etiologies and bone scan patterns in 115 cases

BACKGROUND: Periostitis, usually seen on X-ray, may be diagnosed on bone scan as non-nodular cortical bone hyperactivity. Both the complete form (including clubbing, arthritis and periostitis) and the incomplete form have been described in association with chronic pulmonary disease, neoplasm, hepatopathy and inflammatory bowel disease. It is not known whether the bone scan pattern of non-nodular cortical bone hyperactivity varies with the etiology. METHODS: We conducted a retrospective study to analyze the etiologies and bone scan patterns of 115 cases of non-nodular cortical bone hyperactivity. RESULTS: Eighty percent of our patients were asymptomatic. Thirty-four percent of all cases of periostitis (all bilateral) were associated with cancer. The rate of cancer in cases of periostitis involving both lower limbs was 28.5%; it was 61.3% when both lower and upper limbs were involved. The duration of the disease was not correlated with either the distribution of periostitis or the intensity of uptake. Moreover, the intensity of uptake was not correlated with the importance of the symptomatology. Bone scan pattern (regular versus heterogenous uptake, localized versus diffuse uptake) was not correlated with the etiology. CONCLUSIONS: Bilateral upper and lower uptake should alert the clinician to the risk of association with neoplasm. Bone scan pattern and intensity of uptake are not necessarily correlated with etiology.

Possible association between deep infection and hypertrophic osteoarthropathy. Report of three cases and review of the literature

Hypertrophic Osteoarthropathy is classically associated with chronic pulmonary disease, cancer or inflammatory bowel disease. However, deep infection such as vascular graft infection is an etiology important to recognize because of the risk of life-threatening complication (aorto-enteric fistula). In this study, we reported two cases of aortic graft infection and one case of para-anal abscess associated with hypertrophic osteoarthropathy. The previously reported cases are reviewed.

Value of bone scintiscan for diagnosis of arterial prosthesis infection: preliminary results

Diagnosis of arterial prosthetic infection is often difficult to confirm. Several cases of lower extremity hypertrophic osteoarthropathy (HOA) have been associated with arterial prosthetic infection. The presence of bone and joint abnormalities could constitute an early sign of HOA. The purpose of this prospective study was to determine the diagnostic value of routine bone scintiscan in patients hospitalized for suspected arterial prosthesis infection. Between December 1995 and May 1997, 17 patients with suspected infection were admitted to our institution. All underwent bone scintiscan before surgical treatment. Presence or absence of infection was defined according to the criteria proposed by Yeager. During the same period, bone scintiscan was performed in a control group of 8 patients with arterial prostheses but no clinical or laboratory signs of infection. Scintiscans were studied to detect bone and joint abnormalities distal to the arterial prosthesis. The results of this preliminary study indicate that routine bone scintiscan can assist definitive diagnosis in patients with suspected arterial prosthesis infection. Demonstration of bone and joint abnormalities distal to a prosthesis appears to be a fairly sensitive and highly specific sign of infection.

Subperiosteal new bone formation in association with vascular graft sepsis

Hypertrophic osteoarthropathy (HOA) is a clinical and radiologic syndrome that consists of periosteal new bone formation, synovitis, and digital clubbing. Secondary HOA has been reported confined to one or two extremities that are perfused by Dacron grafts that have become infected. Herein we include a report of a vascular graft infection that shares some of the clinical features with HOA and a brief review of pathophysiologic theories. We conclude emphasizing that periostitis and other HOA signs and symptoms may play a role as a clue to support the suspicion of vascular graft infection when confusing and vague clinical features are present.