Tuberculous aortitis presenting with an aortoduodenal fistula: a case report

Tuberculous Aneurysm of the Supraceliac Aorta

Significant vascular complications are rare following systemic infections with Mycobacterium tuberculosis (TB). This report describes a 33-year-old man who presented with a short history of abdominal discomfort and febrile episodes with no prior history of infection with TB. Ultrasound, CT scan, and aortography confirmed the presence of a pseudoaneurysm originating from the posterior aspect of the supraceliac aorta at the level of the diaphragm. Via a full thoracoabdominal approach, periaortic inflammatory tissue and the aortic wall itself were debrided, and repair of the pseudoaneurysm was achieved with a synthetic patch. Mycobacterium tuberculosis was isolated from the aortic wall, and anti-TB medications were instituted. Postoperatively the patient did well and was discharged after 14 days. As illustrated by this case, tuberculous mycotic aneurysms of the aorta are optimally treated with a combination of medical and surgical therapy, and early diagnosis is essential to ensure survival.

Primary aortoduodenal fistula caused by tuberculous aortitis presenting as recurrent massive gastrointestinal bleeding

Upper gastrointestinal bleeding from primary aortoduodenal fistula (PADF) is unusual and fatal. The etiology of PADF from tuberculous aortitis is rare. We report a 69-year-old male patient who suffered recurrent hematemesis and hematochezia with hypovolemic shock of unknown origin. Initial endoscopy failed to lead to a diagnosis. A bleeder over the third portion of the duodenum was found after the third endoscopy. Exploratory laparotomy showed a ruptured aortic pseudoaneurysm with an aortoduodenal fistula. Dacron graft repair of the aorta and simple closure of the duodenal fistula were carried out. Pathologic examination revealed tuberculous aortitis. The patient survived and was symptom-free following operation and antituberculous therapy. Review of the literature revealed that the clinical presentations in this disorder are insidious. The endoscopic findings are atypical. We conclude that so-called "herald bleeding", a history of tuberculous infection or aortic aneurysm and a high degree of suspicion are critical for successful diagnosis. Early diagnosis and surgical exploration are needed for timely and successful management.

[Thoracic infectious aortitis: microbiology, pathophysiology and treatment]

BACKGROUND

Thoracic infectious aortitis are currently rare. They are always lethal without any treatment. The microorganisms involved are numerous with particular pathophysiological characteristics for each bacterium. Treatment is difficult and must associate medical and surgical care.

RECENT FINDINGS

Bacterial epidemiology of infectious aortitis has been profoundly modified with the large use of antibiotics. Syphilitic aortitis were frequent in the beginning of the twentieth century but its incidence has dramatically fallen. It still exists and its clinical presentation must be known to begin an adequate treatment. Other bacterial aetiologies of these aortitis are more classical with high frequencies of Staphylococcus aureus and Streptococcus, which are often associated with infective endocarditis. Among Gram-negative bacteria, Salmonella spp are the most frequently met microorganisms. Atherosclerosis represents the principal risk factor of these infectious aortitis. It provokes arterial parietal damage useful for bacterial attach. A saccular aneurysm of infective origin can then appear. Treatment must consist on antibiotics before surgery; Tuberculous aortitis are also possible but are much more rare.

CONCLUSION

Thoracic infectious aortitis are very rare but must be known because of their poor prognosis. Treatment is difficult and prevention of atherosclerosis which is the most important risk factor of these diseases is therefore of greatest importance.

Gastrointestinal tuberculosis

Gastrointestinal tuberculosis is defined as infection of the peritoneum, hollow or solid abdominal organs, and abdominal lymphatics with Mycobacterium tuberculosis organisms. Gastrointestinal tuberculosis is relatively rare in the United States and is the sixth most common extrapulmonary location. Populations at risk include immigrants to the United States, the homeless, prisoners, residents of long-term care facilities, and the immunocompromised. The peritoneum and the ileocecal region are the most likely sites of infection and are involved in the majority of cases by hematogenous spread or through swallowing of infected sputum from primary pulmonary tuberculosis. Pulmonary tuberculosis is apparent in less than half of patients. Patients usually present with abdominal pain, weight loss, fever, anorexia, change in bowel habits, nausea, and vomiting. The diagnosis is often delayed and is usually made through a combination of radiologic, endoscopic, microbiologic, histologic, and molecular techniques. Antimicrobial treatment is the same as for pulmonary tuberculosis. Surgery is occasionally required.

Primary aortoenteric fistula related to septic aortitis

CONTEXT

Primary aortoenteric fistulas usually result from erosion of the bowel wall due to an associated abdominal aortic aneurysm. A few patients have been described with other etiologies such as pseudoaneurysm originating from septic aortitis caused by Salmonella.

OBJECTIVE

To present a rare clinical case of pseudoaneurysm caused by septic aortitis that evolved into an aortoenteric fistula.

CASE REPORT

A 65-year-old woman was admitted with Salmonella bacteremia that evolved to septic aortitis. An aortic pseudoaneurysm secondary to the aortitis had eroded the transition between duodenum and jejunum, and an aortoenteric fistula was formed. In the operating room, the affected aorta and intestinal area were excised and an intestine-to-intestine anastomosis was performed. The aorta was sutured and an axillofemoral bypass was carried out. In the intensive care unit, the patient had a cardiac arrest that evolved to death.

Tuberculous aortitis with an aortoduodenal fistula presenting as recurrent gastrointestinal bleeding

Tuberculous aortitis with a tuberculous mycotic aneurysm and an aortoduodenal fistula was diagnosed in a 38-year-old man with tuberculous cervical lymphadentitis and a 3-month history of recurrent gastrointestinal bleeding, in whom extensive investigation of the digestive tract had not revealed a bleeding lesion. Either by septic embolism or by direct extension from a neighboring focus, tuberculous infection can cause a mycotic aortic aneurysm with subsequent fistulation to the duodenum.

Tuberculous infection of the descending thoracic and abdominal aorta: case report and literature review

We report here a case of infrarenal aortic disruption and aortoduodenal fistula secondary to tuberculous aortitis in a 77-year-old man. From a review of experience with operative management of tuberculous infection of the descending thoracic and abdominal aorta reported in the English-language literature, including the current report, we found that operative repair was attempted in 26 patients with tuberculous aortitis of the abdominal (n = 16), thoracic (n = 8), and thoracoabdominal (n = 2) aorta. Six patients had emergent operations for massive hemoptysis (n = 2), aortoduodenal fistula (n = 2), or abdominal rupture (n = 2), with an associated 30-day mortality of 50%. Elective or semi-elective repair was undertaken in 20 patients, of whom 19 (95%) survived for at least 30 days. On the basis of limited experience with this rare entity, in situ graft replacement is an appropriate treatment of tuberculous aneurysms and pseudoaneurysms of the descending thoracic and abdominal aorta.

Primary aortoenteric fistula: report of eight new cases and review of the literature

Primary aortoenteric fistula, a direct communication between the aorta and the intestinal tract, is a rare cause of gastrointestinal hemorrhage. Eight patients who were all treated at one hospital are described, followed by a review of all surgically treated patients reported within the past 10 years. The usual cause is erosion of an atherosclerotic aneurysm into the adherent duodenum, but a wide variety of other causes and localizations have been described. The clinical presentation is usually one of intermittent gastrointestinal hemorrhage resulting in lethal exsanguination within a matter of hours or days. Pain, a pulsatile abdominal mass, or fever may not be present. Endoscopy, arteriography, ultrasound, and CT scan can be useful in the evaluation of these patients, but physical examination and a high index of suspicion remain key to diagnosis. Primary aortoenteric fistula is more often discovered unexpectedly during exploratory laparotomy and is not usually considered as a presumptive preoperative diagnosis. Although contamination is unavoidable, most patients are treated with an in situ vascular graft and primary closure of the intestinal defect with good results.

The arteritides

This article reviews the histopathological, clinical and immunological features of the arteritides. Based on these criteria, a classification scheme is proposed that includes infectious and non-infectious causes. Included in the non-infectious arteritides are: hypersensitivity vasculitis including serum sickness. Henoch-Schönlein purpura, mixed cryoglobulinaemia, hypocomplementaemia, drug and malignancy-associated vasculitis; arteritides of small and medium-sized arteries including polyarteritis nodosa, Kawasaki's disease, Wegener's granulomatosis, Churg-Strauss syndrome, necrotizing sarcoid granulomatosis, thromboangiitis obliterans (Buerger's disease) and localized forms of arteritis; arteritides involving large, medium and small-sized arteries which includes giant cell (temporal) arteritis, Takayasu's disease and arteritis of collagen-vascular disease (rheumatoid arthritis, rheumatic fever, Behçet's disease, Sjörgren's syndrome, systemic lupus erythematosis and systemic sclerosis.