[Fever and persisting calf abscess ten years after aorta-bifemoral bypass]

A 52-year-old woman presented with fever and a persisting calf abscess ten years after she had received an aorta-bifemoral bypass. Her infection parameters were increased and she had anaemia. CT of the abdomen revealed air surrounding the proximal anastomosis of the bypass suggesting bypass graft infection. The diagnosis of an aorta-duodenal fistula was confirmed by gastroduodenoscopy showing migration of the bypass through the wall of the duodenum into the intestinal lumen. The bypass was resected and reconstructed using the superficial femoral vein. The patient recovered uneventful.

Sudden death with massive hemoptysis from aortobronchial fistula

Aortobronchial fistula is an uncommon clinical entity, with unpredictable clinical course and significant mortality. Here, we describe a case of fistulous tract between a descending aortic graft and a branch of the left upper lobar bronchus leading to massive hemoptysis causing death for hemorrhagic shock in a 72-year-old man.

Endocarditis With Fistulization and Rupture of Aortic Root Abscess to the Left Atrium

BACKGROUND

Infective endocarditis (IE) is a difficult emergency department (ED) diagnosis to make. Symptoms are nonspecific and diverse and the classic triad of fever, anemia, and murmur is rare. Severe IE causes considerable morbidity and mortality and should be diagnosed early. However, echocardiogram is essential but not readily available in the ED and can cause diagnostic delay.

CASE REPORT

This case describes severe IE and its unique presentation, diagnostic challenges, and the use of bedside cardiac ultrasonography. A 28-year-old previously healthy male presented with intermittent fevers, arthralgias, and myalgias for 2 weeks. He had twice been evaluated and diagnosed with lumbar back pain. Physical examination revealed moderate respiratory distress, pale skin with a cyanotic right lower extremity, and unequal extremity pulses. He became hypotensive and rapidly deteriorated. Chest x-ray study showed bilateral pulmonary infiltrates with subsequent imaging demonstrating worsening septic emboli. Bedside ultrasound revealed mitral and aortic valve vegetations and a presumed diagnosis of IE with septic embolization was made. Formal echocardiography (ECHO) confirmed IE with an aortic root abscess with rupture and fistulization into the left atrium. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinical criteria for IE include blood cultures and ECHO, however, these are often not available to an emergency physician, making IE a diagnostic challenge even in severe cases. The role of bedside ultrasound for IE continues to evolve and its utility in the diagnosis of severe IE is distinctly demonstrated in this case.

Extracorporeal Membrane Oxygenation as a Bridge to Surgery for Infective Endocarditis Complicated by Aorto-Atrial Fistula and Cardiopulmonary Collapse

The timing of surgery for active infective endocarditis is challenging when patients exhibit mechanical dysfunction and hemodynamic compromise. Extracorporeal membrane oxygenation has been described in treating sepsis but not, insofar as we know, in treating the acute mechanical sequelae that arise from infective endocarditis. We report perhaps the first case that shows the usefulness of extracorporeal membrane oxygenation as a bridge to definitive treatment in a 35-year-old man who had infective endocarditis followed by aorto-atrial fistula and cardiopulmonary collapse.

Death by aortoesophageal fistula due to disseminated tuberculosis: a case study

Tuberculosis remains a serious public health problem worldwide, especially in Korea. Although tuberculosis is generally considered a non-fatal chronic disease, deaths have occurred. In this case study, a 68-year-old man was admitted to the hospital with dyspepsia, vomiting, and abdominal pain. Nine hours later, he suffered severe hematemesis and died despite cardiopulmonary resuscitation. A medico-legal autopsy was performed and an external examination revealed no external injuries. However, an internal examination revealed an aortoesophageal fistula and a large amount of blood in the stomach. A histologic examination confirmed tuberculous mediastinitis with disseminated tuberculosis involving multiple organs, including the heart, lungs, liver, kidneys, and spleen. Both an aortoesophageal fistula and sudden death due to tuberculosis infection are rare. This paper reports the case of a fatal aortoesophageal fistula associated with disseminated tuberculosis.

An unique case of thoracic endovascular aortic repair (TEVAR) graft infection with Streptococcus viridans

The incidence of infection following TEVAR is low. To the best of our knowledge, this is the first case report of post thoracic endovascular aortic repair (TEVAR) with Streptococcus viridans graft infection. A 54-year-old male underwent TEVAR for dissecting thoracic aneurysm with spinal ischaemia. He had an eventful recovery with prolonged period of stay in intensive care unit. Three months later, he presented with persistent chest discomfort and fever. Computed tomography (CT) of the thorax revealed evidence of graft infection and the blood culture grew Streptococcus viridans. The rarity of TEVAR graft infection due to Streptococcus viridans and its management are being discussed.

Successful surgical repair of an infectious thoracic aortic pseudoaneurysm accompanied by aortobronchopulmonary fistula and advanced hepatic dysfunction without assisted circulation

The patient was a 59-year-old female. Because of massive hemoptysis, she was brought to our emergency center by ambulance. Thoracic computed tomography led to a diagnosis of an infectious thoracic aortic pseudoaneurysm accompanied by an aortobronchopulmonary fistula. Emergency surgery followed. Also noted was an advanced hepatic dysfunction, assessed as Child-Pugh score B, caused by an alcoholic liver disease. A localized affected area made it possible for us to perform an aneurysmectomy using a temporary bypass rather than assisted circulation. A patch plasty using expanded polytetrafluoroethylene completed the procedure. Streptococcus agalactiae (GBS) was detected in a sample obtained during the surgery from an abscess located in the aneurysm. The patient made satisfactory postoperative progress and left the hospital walking unaided on the 36th postoperative day.

Management of thoracic endograft infection

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising, less invasive alternative to conventional open surgery for the treatment of thoracic aortic pathology. Most surveillance after TEVAR concentrates on the technical aspects of the procedure, including endoleak, device migration and endograft rupture; so far, the knowledge on endograft infectious complications is limited to anecdotal reports. Several etiopathogenetic factors may play a role in thoracic endograft infections (TEIs), including perioperative contamination, hematogenous seeding, and local bacterial translocation. Moreover, fistulization with the esophagus or the bronchial tree is a common mechanism of secondary TEI, and it represents a dramatic event requiring a multidisciplinary management. Risk factors assessment and prevention have a key role in avoiding the development of new TEIs. When a TEI is established, treatment is demanding, and includes several medical therapies associated with various surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for TEI are still burdened with very high morbidity and mortality. In this paper, we reviewed the English literature regarding the main strategies proposed for operative management of TEI, we reported and analyzed our personal series of 7 patients treated at our institution for TEI from 1999 to 2009, and we summarized results from the data collected during a recent Italian multicenter national survey, performed to investigate aortoesophageal and aortobronchial fistulae treated with TEVAR or developed following TEVAR.

Epidemiology and diagnosis of endograft infection

Endograft infection is reported to occur in between 0.2 and 0.7 of patients and in general presents either within four months of endograft implantation of after more than 12 months. Review of all cases reported to date reveals three modes of presentation: approximately one third of patients present with evidence of an aorto-enteric fistula (although less than half of these present with gastrointestinal haemorrhage), one third present with non specific signs of low grade sepsis (malaise, weight loss) and the remainder with evidence of severe systemic sepsis. Infection is most commonly attributed to Staphylococcus aureus. Diagnosis relies on a high index of suspicion, imaging of the aorta and periaortic tissues (computed tomography or magnetic resonance imaging) and bacteriological culture. This paper presents a detailed analysis of the features of all cases reported to date and examines the aetiology, pathogenesis and imaging of endograft infection and aorto-enteric fistula.

Aortocavitary fistula without aneurysm and transient incomplete atrioventricular block due to infective endocarditis

A 67-year-old man with persistent fever and moderate aortic valve regurgitation was transferred. He suffered from incomplete atrioventricular block (AVB), and temporary pacing was needed. Left-to-right shunt flow from the aorta to the right atrium was found without an aneurysm. Operative findings indicated that the aortic valve was highly calcified. The orifice of an aortocavitary fistula (ACF) was detected in the sinus of Valsalva and the right atrium. Patch repair of the aortic annulus with complete débridement of the abscess cavity was performed, a procedure that consisted of aortic valve replacement directly to the Gore-Tex patch and aortic root replacement. His postoperative course was uneventful, but a pacemaker was implanted owing to complete AVB. To our knowledge, this is a rare case in which infective endocarditis was complicated by ACF without an aneurysm of the sinus of valsalva (SV) on the noncoronary cusp to the right atrium and transient incomplete AVB (Mobitz type II) occurring simultaneously.

Reconstruction of the fibrous trigone

A 48-year-old man with a history of infective endocarditis and severe aortic regurgitation had undergone prosthetic aortic valve replacement at another institution. Two months later, the patient developed prosthetic valve endocarditis with an aortic root abscess and an aorto-left atrial periprosthetic valvular fistula through the detached posterior annulus of the mitral valve. We repaired the fistula by constructing a fibrous trigone made of bovine pericardium. We also replaced the prosthetic aortic valve with another prosthetic valve, while protecting the native mitral valve.

Streptococcus milleri group infection associated with digestive fistula in patients with vascular graft: report of seven cases and review

We described seven patients with Streptococcus milleri group aortic (six patients) or vena cava (one patient) graft infection secondary to a vasculo-digestive fistula. Time between vascular graft setting and first clinical signs varied from eight months to more than thirteen years. Six patients had fever. Three patients presented with recurrent fever for more than nine months and in two of these cases, delay before diagnosis was long because repeated blood cultures were sterile. Three patients had abdominal pain and/or digestive haemorrhage. Abdominal CT-scan S. milleri was not contributive for the diagnosis in four patients. Streptococcus anginosus was isolated in four patients, Streptococcus constellatus in three patients. One patient died before surgical management. The other six patients were cured by a surgical management associated with a prolonged antibiotic (lactams) treatment. S. milleri group graft infections are rare (or misdiagnosed) while we found only 4 similar cases in the English medical literature. We conclude that a peri-prosthetic infection secondary to a digestive fistula must be insistently searched (and blood cultures must be repeated many times) in any patient with an aortic (or any other vascular) graft presenting prolonged or recurrent fever or acute digestive symptoms.

Periannular complications in infective endocarditis involving native aortic valves

The extension of infection in native valve infective endocarditis (IE) from valvular structures to the periannular tissue is incompletely understood. It is unknown, for example, whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinct clinical characteristics of patients with aortocavitary fistulae and nonruptured abscesses in native valve IE and to evaluate the impact of fistulization on the outcomes of patients with native aortic valve IE complicated with periannular lesions. In a retrospective multicenter study of 2,055 native valve IE episodes, 201 patients (9.8%) with periannular complications in aortic valve IE were identified (46 with aortocavitary fistulization and 155 with nonruptured abscesses). Rates of heart failure (p = 0.07), ventricular septal defect (p <0.001), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 172 patients (86%), and in-hospital mortality in the overall population was 29%. Multivariate analysis identified age >60 years (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.3 to 5.2), renal failure (OR 3.0, 95% CI 1.5 to 6.0), and moderate or severe heart failure (OR 2.5, 95% CI 1.2 to 5.2) as independent risk factors for death. There was a trend toward increased in-hospital mortality in patients with aortocavitary fistulae (OR 1.5, 95% CI 0.7 to 3.0). The actuarial 5-year survival rate in surgical survivors was 80% in patients with fistulae and 92% in patients with nonruptured abscesses (log-rank p = 0.6). In conclusion, aortocavitary fistulous tract formation in the setting of native valve IE is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscess. Despite these higher rates of complications, fistulous tract formation in the current era of IE is not an independent risk factor for mortality.

Mitral valve ring dehiscence with an aorta-left atrial fistula

In an era with the increasing use of various imaging modalities including echocardiography, ventriculography and cardiac magnetic resonance (CMR) imaging, one must be aware of the limitations of each discipline. We report a case of an individual who presented with both a partial dehiscence of a mitral valve annuloplasty ring and an aorta-left atrium fistula following surgical management of infective endocarditis that was correctly identified using transesophageal echocardiographic imaging.

Aorto-right atrial fistula: a complication of prosthetic aortic valve endocarditis. A case report

The case presented is of prosthetic aortic valve endocarditis in a 23-year-old male patient, complicated by an inflammatory periprosthetic valvular leak, and fistula formation between the aorta and the right atrium. The fistulous tract was diagnosed intraoperatively. Closure of the fistula was performed successfully in concordance with re-replacement of the aortic valve.

Salmonella reinfection manifesting as a fistula between the duodenum and an aortic stump pseudoaneurysm

Despite the worldwide increase in Salmonella infections, a Salmonella infection of an aortic graft is an exceptional event. A Salmonella reinfection manifesting as a fistula between the duodenum and an aortic stump pseudoaneurysm 30 months after prosthetic excision, aortic ligature and extra-anatomic bypass for a Salmonella graft infection is a unique event. This unusual late complication described in this case report developed in 1 of the 5 patients whose Salmonella aortic graft infections have been previously reported. The reinfection causing septic aortitis responded to conventional surgery.

Aortoduodenal fistula complicated by acupuncture

Recently, acupuncture has become a common therapeutic procedure for pain control worldwide. Although it has been repeatedly reported that acupuncture is effective and safe, several serious complications were also reported. In this article, we present a case of 68-year-old man who died of massive hematemesis resulting from aortoduodenal fistula (ADF), a rare complication of acupuncture therapy.

Vegetation and bilateral congenital coronary artery fistulas

This report describes the case of a man who presented with fever, weight loss, and Streptococcus mitis septicemia. He was found to have congenital bilateral coronary artery fistula, a rare condition. There was no evidence of vegetation on the heart valves on transthoracic or transesophageal echocardiography. Instead, transesophageal echocardiography showed vegetation within the coronary sinus near its entrance into the right atrium. Coronary angiography confirmed the presence of a left circumflex artery to coronary sinus fistula and a right coronary artery to coronary sinus fistula. To the authors' knowledge this combination of findings has never been reported before.

Aortobronchial Fistula in a Pediatric Patient With Massive Hemoptysis: Treatment by Means of an Aortic Endograft

We present an 11-year-old girl with acute myelogenous leukemia and hemoptysis from abscess erosion into the descending thoracic aorta. We report a pediatric case of an aortobronchial fistula treated with an aortic endograft and discuss the technical limitations and potential complications of this procedure.

Transoesophageal echocardiographic diagnosis of aortico-left atrial fistula in aortic valve endocarditis

Intra-cardiac fistulas are rarely seen and they are estimated to account for <1% of all cases of infective endocarditis. Fistulization of paravalvular abscesses has been found in 6% to 9% of cases. This is a report of an unusual communication between the abscess region in the aortic root and the left atrium. A 44-year-old patient diagnosed with infective endocarditis had continuous fevers despite antibiotic therapy. Transoesophageal echocardiography revealed multiple vegetations on aortic valve, fistulization of an aortic root abscess to the left atrium and mitral regurgitation and moderate aortic regurgitation. At surgery, multiple vegetations on the aortic valve and a large abscess cavity establishing direct communication between aortic root and the left atrial cavity through a fistulous tract were discovered. This experience demonstrates the improved sensitivity and specificity of transoesophageal echocardiography in defining periannular extension of infective endocarditis.

Gastrointestinal mucormycosis complicated by arterio-enteric fistula in a patient with non-Hodgkin's lymphoma

Gastrointestinal mucormycosis is a rare, often fatal, systemic infection found predominantly in immunocompromised patients. We report a case of gastrointestinal mucormycosis in a 53-year-old female with non-Hodgkin's lymphoma. Following her first course of chemotherapy, bowel obstruction developed as a result of mucormycosis. Despite treatment with antifungal therapy, she required a laparotomy owing to severe haemorrhage caused by mucormycosal invasion of her iliac artery. With continued antifungal treatment and further chemotherapy, she ultimately underwent reversal of her Hartmann's procedure and remains disease-free.

[An unusual cause of aorto-bronchial fistula: tuberculosis aortitis]

The aortic rupture in the pulmonary parenchyma or the bronchi rarely results in an haemoptysis. It means in most of the cases the rupture of an aortica aneurysm. We relate the observation of a aorto-bronchial fistula from a tuberculosa origin in an old woman case. Although the tuberculosa aortitis is becoming very exceptional, it still remains the cause of aorta rupture, with the formation of a false aneurysm which is rapidly fatal and so, it is important to search for it before any capricious haemoptysis.