Free
Clinical Images  |   April 2018
Aortic Arch Mycotic Aneurysm
Author Notes
  • From the Department of Internal Medicine at the Northeast Ohio Medical University in Rootstown (Drs Marnejon and Dangol); the Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania (Dr Marnejon); the Ohio University Heritage College of Osteopathic Medicine in Athens (Dr Marnejon); and the St Elizabeth Youngstown Hospital in Ohio (Drs Marnejon and Dangol). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Thomas P. Marnejon, DO, St Elizabeth Health Center, Department of Internal Medicine, 1044 Belmont Ave, Youngstown, OH 44501-1096. Email: thomas_marnejon@mercy.com
     
Article Information
Cardiovascular Disorders / Imaging / Clinical Images
Clinical Images   |   April 2018
Aortic Arch Mycotic Aneurysm
The Journal of the American Osteopathic Association, April 2018, Vol. 118, 280. doi:https://doi.org/10.7556/jaoa.2018.055
The Journal of the American Osteopathic Association, April 2018, Vol. 118, 280. doi:https://doi.org/10.7556/jaoa.2018.055
A 74-year-old man was admitted to the hospital after presenting with neck pain, sudden-onset dyspnea, and dysphagia. His vital signs were as follows: heart rate, 101 beats/min; respiration rate, 22/min; blood pressure, 144/83 mm Hg; and temperature, 96.7°F. His white blood cell count was 18,100/μL and erythrocyte sedimentation rate, 82 mm/h. Physical examination revealed wheezing, tachycardia, and bilateral lower extremity edema. Chest computed tomographic scan revealed a 6-cm anterior mediastinal mass. A magnetic resonance image revealed a pseudoaneurysm of the aortic arch beyond the left subclavian artery origin (image A, arrow) with an abscess surrounding the aneurysm (image B, arrow). The patient was given vancomycin intravenously and transitioned to nafcillin, 2 g every 4 hours, after blood culture results were positive for Staphylococcus aureus on hospital day 3. Magnetic resonance image of the cervical spine showed discitis and osteomyelitis from C6 to C7, with epidural abscess and prevertebral space fluid, extending inferiorly to the aorta. The patient died on hospital day 10. 
The term mycotic aneurysm was first described by Osler in a case of ulcerative bacterial endocarditis, in which ulcerative endarteritis in the aortic arch produced multiple aneurysms.1 Direct inoculation, contiguous infection, bacterial seeding, or septic emboli can cause mycotic aneurysm.2-6 Management includes antibiotics, debridement, and revascularization.7 
References
Osler W. The Gulstonian lectures, on malignant endocarditis. Br Med J. 1885;1(1263):467-470. [CrossRef] [PubMed]
Macedo TA, Stanson AW, Oderich GS, Johnson CM, Panneton JM, Tie ML. Infected aortic aneurysms: imaging findings. Radiology. 2004;231(1):250-257. [CrossRef] [PubMed]
Parkhurst GF, Decker JP. Bacterial aortitis and mycotic aneurysm of the aorta: a report of twelve cases. Am J Pathol. 1955;31(5):821-835. [PubMed]
Müller BT, Wegener OR, Grabitz K, Pillny M, Thomas L, Sandmann W. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases. J Vasc Surg. 2001;33(1):106-113. [CrossRef] [PubMed]
Kyriakides C, Kan Y, Kerle M, Cheshire NJ, Mansfield AO, Wolfe JH. 11-year experience with anatomical and extra-anatomical repair of mycotic aortic aneurysms. Eur J Vasc Endovasc Surg. 2004;27(6):585-589. [CrossRef] [PubMed]
Weis-Müller BT, Rascanu C, Sagban A, Grabitz K, Godehardt E, Sandmann W. Single center experience with open surgical treatment of 36 infected aneurysms of the thoracic, thoracoabdominal and abdominal aorta. Ann Vasc Surg. 2011;25(8):1020-1025. doi: 10.1016/j.avsg.2011.03.009 [CrossRef] [PubMed]
Wilson WR, Bower TC, Creager MA, et al Vascular graft infections, mycotic aneurysms and endovascular infections: a scientific statement from the American Heart Association. Circulation. 2016;134(20):e412-e460. [CrossRef] [PubMed]