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Infective Aneurysm of the Popliteal Artery Due to Salmonella Enteritidis
Infective Aneurysm of the Popliteal Artery Due to Salmonella Enteritidis Bernard Habozit, MD, Jean-Pierre Cressens, MD, Jean-Marc Battistelli,
MD,
Chamb~ry, France
Infected aneurysms of the popliteal artery are rare and Salmonella enteritidis infection in this site has not been previously reported. In the case reported herein, septic thrombophlebitis was found to be in contact with the aneurysm. Preoperative diagnosis was made through arteriography, computed tomographic (CT) scan, and positive blood cultures. The infected aneurysm was treated by resection without any reconstruction while phlebitis was treated by thrombectomy. Appropriate antibiotic therapy was administered. The patient made an uneventful recovery. (Ann Vasc Surg 1992; 6:000--000). KEY WORDS: Popliteal artery; aneurysm; arterial infection; Salmonella enteritidis; septic phlebitis.
Infected a n e u r y s m s of the popliteal artery are rare. In 1990, GoEau-Brissonni6re and associates [1] found only 14 indisputable cases of infected popliteal a n e u r y s m s in the literature. Our observation is the first case published in association with Salmonella enteritidis. The originality of our observation lies in the fact that septic thrombophlebitis was found to be in contact with the aneurysm.
CASE REPORT A 63-year-old man, with no prior lower limb arterial disease, sought medical advice for violent pain in his right knee associated with complete functional impotence. Three days before the patient's body temperature had oscillated between 38° and 39.5 ° C and he had experienced rigor. Three blood cultures were positive for Salmonella enteritidis. Clinically, the knee was warm, and a large nonpulsatile painful mass was palpated in the right popliteal fossa. Two days prior to hospitalization, the patient experienced subacute ischemia of his right foot associated with abolition of peripheral pulses and distal edema. Plain films of the knee were normal.
From the Clinique Chirurgicale, Chamb~ry, France. Reprint requests: B. Habozit, MD, Clinique Chirurgicale, 306 boulevard Massenet, Chamb~ry, France.
Sonography showed a 44 mm diameter mass in the right popliteal fossa, centered on the popliteal vessels. Sonography also showed that the popliteal artery was occluded. The popliteal and sural veins were thrombosed. Arteriograms showed extended obliteration between the end of the superficial femoral artery and the leg arteries (Fig. 1). The tibial arteries were reinjected just distal to their origin. The peroneal artery was thrombosed. All visualized arteries were free of atheroma. Computed tomographic (CT) scan of the knee showed that the popliteal artery was thrombosed and that there was intensive cellulitis with thrombophlebitis of the adjacent vein in contact with the aneurysm (Fig. 2). Echocardiogram was normal. This patient had been treated one month before for intestinal salmonella with amoxicillin, 2 grams per day for 10 days. The patient's history revealed splenectomy followed by radiation therapy for Hodgkin's disease in 1975, cholecystectomy in 1977, and gastrectomy for carcinoma in 1988. As there were no signs of ischemia, amoxicillin was given intravenously (2 g/day) for three days before operation. Through a posterior approach, the aneurysm, which was in fact ruptured and thrombosed, was resected. In addition to arterial resection, venous thrombectomy was performed. The wound was irrigated for 48 hours. The cultures of the different specimens (thrombosis and arterial wall) grew for Salmonella enteritidis, Pathohistological examination confirmed that lesions were necrotic suppurated arteritis without atheroma.
464
VOLUME 6 N o 5 - 1992
INFECTIVE A N E U R YSM OF THE POPLITEAL A R T E R Y
Fig. 1. Femoral arteriogram: femoropopliteal obliteration of otherwise healthy arteries.
The patient's postoperative course was uneventful. Amoxicillin was continued for 60 days. Long-term anticoagulant therapy was prescribed. At 30 months, the popliteal vein has remained patent and arterial claudication has disappeared progressively.
DISCUSSION Infected aneurysms of the poptiteal artery are rare, as they represent 1 to 2% of all popliteal aneurysms [2]. In 1990, Go~au-Brissonni~re and associates [1] found 14 observations documented in the literature to which they added their case. In 1985, Brown and colleagues [3] found a 15% salmonella infection rate in 194 infected aneurysms with positive bacteriologic findings. Salmonella represented the principal cause of infected aneurysm before 1965 (38%). Presently, infected aneurysms are most often traumatic in origin (51%) and the most frequently encountered germs are Staphylococcus (30%), Salmonella, and Streptococcus (10% each). Higgins and coworkers [4] underscored that the arterial wall was more sensitive to Salmonella when the patient was over 50 years old or when
465
Fig. 2. Enhanced CT scan of knee showing thrombosed aneurysm of popliteal artery (44 mm in diameter), contained within intensive cellulitis.
there was comorbidity (carcinoma, diabetes mellitus, immunosuppression). Infected aneurysms due to Salmonella are the consequence of septicemia or bacteremia, whose origin is extracardiac (i.e., alimentary or biliary tract). Salmonella infestation is often associated with brief bacteremia in the aged and there is generally a long interval before the constitution of arterial infected lesions [5]. Blum and Keefer [6] introduced the concept of cryptogenic infected aneurysms which occasionally develop in the absence of local or distant infection, as opposed to infected aneurysm due to septic embolism. Patel and Johnston [7] described four mechanisms of infection of the arterial wall: septic embolism, suprainfection of an atheromatous lesion, infection by septic contact, and direct trauma. Dean and associates [8] reported the case of postendocarditic infected aneurysms with multiple localizations. Barthel and colleagues [9] observed a patient with infected aneurysms due to Salmonella in the right femoral and then, three months later, in the left iliac artery. The usual clinical findings in infected popliteal aneurysms are fever, pain, and the palpation of the
466
INFECTIVE A N E U R YSM OF THE POPLITEAL ARTER Y
aneurysm. The aneurysm can be thrombosed (as in our case) or compressed by perivascular abscess, leading to ischemia of variable degrees. The diagnosis can be made by sonography, CT scan and arteriograms. Antecedent gastroenteritis and positive blood cultures can provide identification of the bacterial agent responsible for infected popliteal aneurysms, as in our observation. On the other hand, bacteriologic diagnosis of infected popliteal aneurysms due to Salmonella is impossible in the absence of formal evidence of Salmonella infection or if the blood cultures remain negative. When Salmonella is found in operative specimens, only 76% of blood cultures will be positive [3]. Antibiotic treatment must be initiated as soon as the diagnosis of infected aneurysm of the popliteal artery is envisaged. Large spectrum antibiotics must be given when no precise bacterial agent is known, whereas it should be specific when Salmonella infection has been isolated. Specific antibiotics include the aminopenicillins, chloramphenicol or the association of trimethoprim/sulfamethoxazole. Antibiotic therapy should precede and then follow the operative procedure and be maintained for at least six weeks [8]. Repeated infection should suggest a new localization of infected aneurysms. Iterative infected aneurysms can be promoted by antibiotic therapy which is too short or by incomplete resection of infected tissues. Cholecystectomy has been proposed after the cure of infected aneurysms of the abdominal aorta due to Salmonella [10]. Barthel and coworkers performed cholecystectomy after a second localization was found [9]. Surgery is the only radical treatment of infected aneurysms of the popliteal artery. Even though nearly 50% of infected popliteal aneurysms rupture before operation, emergency operative treatment has never been reported in the literature [1]. The popliteal artery is best approached posteriorly so that all the infected tissues may be resected. Bacterial examination of lesions can show the responsible germ, as in our observation, or, to the contrary, remain negative if preoperative treatment has been long and adapted. Histological examination shows infection of the arterial wall and possible associated atheromatous lesions. An associated revascularization procedure is not always required. A vein bypass can be performed in a noncontaminated area prior to the septic procedure. Most often, revascularization is made in situ, as in seven of 14
nun
AYNALS OV VASCULAR SURGERY
observations culled by Go~au-Brissoni6re and associates [1]. Even though two synthetic bypasses have been used without any complication [11,12], a vein autograft seems preferable. Only one other observation of infected popliteal aneurysms associated with phlebitis has been reported in the literature [13]. In this case infected popliteal aneurysm was due to S t a p h y l o c o c c u s aureus and was complicated by septic arthritis of the first toe and purpura of the leg and foot. The prevention of arterial involvement during alimentary tract infection is a debatable subject. The risk of arterial involvement is rare before the age of 50 [14], but routine antibiotic therapy after 50 is controversial. Winocour and coworkers [5] advocated antibiotic therapy in patients over 60, with atherosclerosis and positive blood cultures.
REFERENCES 1. GOEAU-BRISSONNIERE O, HARDY C, RENIER JF, et al. Le traitement chirurgical des an6vrysmes infectieux de l'art~re poplit6e. J Chir 1990;127:223-22@ 2. BONDS JW, FABIAN TC. Surgical treatment of mycotic popliteal artery aneurysm: a case report and review of the literature. Surgery 1985;98:979-982. 3. BROWN SL, BUSUTTIL RW, BAKER JD, et al. Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984;4:541-547. 4. HIGGINS GA, SANDIFORD JA, BLAIR WC. Remote Salmonella infections. World J Surg 1982;6:236-240. 5. WINOCOUR PH, WILLIAMS GR, BOYD JF, et al. Septic arteritis complicating salmonellosis. Br Med J 1983 ;287:972975. 6. BLUM L, KEEFER EBC. Cryptogenic mycotic aneurysm. Ann Surg 1962;155:398-405. 7. PATEL S, JOHNSTON KW. Classification and management of mycotic aneurysms. Surg Gynecol Obstet 1977;144: 691-694. 8. DEAN RH, MEACHAM PW, WEAVER FA, et al. Mycotic embolism and embolomycotic aneurysms: neglected lessons of the past. Ann Surg 1986;204:300-307. 9. BARTHEL J, BOSSCHAERTS T, LOCUFIER JL, et al. Andvrysmes infectieux successifs au cours d'une salmonellose. Ann Chir Vasc 1988;2:79-81. 10. CONNOLLY JF, KWAN JH, Mc CART PM, et al. Aortoenteric fistula. Ann Surg 1981;194:402-412. 11. NABSETH DC, DETERLING RA. Surgical management of mycotic aneurysms. Surgery 1961;50:347-353. 12. PRIOLET B, FOURCADE N, BASHOUR G, et al. Andvrysme poplit6 rompu/i Listeria monocytogenes. J Mal Vasc 1988;13:55-56. 13. MERRY M, DUNN J, WEISMANN R, et al. Popliteal mycotic aneurysm presenting as septic arthritis and purpura. JAMA 1972;221:58-59. 14. COHEN PS, O'BRfEN TF, SCHOENBAUM SC~ et al. The risk of endothelial infection in adults with salmonella bacteremia. Ann Intern Med 1978;89:931-932.
MD,
Chamb~ry, France
Infected aneurysms of the popliteal artery are rare and Salmonella enteritidis infection in this site has not been previously reported. In the case reported herein, septic thrombophlebitis was found to be in contact with the aneurysm. Preoperative diagnosis was made through arteriography, computed tomographic (CT) scan, and positive blood cultures. The infected aneurysm was treated by resection without any reconstruction while phlebitis was treated by thrombectomy. Appropriate antibiotic therapy was administered. The patient made an uneventful recovery. (Ann Vasc Surg 1992; 6:000--000). KEY WORDS: Popliteal artery; aneurysm; arterial infection; Salmonella enteritidis; septic phlebitis.
Infected a n e u r y s m s of the popliteal artery are rare. In 1990, GoEau-Brissonni6re and associates [1] found only 14 indisputable cases of infected popliteal a n e u r y s m s in the literature. Our observation is the first case published in association with Salmonella enteritidis. The originality of our observation lies in the fact that septic thrombophlebitis was found to be in contact with the aneurysm.
CASE REPORT A 63-year-old man, with no prior lower limb arterial disease, sought medical advice for violent pain in his right knee associated with complete functional impotence. Three days before the patient's body temperature had oscillated between 38° and 39.5 ° C and he had experienced rigor. Three blood cultures were positive for Salmonella enteritidis. Clinically, the knee was warm, and a large nonpulsatile painful mass was palpated in the right popliteal fossa. Two days prior to hospitalization, the patient experienced subacute ischemia of his right foot associated with abolition of peripheral pulses and distal edema. Plain films of the knee were normal.
From the Clinique Chirurgicale, Chamb~ry, France. Reprint requests: B. Habozit, MD, Clinique Chirurgicale, 306 boulevard Massenet, Chamb~ry, France.
Sonography showed a 44 mm diameter mass in the right popliteal fossa, centered on the popliteal vessels. Sonography also showed that the popliteal artery was occluded. The popliteal and sural veins were thrombosed. Arteriograms showed extended obliteration between the end of the superficial femoral artery and the leg arteries (Fig. 1). The tibial arteries were reinjected just distal to their origin. The peroneal artery was thrombosed. All visualized arteries were free of atheroma. Computed tomographic (CT) scan of the knee showed that the popliteal artery was thrombosed and that there was intensive cellulitis with thrombophlebitis of the adjacent vein in contact with the aneurysm (Fig. 2). Echocardiogram was normal. This patient had been treated one month before for intestinal salmonella with amoxicillin, 2 grams per day for 10 days. The patient's history revealed splenectomy followed by radiation therapy for Hodgkin's disease in 1975, cholecystectomy in 1977, and gastrectomy for carcinoma in 1988. As there were no signs of ischemia, amoxicillin was given intravenously (2 g/day) for three days before operation. Through a posterior approach, the aneurysm, which was in fact ruptured and thrombosed, was resected. In addition to arterial resection, venous thrombectomy was performed. The wound was irrigated for 48 hours. The cultures of the different specimens (thrombosis and arterial wall) grew for Salmonella enteritidis, Pathohistological examination confirmed that lesions were necrotic suppurated arteritis without atheroma.
464
VOLUME 6 N o 5 - 1992
INFECTIVE A N E U R YSM OF THE POPLITEAL A R T E R Y
Fig. 1. Femoral arteriogram: femoropopliteal obliteration of otherwise healthy arteries.
The patient's postoperative course was uneventful. Amoxicillin was continued for 60 days. Long-term anticoagulant therapy was prescribed. At 30 months, the popliteal vein has remained patent and arterial claudication has disappeared progressively.
DISCUSSION Infected aneurysms of the poptiteal artery are rare, as they represent 1 to 2% of all popliteal aneurysms [2]. In 1990, Go~au-Brissonni~re and associates [1] found 14 observations documented in the literature to which they added their case. In 1985, Brown and colleagues [3] found a 15% salmonella infection rate in 194 infected aneurysms with positive bacteriologic findings. Salmonella represented the principal cause of infected aneurysm before 1965 (38%). Presently, infected aneurysms are most often traumatic in origin (51%) and the most frequently encountered germs are Staphylococcus (30%), Salmonella, and Streptococcus (10% each). Higgins and coworkers [4] underscored that the arterial wall was more sensitive to Salmonella when the patient was over 50 years old or when
465
Fig. 2. Enhanced CT scan of knee showing thrombosed aneurysm of popliteal artery (44 mm in diameter), contained within intensive cellulitis.
there was comorbidity (carcinoma, diabetes mellitus, immunosuppression). Infected aneurysms due to Salmonella are the consequence of septicemia or bacteremia, whose origin is extracardiac (i.e., alimentary or biliary tract). Salmonella infestation is often associated with brief bacteremia in the aged and there is generally a long interval before the constitution of arterial infected lesions [5]. Blum and Keefer [6] introduced the concept of cryptogenic infected aneurysms which occasionally develop in the absence of local or distant infection, as opposed to infected aneurysm due to septic embolism. Patel and Johnston [7] described four mechanisms of infection of the arterial wall: septic embolism, suprainfection of an atheromatous lesion, infection by septic contact, and direct trauma. Dean and associates [8] reported the case of postendocarditic infected aneurysms with multiple localizations. Barthel and colleagues [9] observed a patient with infected aneurysms due to Salmonella in the right femoral and then, three months later, in the left iliac artery. The usual clinical findings in infected popliteal aneurysms are fever, pain, and the palpation of the
466
INFECTIVE A N E U R YSM OF THE POPLITEAL ARTER Y
aneurysm. The aneurysm can be thrombosed (as in our case) or compressed by perivascular abscess, leading to ischemia of variable degrees. The diagnosis can be made by sonography, CT scan and arteriograms. Antecedent gastroenteritis and positive blood cultures can provide identification of the bacterial agent responsible for infected popliteal aneurysms, as in our observation. On the other hand, bacteriologic diagnosis of infected popliteal aneurysms due to Salmonella is impossible in the absence of formal evidence of Salmonella infection or if the blood cultures remain negative. When Salmonella is found in operative specimens, only 76% of blood cultures will be positive [3]. Antibiotic treatment must be initiated as soon as the diagnosis of infected aneurysm of the popliteal artery is envisaged. Large spectrum antibiotics must be given when no precise bacterial agent is known, whereas it should be specific when Salmonella infection has been isolated. Specific antibiotics include the aminopenicillins, chloramphenicol or the association of trimethoprim/sulfamethoxazole. Antibiotic therapy should precede and then follow the operative procedure and be maintained for at least six weeks [8]. Repeated infection should suggest a new localization of infected aneurysms. Iterative infected aneurysms can be promoted by antibiotic therapy which is too short or by incomplete resection of infected tissues. Cholecystectomy has been proposed after the cure of infected aneurysms of the abdominal aorta due to Salmonella [10]. Barthel and coworkers performed cholecystectomy after a second localization was found [9]. Surgery is the only radical treatment of infected aneurysms of the popliteal artery. Even though nearly 50% of infected popliteal aneurysms rupture before operation, emergency operative treatment has never been reported in the literature [1]. The popliteal artery is best approached posteriorly so that all the infected tissues may be resected. Bacterial examination of lesions can show the responsible germ, as in our observation, or, to the contrary, remain negative if preoperative treatment has been long and adapted. Histological examination shows infection of the arterial wall and possible associated atheromatous lesions. An associated revascularization procedure is not always required. A vein bypass can be performed in a noncontaminated area prior to the septic procedure. Most often, revascularization is made in situ, as in seven of 14
nun
AYNALS OV VASCULAR SURGERY
observations culled by Go~au-Brissoni6re and associates [1]. Even though two synthetic bypasses have been used without any complication [11,12], a vein autograft seems preferable. Only one other observation of infected popliteal aneurysms associated with phlebitis has been reported in the literature [13]. In this case infected popliteal aneurysm was due to S t a p h y l o c o c c u s aureus and was complicated by septic arthritis of the first toe and purpura of the leg and foot. The prevention of arterial involvement during alimentary tract infection is a debatable subject. The risk of arterial involvement is rare before the age of 50 [14], but routine antibiotic therapy after 50 is controversial. Winocour and coworkers [5] advocated antibiotic therapy in patients over 60, with atherosclerosis and positive blood cultures.
REFERENCES 1. GOEAU-BRISSONNIERE O, HARDY C, RENIER JF, et al. Le traitement chirurgical des an6vrysmes infectieux de l'art~re poplit6e. J Chir 1990;127:223-22@ 2. BONDS JW, FABIAN TC. Surgical treatment of mycotic popliteal artery aneurysm: a case report and review of the literature. Surgery 1985;98:979-982. 3. BROWN SL, BUSUTTIL RW, BAKER JD, et al. Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984;4:541-547. 4. HIGGINS GA, SANDIFORD JA, BLAIR WC. Remote Salmonella infections. World J Surg 1982;6:236-240. 5. WINOCOUR PH, WILLIAMS GR, BOYD JF, et al. Septic arteritis complicating salmonellosis. Br Med J 1983 ;287:972975. 6. BLUM L, KEEFER EBC. Cryptogenic mycotic aneurysm. Ann Surg 1962;155:398-405. 7. PATEL S, JOHNSTON KW. Classification and management of mycotic aneurysms. Surg Gynecol Obstet 1977;144: 691-694. 8. DEAN RH, MEACHAM PW, WEAVER FA, et al. Mycotic embolism and embolomycotic aneurysms: neglected lessons of the past. Ann Surg 1986;204:300-307. 9. BARTHEL J, BOSSCHAERTS T, LOCUFIER JL, et al. Andvrysmes infectieux successifs au cours d'une salmonellose. Ann Chir Vasc 1988;2:79-81. 10. CONNOLLY JF, KWAN JH, Mc CART PM, et al. Aortoenteric fistula. Ann Surg 1981;194:402-412. 11. NABSETH DC, DETERLING RA. Surgical management of mycotic aneurysms. Surgery 1961;50:347-353. 12. PRIOLET B, FOURCADE N, BASHOUR G, et al. Andvrysme poplit6 rompu/i Listeria monocytogenes. J Mal Vasc 1988;13:55-56. 13. MERRY M, DUNN J, WEISMANN R, et al. Popliteal mycotic aneurysm presenting as septic arthritis and purpura. JAMA 1972;221:58-59. 14. COHEN PS, O'BRfEN TF, SCHOENBAUM SC~ et al. The risk of endothelial infection in adults with salmonella bacteremia. Ann Intern Med 1978;89:931-932.