Aortotomy site infections: case presentation and review of the literature

Case Report Aortotomy site infections: case presentation and review of the literature JOHN MIDDLETON, M.D HERMAN CHMEL, M.D. FLOR TECSON, M.D. JASBIR S. SARKARIA, M.D. WILLIAM E. NEVILLE, M.D.

ABSTRACT: A patient with Aspergillus fumigatus infection involving an aortotomy site with multiple peripheral emboli following implantation of an aortic valve prosthesis for rheumatic heart disease is described. Eleven aortotomy site infections are reviewed from the literature. Eight cases were caused by fungi with Aspergillus sp accounting for four cases. Presenting symptoms were nondiagnostic and multiple. However, the diagnosis of aortotomy site infection should be entertained in patients who have had aortic valve surgery who develop fever and embolic phenomena with or without positive blood cultures coupled with no evidence of valve dysfunction, and who respond inappropriately to antibiotic therapy. Ten of the 11 patients reviewed from the literature died. Therapy should be directed at early recognition followed by prompt early surgery combined with the use of proper antimicrobial agents directed against the isolated microorganism. KEY INDEXING TERMS Aspergillus fumigatus infection

Aortotomy infections

Fungal infections due to Aspergillus

The infectious complications following prosthetic heart valve replacement usually arise on the prosthesis or within the surgical wound. In prosthetic valve endocarditis, bacteria, esspecially Staphylococcus sp, are most often implicated although fungi such as Candida sp and Aspergillus sp may be encountered. I ,2 Local wound infections are usually limited to the sternotomy or thoracotomy incision and are due to Staphylococcus sp, gram-negative bacilli and, rarely, fungi. 3,.1

Fungal endovascular infection

Aortotomy site infections are infrequently encountered. 5- 15 In this report, we describe a patient with a prosthetic aortic valve who initially developed clinical evidence compatible with an Aspergillus Jumigatus endocarditis with a negative echocardiogram and negative precipitin tests for antibody to Aspergillus sp. The patient was found at surgery to have an aortotomy site infection. The clinical, laboratory and operative findings as well as therajJy of aortotomy site

From the Infectious Disease Section. Medical Service and Thoracic Surgery Service. Veterans Administration Medical Center. East Orange. Nell' Jersey and Departments of Medicine and Preventive J\1edicine and Cardiothoracic Surgery. College of Medicine and Dentistry of Nell' Jersey. Nell' Jersey Medical School. Nell'ark. Nell' Jersey 07103. Requests for reprints should be addressed to Herman Clullel. lvl. D .• Infectious Disease Section. Medical Service (III). Veterans Administration Medical Center. East Orange. Nell' Jersey 07019. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES

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TABLE I

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CHARACTERISTICS OF AORTOTOMY SITE INFECTIONS

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Case Number (Year) I (1960)

2 (1962) 3 (1965)

4 (1967)

5 (1969)

Age

Sex

25

M

39 18

26

46

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Surgery Resected congenital subaortic tissue Aortic valvuloplasty Aortic valvulotomy

Prosthetic aortic valve replacement

Prosthetic aortic valve replacement

Symptoms Fever & emboli Fever & emboli Emboli & fever

Fever & emboli

Fever

Time Interval to Onset of Symptoms 60 days

8-11 mos 18 mos

15-37 days

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Organism Aspergillus fumigatus Candida albicans

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50

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Prosthetic aortic valve replacement

chest pain

4-7 mos

9

Antemortem aortography showed saccular aneurysm ascending aorta; expired in operating room; postmortem showed normal valve with disruption of aortotomy suture line

10

Aspergillus navis

Antemortem diagnosis from culture popliteal artery embolus as endocarditis; postmortem showed saccular aneurysm ascending aorta at aortotomy site

II

Sarcina lutea

Diagnosis of endocarditis was made; also I month after therapy, blood cultures still positive, a diagnosis

12

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infections are discussed and compared with prior reports from the literature. Case Report

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A 49-year-old black male was admitted to the Veterans Administration Hospital in East Orange, New Jersey, with recurrent femoral emboli in July 1976. Past history was significant for chronic rheumatic heart disease, aortic stenosis and insufficiency with congestive heart failure, anginal syndrome and syncope requiring an aortic valve prosthesis in February 1976. Postoperatively the patient was discharged from the hospital on digoxin and anticoagulant therapy. He did well until May 28, 1976, when he was admitted for a right femoral embolus which was removed surgically. During this admission, the patient was evaluated with numerous blood cultures, which were negative, as well as with an echocardiogram. The patient was discharged from the hospital June 26, 1976, doing well. On July 10, 1976, the patient was readmitted with pain, numbness and coldness involving the right lower extremity. A femoral arteriogram demonstrated occlusion of the right superficial femoral artery just above the knee. The patient was taken to surgery, and two pieces of grayish material were removed from the artery. H istologic examination of the material revealed a fungus which subsequently on culture grew Aspergillusjumigalus. On July 12, the patient had another embolus to the right femoral artery which was also removed. Postoperatively, the patient was doing well until July 26, 1976, when he complained of numbness, pain and coldness in both lower extremities. Physical examination revealed a thin black male in acute distress with a temperature of 100 F, pulse of 100 beats per minute and blood pressure of 100/70 mm Hg. Positive physical findings were confined to the lower extremities where no pulses were felt below the femoral arteries. Laboratory data included a white blood cell count of 23,300 cells per mm 1 with 90% polymorphonuclear leukocytes and 10% lymphocytes. All other laboratory data were within normal limits. An emergency left axillary aortofemoral arteriogram was performed which revealed complete occlusion of both external iliac arteries. A repeat echocardiogram was normal, and the patient was taken to surgery where a large thrombus was' evacuated from the distal aorta. Postoperatively, the patient was started on amphotericin B therapy. Culture and histologic examination revealed A jumigalus. On July 30, 1976, the patient was returned to the operating room for emergency replacement of his prosthetic heart valve. At surgery, the aortic valve prosthesis was entirely free of vegetation. On opening the aorta, vegetations were found along the suture line of the previous aortotomy inside the aortic lumen. The vegetations were removed and the operative site closed. Postoperatively, the patient deteriorated and expired on July 30, 1976. No postmortem was obtained. Precipitating antibody for Aspergillus sp was negative

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CASE REPORT: ENDOVASCULAR INFECTION WITH ASPERGILLUS FUMIGATUS

on three separate occasions as well as in numerous blood cultures.

Discussion Aortotomy site infections are reported infrequently. H5 Table I lists some of the clinical characteristics of aortotomy site infections reported in the literature. Most infections occur in patients who have had either a prosthetic aortic valve inserted or an aortic valvuloplasty. The interval of time between surgery and the diagnosis varies from one day to 18 months, with most occurring after four months. Patients usually presented with fever and signs of peripheral embolization suggesting endocarditis as was seen in the patient described above. Occasionally recurrent chest pain was the only manifestation. 16 The diagnosis was usually made at necroscopy. The microorganisms responsible for aortotomy site infections fall into two groups; that is, those caused by bacteria and those by fungi. The bacteria include Serratia sp, Sarcina lutea and Listeria monocytogenes. The fungi most often recovered include Candida sp, Mucor sp and Aspergillus sp. All of the microorganisms may be considered opportunists and usually establish themselves when a patient is compromised. Cultures of blood may be positive when bacteria or yeast are the responsible agent. However, blood cultures are usually sterile in patients with Aspergillus or Mucor infections, as was seen in the patient described above. The source of bacteremia or fungemia in patients who have had open heart surgery can be difficult to determine. Sande et al 16 suggested a method of differentiating sustained bacteremia in patients with prosthetic heart valves from other causes. If infection (bacteremia) occurred 60 days after prosthetic valve surgery, the prosthesis was most likely infected. Bacteremia occurring earlier was associated with extravalvular infection. This observation can be useful when considering patients who have aortotomy site infections due to bacteria. Early "sustained bacteremia" without evidence of prosthesis malfunction should direct the physician's attention toward lOS

further studies in considering aoriotomy site infection. These other studies would include the use of (I) aortography looking for an aneurysm at the prior aortotomy site and (2) phonocardiography, echo cardiography or fluoroscopy to exclude prosthetic valve dysfunction and endocarditis. The patient described in this report had an aortotomy site infection due to Aspergillus fumigatus. Aspergillus sp are ubiquitous in nature and have a low pathogenicity for a normal individual. They reproduce vegetatively, spread through the air in spore form and are found near decaying material. The organism is considered an opportunistic pathogen. These microorganisms as well as others gain access to the circulatory system usually at the time of surgery, either proliferate on the prosthesis, at the prosthesis suture line or at the aortotomy suture site. Gage et al 17 demonstrated the isolation of A fumigatus from the ventilation system in the operating .room as the source of Aspergillus endocarditis. Burton et ails found A fundgatus spores contaminating the air ducts leading to an isolation room in which renal transplant patients apparently had acquired aspergillosis. At the time the presently described patient had his initial surgery in February 1976, the floor where the surgical operating rooms are located was undergoing active construction, suggesting the possibility that Aspergillus may have gained entrance through the air and become implanted in the patient. Other investigators have attempted to correlate infection with the use of antimicrobial agents or corticosteroids without success. 19 Most authors feel that Aspergillus sp and probably other fungi gain access at the time of surgery, but why the incidence of infection is so low and sporadic has not been fully elucidated. 1-2,19 Overall aortotomy site infections are usually fatal because of delayed recognition. Therapy should be directed at early recognition, surgery and use of appropriate antimicrobial antibiotics. As in the case of fungal endocarditis, one should consider the diagnosis of fungal aortotomy site infection when MARCH / APRIL 19S0 VOLUME 279 NUMBER 2

MIDDLETON ET AL

the patient has had the following: (1) aortic valve surgery; (2) fever and evidence of embolization to major vessels, particularly the lower extremities; (3) sterile blood cultures; (4) failure to respond to empirical antibiotic therapy; (5) negative echocardiogram in the face of large peripheral emboli; (6) no evidence of valve dysfunction as evaluated by phonocardiogram or fluoroscopy; and (7) demonstration by aortic arch angiography of a mycotic aneurysm. Bacterial aortotomy site infection should also be considered when the aforementioned conditions are present although blood cultures are always positive and the patient usually responds to antibiotic therapy even though relapses may occur during or at cessation of specific antibiotic therapy. In summary, aortotomy site infections are an overwhelmingly lethal disease. The presenting symptoms are mUltiple and nondiagnostic. However, the appearance of embolic phenomena with or without positive blood cultures and inappropriate response to antibiotic therapy coupled with a negative echocardiogram of the suspect valve and no evidence of valve dysfunction should suggest the diagnosis. Blood cultures by themselves and/or serologic tests, when available for fungi, appear to be of little value in the diagnosis of aortotomy site infections. Combined early surgical and medical therapy is the hallmark in the treatment of aortotomy site infections due to fungi or bacteria. Acknowledgments We thank Donald Armstrong, M.D., for performing the Aspergillus serology at Memorial Sloan Kettering Cancer Center, New York, New York, and Miss MaryLouise Ponzio for secretarial assistance. This work was supported in part by General Medical Research Funds from the Veterans Administration Medical Center, East Orange, New Jersey.

References . 1. Harford CG: Post-operative fungal endocarditis:

Fungemia, embolism and therapy. Arch Intern Med 134: 116-120, 1974.

2. Petheram IS, Seal RM: Aspergillus prosthetic valve endocarditis. Thorax 31 :380-390, 1976. 3. Chmel H, Grieco MH, Zickel R: Candida osteomyelitis: Report of a case. Am J Med Sci 266:299304, 1973. 4. Sanfelippo PM, Danielson G K: Complications associated with median sternotomy. J Thorac Cardiovasc Surg 63:419-423, 1972. 5. Hadorn W: Aortenruptur durch Aspergillus Infektion nach Operation einer Aortenstenose. Endaortitis Polyposa Mycotica Schweiz Med Wxchr 90:929-934, 1960. 6. Sanger PW, Taylor RH, Robicsek F et al: Candida infection as a complication of heart surgery. JAMA 181:88-91, 1962. 7. Edelstein R, Katz SS, Forgacs J: Supra-valvular aortotomy infection: Caused by Listeria monocytogenes. masquerading as subacute bacterial endocarditis. Arch Intern Med 116:937-939, 1965. 8. Leffert RL, Hackett RL: Aspergillus aortitis following replacement of aortic valve. J Thorac Cardiovasc Surg 53:866-874, 1967. 9. Marsten JL, Freenberg JJ, Piccinini JC et al: Aortit is due to Candida stellatoidea developing in a supravalvular suture line. Ann Thorac Surg 7: 134138, 1969. 10. Raimer WG, Liggett MS, Quianzon EP: Infected aortotomy due to Mucor following aortic valve replacement. J Thorac Cardiovasc Surg 59:781-784, 1970. II. Malcolm AD, Bakerspigel A, Enriquz AA: Aspergillus flavus endaoritis following aortic valvotomy. Thorax 26:435-441, 1970. 12. Lopez GA, Dobell ARC: Mycotic aneurysm of ascending aorta due to Sarcina IlIIea. Ann Thorac Surg 13:607-611, 1972. 13. Garfein OB, Buckley MJ, Kurland GS: Postaortotomy mycotic pseudoaneurysm. JAMA 225: 410-411, 1973. 14. Meyers BR, Shah R, Lefkiwitz M: Mycotic aneurysm of the ascending aorta secondary to Serratia infection: Differentiation from prosthetic valve endocarditis. Chest 65:215-217, 1974. 15. Irvin RG, Sade RM: Endocarditis and musculoskeletal manifestations. Ann Intern Med 88:578, 1978: 16. Sande MA, Johnson WD, Hood EW et al: Sustained bacteremia in patients with prosthetic cardiac valves. N Engl J Med 286: 1067-1070, 1972. 17. Gage AA, Dean DC, Schimert G et al: Aspergillus infection after cardiac surgery. Arch Surg 101:384387, 1970. 18. Burton JR, Zachery JB, Bessin R et al: Aspergillosis in four renal transplant recipients. Ann Intern Med 77:383-388, 1972. 19. Kammer RB, Utz JP: Aspergillus species endocarditis. Am J Mcd 56:506-521, 1974.

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