Mycotic aneurysm and endocarditis

Case Reports Mycotic Aneurysm and Endocarditis Two Uncommon Complications of Salmonella Infection in the Same Patient* JAMES R . TILLOrSON,

Mm . and A .

MARTIN LERNER,

tin .

Detroit, Michigan

manifestation of infections due to various species of salmonella are diverse . 1 . 2 t)f these . endocarditis and my-cotic aneurvsms are among the least cononon . s,a Lnlike bacterial endocarditis due to other or,ganisnrs, endocarditis and a peripheral utvcotic aneury'snr have not been reported previously in the same paticnt .i' Here, we record such a case in a 53 year old titan with apparent recovery after surgical excision of the infected fer oral aneuryten and parenteral therapy with ampicillin I,,Pohcillin N'"-) .

T

bowel sounds, and a firm, nontender liver which extended 4 cm . below the right costal margin were also noted . The spleen was not palpable . and there was no tenderness at the eostovertebral angle. A 3 car ., tender, pulsating mass was present in the' mid-region of the left thigh . 'I here was a systolic bruit directly over the mass . Popliteal and pedal pulses were diminished on the left as were superficial pain and touch in the left leg and foot . Laboratory Truthnec : The hemoglobin teas 11 .3 gm . hetnatoerit . 35 vol .""' : white blond cells, 4 .650, rams blood urea nitrogen . 9 mg ./100 ml . ; creati: plasma sugar . I ') mg 100, . nine, 1 .4 ntg ./1010 ml ml. ; serum, amylase, 200 Russell unit ; alkaline phosphatasc, 7 .2 Bodanski traits ; s(mua alutamic oxalacetie traosaminase, 130 Sigma-Franklr' units ; bilirnbin . 1 .2 mg 100 ml . ; scrum albumin . 32 got . 100 ml . ; and globulin . ? .9 gm 1101 in[, I he prothrmnbin tittle was 15 .0 seconds icontrol. 13 .8 se( .) ; serum calcium, 3 .6 m Ey .IL . ;nonnal_ 4.35 .5) ; serum phosphorus . 3.4 [1 1g, 1(1(1 uul .' and the venereal disease research laboratory test lot syphilis was nonreactive. . A urine specimen showed I plus alhuminuria . 3 to 4 white blood cells and marry red blood cells per high power field . A few gram-negative rods were seen on stained sediment of the urine, but, _mforrunatelv, a culture was tot obtained at this time . 'I'hree blood cultures were negative, and a throat culuure revealed normal flora . M elect roeardiogtan showed depression of the 5-I' segmenis in leads \'1 through V,t . A left femoral arteriogrant demonsu ;nrd a patent aneurysm of the superficial femoral artery (Fig . 1) . An oral cholecystograin showed poor visualization and contraction after a fatty meal. Ruaugenograms of the chest and abdomen, an upper and a lower

Hr

er ;

CASTE RErotrr A 53 year old white man entered Detroit General Hospital for the first tine on Not . 11 . 1964 . He compluined of fever, anorexia . a recent 12 pound weight loss and a tender mass which had appeared in the left thigh three weeks earlier . Later he suddenly became ill with nausea, vomiting, diarrhea and bilateral lower abdominal pain . One week before admission, urinary frequency, urgency, dvsuria, not'turia and henraturia ensued . The patient was single . lived alone, was a heavy drinker and ate all of his meats in resumrants . He denied previous urinary symptoms, venereal disease, anemia, joint pains, tuberculosis, or known contacts with persons having this latter disease . Physical Iaaairnation : At admission he was well developed . moderately well nourished . and was perspiring profusely . His blood pressure was 140,'80 mm . Hg, pulse 88, respirations 18 . and temperature 100° F . by mouth . A grade 1 %6 mid-systolic ,murmur was heard at the left sternal border . Otherwise, examination indicated the heart was completely normal . Diffuse abdominal tenderness, hyperactive

v From the Detroit General Hospital and the Departments of Medicine, Microbiology and Pathology, \9aync State . niversity School of Medicine, Detroit, Mich . '['his study was aided by Grant 15 '1'1 AT 261-02) from the National Institutes of health, 8cthcsda . Md . I

vot .uME 18, at :GUS' 1966

267

2oR

Iillotxro and Lernr,

Fir, . 2 . N -c -ction ( X duced by f the wall of them, I feroor :d nrterv wal, pcriurt abscess and hose aneuo'vsut . I

. 13 . 1964) showFR: . 1 . Left femoral arteriogra,, (Nov iug iui :me t wares of du left superlii al feu-ur : I nrterv . gastrointestinal series, intravenous and retrograde pyelograms, and result' of c'ystoscnpy were normal . Clinical : Course A presumptive diagnosis of a urinary tract infection was made, and sulfamethoxazole was begun . After 3 .0 gm . were received . a urine culture showed <1 .000 colonies per milliliter . A remittent fever Continoecl with daily elevations to 102° F . On November 17, the spleen was felt for the first time, and six more blood cultures were obtained . Sulfamethoxazole was discontinued and penicillin G and streptomycin begun (40,000,000 units and 2 gin . daily, respectively) . Fever defervesecd within 36 hours . One of the blood cultures grew a species of Salmonella, later identified by the Michigan Department of Iiralth Laboratory at Lansing as Saimori1lu typhimuriton . Tests of sensitivity of this bacillus using antibiotic discs revealed chloramphenicol, ampicillin . kanamycin, colimycin, and demeThy lchlortetracycline to be effective . WFidal reactions were positive at 1 :20 and 1 :40 with Sal . paratyphi d and Sal . paratrphi B, respectively, but were negative with Sal . h~phnsa H and O . On --November 20, streptomycin was discontinued and chloramphenicol begun intravenously (2 gm /day) . Over the following 10 days the hemoglobin fell to gm ./100 ml . Purpura appeared (November 29) at which time a platelet count was 55,000/mm . •" 7,1

'I he white blood cell count and diticrential remained constant . Chloramphenicol was discontinued after 18 gm . had been administered intravenously . Within a week the platelet count returned to normal, and a retieulocvcosis f I I .5%) ensued . However, the hemoglobin and hematocrit did not increase, the former ranging from 6 .2 to 8 .1 gm . . 100 mL His blood urea nitrogen was 23 mg . 100 inl . and ranged front 19 to 28 throughout hospitalization . the erythrocyte sedimentation rate remained persistently elevated (>10(1 an ., he., Westergrcn), and albuminuria and microscopic hematuria continued . Ampicillin, 250 ing . orally every six hums with 0 .5 gin . probe necid with each tablet . was begun on December 1 and was continued for 21 days . During this time he felt well except for the tender mass and paresthesias of the left leg and thigh . Cultures of blood, urine . stool and sputum failed to yield salmonella organisms . Ampicillin was discontinued on December 21, at which time Sal . paratsphi .1 and B agglutinins were 1 : 40 . Five days later, fever, cough, pleuritic chest pain and anorexia appeared . the pain in the left anterior Thigh was more intense. Cardiac auscultation revealed a loud and widely split second pulmonic sound . but there were no other changes . On one occasion a pleural friction rub was heard . - Lire mass in the thigh was now larger and was no longer pudsatile ; a bruit was no longer heard . The popliteal and pedal pulses were no longer palpable . An infiltrate of the right upper lobe, demonstrated on the chest roentgenogram, was thought to be compatible with a pulmonary infircuon . Tm9 AMERICAN JOURNAL OF CARDIOLOGY

"-"s The first reported case"

'Vlvcofic Aneurt-sna and l' .nclocau'tlitis )n l)eccutber 26 frank congestive failure appeared . )cspnea :n 0 C orthopnea became marled . and a protodiastolic gallop as well as an apical presystolic . murmur which Hocwated in intensity- was heard I lie heart tea' enlarged ; the edge of the liver Lender. and there tea- edema of both ankles . 'Ihc spleen was not felt . n, electrocardiogram showed more ti T depression and I wave inversion . 'III( white blood cell count at this time was 10,950 cells inn'5 ,iIli 68 per cent polvurorphonuclear leukocytes- Ao histiocvIe s were seen on sinears of blood taken Gam the ear lobes . A 12 hour ereatinine clearance wa- 18 ml . : ruin . Multiple studies of liver function wcr, normal except that the htoinstilphalein retention was : per cent, and the serum albumin to globulin ratio was 4 .0 : :5 .3 . Agglutination titers were 1 :40 with l,,, . typhus bill had risen with Sal, pa'ottphi .1 and R to i 160 and 1 040, respectively . An aspilate of duadrnal contents and cultures of blood, stool and mine weir negative foi salmonella . :1 diagnosis of endocarditis due to Sal . tsphimarzmn was finally' made and parenteral ampieillin begun oil Dec . 30, 19t,} . Light grams of ampieillin daily were administered intramuscularly for six weeks (2 gm . every six hoot's with 0 .5 gm . of pmhenerid) . (I Ire patient improved dramatically and was afebrile in tlucc days . His clectrocaidiogra01 and chest ruentgenogranr turned toward normal . A Jell /rmoe
sot 'Mr . 18, At scsT 1966

bli oplc section IIIIll 'coal Iiiol :-v I tIdueed bs 2" -of 1'v h . 1, .196S t,ith toed glntileim ti.Id pr ro'ric-I iullanen :n ;on . : (.'.O V niIt5T5 Yeogcnic Courplications of salu,ouella inleetions arc much less common with Sal . f))-how than with other species . particularly prone to cause endocarditis, pneumonia, plnuisv and osteoutyelitis is Sal . ckolerae.su/s which accomited for 22 .3 per cent of the focal manifestations of 779 cases of sale h-mil the, Sew York Salmonella Center but was only 4 .6 per cent of the total nunther of cases .' On the other hand Sal . tt;biiimurium, the infecting type here, tvas responsible for 30- per cent of the total eases and 20 .4 per cent of the focal cotuplicalions in the New Fork series . Similar data hate been reported from elsewhere .°-` With the exception of species of Sahnondla and Staphylococcus, ntycotic aneurvsius occur predontinantis' in patients with endocarditis . Sepsis leading to infection of the yasa x-asorunt of an arteriosclerotic vessel wall with subsequent frank formation of an anenn,m, or infection of a clot in the lumen of a pre-existing arteriosclerotic aneurysm (especially with salmonella) are two common pathogenetic nrechanisnts of infected aneurysms,"-10 Ildvenlic aneur}sm.r caused by sabnonella rnjeclions have been documented in 26 cases in the English literature including the present one (Table t} .a=s •s (1943) was fit a 74 rear old man with an antn-n-sin of the abdominal aorta infected by Sal .

Tillolson and Lernei

270

'ABLE I

Reported Cases of Arterial Aneurysms Infected by Genus Sah o i,i Ila (lase

0'1'0u" .

Age & Sex

Year

Salmonella

74 M 68 F 74 M 69 M

1943 1945 1945 1945

nrlaporl aranleniirg

67 F

1953 1953 1954 1955 1956 1956 1956

typhimvriom choleraesuis

10 1 ' 11"

76 F 63 Nt 56 M 58 M 55 M 70 M

12 0 13" 14''

58 M 62 M 60 F

1936 1956 195 ,

pphvnvrium depleraerue:c

15" 16 2 17'° 18" 191"

61 M 64 F 53 M 61 M 63 M

1957 1957 1957 1957 1958

ehoheraeoeiv

Abdominal aorta aorta Abdominal aorta Abdominal aorta Abdominal aorta

+

sainipatd typhose dwlerarcuis "'fwd's

Thoracic

2020 21 21 22"

37 Nl 72 M 75 M

1959 1960 1961

dmlrraeruo

choleraecurt Group C-2

External iliac Abdominal aorta Abdominal aorta

+ + +

23"'

68 M

1962

Group D

AbdominaI aorta

24' 25' 26°

72 M 58 F 53 M

1962 1963 1964

lvph'marium cirnleraesvis

Femoral 'thoracic aorta Feruoral

&

Re6 ' 4 5"a

bra

'Fatal or M

Species of

ivphunurium Group B

rhaleraerrrie' Group C-1 lyphimuriam cholerae,ws

tvphin'urium

hole,aesuis

t4J'himvrium

64 (mean) 20 males

Artery 1r Valved

Pre-exist. Anent .

Abdominal aorta Femoral Abdominal aorta Abdoninal aorta

+ + +

Abdominal aorta Femoral Abdominal aorta Abdominal aorta Femoral Femoral Common iliac

Do, to SalwoneI .

+ + I-

Fanoral Femoral Abdominal aorta

Abdominal aorta ; 14 Thoracic aorta, 2 Femoral artery, 8 lilac artery, 2

-r

15/26

8 .26

e = present ease . AHD = artcriosclerotic heart disease ; :\nesr . _ .ureurysur ; Usteawv . = osteonryelitis ; Sabnonel . = Salmonella ; - = absent : and + = present . The awareness, incidence, or both, of this complication of arteriosclerotic aneurysms are increasing as evidenced by the fact that roost of the cases were published within the last 10 years (Table t) . 'I he average age of patients with mycotic aneurysos due to salmonella is 64 ; )nalc patients predominate 3 :1 . Pre-existing arteriosclerotic aneurysms were present in 15 . In . choleraesuis ; 10, the infecting organism was Sal seven, .Sal . typhirmeriam ; and in only I was the pathogen Sal . typliosa . The rest were due to various species of Salmonella .

newport.

These aneurysms were of the abdominal aorta (14 cases), femoral arteries (8 cases), and thoracic aorta and iliac arteries (2 cases each) . Chronic diseases consistent with the age of these patients were emnnron, such as diabetes mellitus (9 cases), gout (2), hypertension (2), carcinoma (2), central nervous system syphilis (2), alcoholism (2), pulmonary tuberculosis (1), chronic pyelonephritis (Aerohacier aerogenes) (1), icfractory anemia (1), and rheumatoid arthritis (1) . Five of these patients had decreased gastric acid secretion, a known factor predisposing to salmonella infections eh OsteonryeTAE AMERICAN JOURNAL OF CARDIOLOGY



D4ycotit'

Aneurysm and Endot'arditi,

?-1

IAPLY.I (CUnl77/bed)

C :aSc

Therapy Surgery

Ref.

Usher Associated Conditions

I" 2"

Ash ion ivdria, puInl . tuberculosis None Achlorhvdria . refractory anemia Diabetes

None Excision & ligntion None No,,,

Diabetes Rheumatoid artlnitis None None

None Excision & ligntion None Excision & graft

AlII) None Tabes dorsalis . chron . pyeloniph ., a lenhnliiin I lyperten . Ca . ofstornarlr 1liabetes

Excision & graft Excision & graft None

s" 4 12 5O1

6" 8 11 911 10 11 II" 12 , 13 9 14 17

15 17 GOUL . diabetes 163 Diabetes, ca . vulva 17" Cirrhosis 1811 Gout . diabetes 19 19 Non, 212 1

22® 23 17 24" 25 1 26'

Excision & graft Excision & gr .St None None None None Excision & graft Now,

t)utm,ne

Sulfonamide None Penicillin G Penicillin G, sulfonamide, streptomvcin Non, Penicillin C, chloramphenicol Chlorantphenieol 'Fetracvclinr, chloronphenicol, stropton,vcin None Chloralnphenical None

Dcath Death Death Deatl,

ChlaramphenicaI Non, Chloramphenicol,streptnInvein,titracycline None None Chloramphenieol None (7hloramphenieol, neomycin, nitrefurantoin, streptomycin Chloramphenicof Chloramphcnieol, tetracycline None

Recovery Recovery Death

i ivpochlorhydria None None Excision & gr ;tft 1iypertcn . .diabets,pogruyI None azotcmia Hvperten ., azotemia, aneur . thoracic None Chlesnmphenieol aorta Nlenmgovasenlar avphilis Excision & ligntion None Diabetes None None Alcoholism, endocard ., focal glonter- Excision & ligntion Penicillin . streptomycin, chloramaloneph . phenicol, ampicillin 11 :26

Death Recovery Death Death Recovery Recovery Ucath

Death Dc ash Death Death Death Recovers Death Depth Death Recovery Death Recovery 18%26 deaths

Pulnt . - pulmonary : chron- = chronic ; pyelonephr . = pvelonephritis ; hypertrn . = hypertension ; ca . - r .uriInellat e,ducard . = endocarditis,

litis of the lumbar vertebrae occurred in 7 thoracic or abdominal aorta . Rupture of these of the patients with mycotic aneurysms of the aortic aneurysms seems inevitable once inabdominal aorta . fection has occurred . Hope for recovery rests They usually had Icukocytosis as opposed to with suspicion in the mind of the attending the usual leukopenia of typhoid fever, and their physician, the use of appropriate antibiotics, fevers were generally higher .' Blood cultures and early surgery with replacement of the obtained during life in 21 cases revealed excised aortic wall by graft. Salmonella species in 15, but despite adminissThe incidence of endoearditis due to rarion.s spedes tration of antibioticst cultures of the aneurysm at of the genus calmone7la is about 0 .5 per cent"-`° surgery orpostmortentexaminationwereusually We could find reference to 21 previously well positive . described cases (Table it) . Endocaiditis due There were 18 deaths ; these included all of to salmonella and a mycotic aneurysm in the the patients with infected aneurysms of the same patient have been reported only once vol urn . 18 . soous'r 1066



272

'I

Reported Cases

It

illotson and Lerner

'FAHI.i . u Lodnr :uditis Due m Members of the Genus Sulmonellu

Age & Sex

Year

1"--'

50 M

1936

!)phunurtvrn

Mitral valve

22'

36 M

1937

fvvalvpht 13

Aortic & mitral calcs

14hemnatie heart ( RHD ) ItHI)

3P 1 42 0 520 6 21

47 M 31 M 49 F 58 F

1937 1937 1939 1940

oho/eroeruu

Right atrium, left ventricle Mitral valve Aortic valve Mitral valve

Ludic RHD None RHD

. . M 19 F 59 M

1945 1946 1946

fayed

Aortic valve Mitral valve Left atrium, aortic valve

I lFt° I ld 0

56 F 44 F

1947 1950

Able, nrorrienbarg

Left ventricle, aortic valve Left atrium, mitral valve

Bicuspid aortic valve None Arterinsderntic heart disease (AS1iD) None RHD

12 0 '

50 M

1951

drolrracruu

Minral valve

None

13 2 " 14 2 B

29 F 30 M

19 .52 1953

seodat

Aortic valve Mitral valve

None RHD

15J 0 l6° 0 1`

53 M 42 F 47 F

1953 1954 1956

choleraernis lvphinuuirmz

Left ventricle Mitral valve Mitral valve

ASHD (/) RHD RI ID

1841

57 M

1958

role,

Left atrium, mitral valve

RI ID

19'" 20 12 211 2 22*

53 M 65 M 64 F 53 M

1958 1961 1963 1964

choicrarnay

Aortic Mitral Aortic Mitral

Bicuspid aortic valve RIID LIII) None

702

Hat qaa

Species

Pr(-cxis,iii Ilcart Disc~>e

Case & Ref.

of

Site of Vegc iort

Snh a

choleraeuwir droleracsuis

A"/""m"o

11p/,hoa

lam

menncrnfn

choleraciLilt

Salmonel . species

pmeum

Group C tsphimurwm

Total or M 47 (mean) 13 males

valve valve valve valve

tIb

ease

16/22

* This study_ previously . This was an infected aneurysui of the sinus of Valsalva in a 36 year old man with rheumatic heart disease and infection of the aortic and mitral valves . t he average age of the 22 patients with Salmonella endocarditis was 47, seventeen years younger than that of patients with infected aneurvsurs . 177 42 Previous heart disease was present in 16 (73%) : rheumatic heart disease in 10, luetic in 2, congenital (bicuspid aortic valves) in 2, and arteriosclerotic in 2 . Salmonella c/ioleraesuis and Sal . tvphimuriurn again were the most prevalent species, but various others were found . Infection occurred on the mitral valve in 12, the aortic in 7, and both of these in 1 case . Mural endocarditis without valvular involvement occurred twice . Fever

and petechiae were usual, and congestive heart failure and splenontegaly were seen in about half of the cases . Other complications were myocarditis, pcricarditis, focal gloineruloncphritis, pneumonia, bronchitis, pleurisy, pyelonephritis, cystitis, choleeystitis, peritonitis with an infected ovarian cyst, and septic arthritis . Leukocvtosis and positive blood cultures were usually found . Eighteen patients died . Antibiotics, especially ehlorantphenicol, appeared to be only partially successful therapy in the 4 patients who recovered . The present case involves first use of ampicillin in salmonella endocarditis . Unlike chloramphenicol, atnpicillin is bactericidal rather than bacteriostatic in aitro . 44-4s It is hoped that this new setnisynthetic penicillin will be more successful THE AMERICAN JOURNAL

of

CARUtOI .OCI'

Ma( -olit

_Atteurvsin and Endocarditi 1 'ci r: a ,, mvinur'l ,

C'Sc & R, i'.

32) 4e-a 5ein

8s'

)t lie,' Manifestations of Salmonella Infectim, Vlyoearditis, pneuuwnia, focal gloua'rulouephritis Pneuuronia, mrycotic aneur . of sinus of Valsah a Pyelitti, cystitis Pneumonia, periearditis, cholceystitis Peitonie,, oophoritis, (P) periearditis Pneumonia, focal glomeruloneph ., myocarditis bronchitis, periearditis, femoral embolus Septic arthritis, mynearditis Mynr,rditiis, nephritis, chnlecystitis

ID1 ° 1Io

Myocarditis Pen, arditis,myocarditis

12"

Pncmnonia, pleuritis, myocarditis

131, 14 35 1511 It^° 171

Pcricarditis- cerebral embolus Ileitis Pericarditis

I8° 19P'' 2) )u 21 ' 22 3

Myucardiris Focal glomeruloncphritis Femoral aneurysny focal glowerulonephritis

Chc,nothcrapy

Uvtc,nnc

Non . .

Dcoth

Non,

Dent,

Sulfonamide Sulfonamide None Sulfonamide

Dvadt 7 )ea tl Death Death

Sulfonamide Penicillin G . streptomycin, chloramphenicol Penicillin G, streptoavein, sulfonamide

Death Death Death

Penicillin C Penicillin C . tetracycline . chlnraniphenieol, streptoinycin Penicillin G, streptomycin, tetracycline, ehloram,phenicol Penicillin G, chlorauiphenicol 'tetracycline, streptomycin . chloranaplie dent, ncomvcin, poly,nyxin B None Penicillin G, tetracycline, ehlorainphenieol Penicillin G, novobiocin . streptomycin, furadantin . ehbrantphcnicuI tetracyclitic, crythromycin, Sulfonamide Chlorunphenieol, neomycin, kanamycin, novobioein, tetracycline Penicillin G, SOreptonayein Kanrunycin chloramphenicnl None SoIfonauide, penicillin G, streptomycin, chloran,phcoicol, ampicllin

Dead, Death Dr at l, Re to' cry Rccuscrc Dead, Death Death

Death Dead, Kecocrry Death Recovery 18 22 rlc,tha

than chloramphenicol has been in the therapy

Persistent fever and leukocytosi ; in a patient

of chronic salmonella infections and in clearing

with salntonellosis, especially in a patient with

the carrier state . Results of adequate clinical

an arteriosclerotic aneurysm or valvular heart

trials with this relatively benign drug without

disease, should suggest focal complications Such

the henuuopoietic toxicity of ehlorau)phenicol

as those seen in the present patient .

are awaited . REFERENCES

S t ; )tKIARY 1'he case

of

a

33

year old Stan with Salmonella

is/rkamurium endocarditis of the mitral valve and an infected mvcotic aneurysm of the femoral artery is presented . Focal glomerulitis, a pulmonary embolus and anemia were further complications . The patient recovered after a prolonged three and a half month course following excision

of

the infected inenrxsin arid

vigorous therapy with parcntcral ampieiilin . VOLUME 18, AUGUST 1966

1 . SAPURA, I . and Hrxrea . .J . AV' . Clinical n ;anilcvtetions of saInonellosis in man : An ec :duation of 7779 ha man infections identified at the New Fork Salmonella Center . AKen: kagland .1 . . died_ 2 ;6 : 1128 . 1957, 2 . BLACK, P . 11 . . Kusz, L . f . and SWAETZ . M . N . Sahnonellosis : a review of some unusual aspects . New England J . Med. . 262 : 811, 804, 921, 1960 . 3 . Y .nxorr, M ., FRANC, I . II, and Pnos-r, J . W . Primary u,ycotic thoracic aortic aneurysm caused by . SWbno . . .IZ, c/a/csoeredr . An, . J . ;fled- . 38 : 145 . 1965 . 4 . NcSEAN, Il . . Sm,v Lr: . C . G ., Roceas, K . () . :,ncl



274

Tillotson and Lerner 1VIllIII, .

N . U'N .

Bacterial endocarditis due to dm . .f. Catbird ., 7 :6118 .

S'almaerllu lrph,mnrirw .

1961 .

n, S, ANGLE . A . and tinsSER'114, CL C .

Mycotic (baetcrinl) aneurysts of intra'vascular origin . :Ldl . Im, bled ., 31 : 527, 1923 . 6 . MACCREAnv . R. A ., REARDON, J . P . and SAPHRA . I Sahuonellosis in Massachusetts : A sixteen year experience- Arm England . 1 . Med., 256 : 1121 . 1957 . RrNxE:rl' . 1. L, JR . and I-foox, E . W. infectious diseases (some aspects of salnnoellosis) . Anu . Per . ;Hed ., 10 : 1 1959 . 8 . EDw-anon . P . R ., BRUNER, D . W . and MORAN, A . B . Further studies on the occurrence and distribution of salmonella types in the United States . .1 . Iaf d . Die. . 83 : 220, 1948 . 9 . BLC+t, L . and KEEFER, I5 . B . C'C . Clinical entity of cryptogenic ntveotic aneurysm . .I .A .M . .4 ., 188 : 505, 1964 . 10 . BARKER, ii' . F . MYcntic aneurysms, 9nn_ Sa,, t' ., 139 : 84, 1954 . 11 . ZAK, F . G ., STRAUSS, L . and SAensA, I, Rupture of diseased large arteries in the course of cnteroNow Ertnland bacterial Isahnonclla1 infections . .1 . 4te
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