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Mycotic Aneurysm of the Ascending Aorta Secondary to Serratia Infection: Differentiation from Prosthetic Valve Endocarditis
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tachycardia initiated and terminated by a single electrical stimulus. Am J Cardiol24:37-48, 1969 Kitchen JG, Goldreyer BN: Demand pacemaker for refractory supraventricular tachycardia. N Engl J Med 287 :596-599, 1972 Kramer DH, Moss AJ: Permanent percutaneous atrial pacing from the coronary vein. Circulation 42:427-436, 1970 Moss AJ, Rivers RJ, Cooper M: Long-term pervenous atrial pacing from the proximal portion of the coronary vein. JAMA 209:543-545, 1969 Nepodono RJ, Cannon E, Zaroff L: Two observations regarding pervenous atrial pacing from the coronary sinus. J ElectrocardioI4:275-278, 1971
Mycotic Aneurysm of the Ascending Aorta Secondary to Serratia Infection: Differentiation from Prosthetic Valve Endeeerditis" Burt R. Meyers, M.D., Rashmikant Shah, M.D., and Martin Lefkowitz, M.D.
Twenty-one months after prosthetic aortic and mitral valve replacement, a 64-year-old man developed bacteremia secondary to a Serratia infection. Intensive investigation failed to reveal the origin of infection and gentamicin therapy did not eradicate the organisms from the bloodstream. The patient died. Postmortem examination revealed a large mycotic aneurysm arising from the aortotomy site but no evidence of prosthetic valve endocarditis. Late occurring bacteremia following valve replacement is discussed. Aortography may be necessary to deUneate this problem.
and fungal endocarditis in patients with B acterial prosthetic cardiac valves may respond to antibiotic therapy alone but generally requires surgery with valve replacement for cure.':" Sande et all recently reported 22 patients with prosthetic cardiac valves who had sustained bacteremia and suggested a way of differentiating valvular involvement from other causes. We recently treated a patient with prosthetic aortic and mitral valves who developed sustained Serratia bacteremia. This was secondary to a mycotic aneurysm of the ascending aorta, which could not be clinically differentiated from bacterial endocarditis. Mycotic aneurysms in this area are uncommon and involvement with the ·From the Division of Infectious Diseases Department of Medicine, The Mount Sinai School of M;;dicine of the City University of New York, New York, N.Y., and the Department of Pathology, Grasslands Hospital, Valhalla, N.Y. Reprint requests: Dr. Meyers, Mount Sinai Hospital, lOOth Street and Fifth Avenue, New York: City 10029
CHEST, 65: 2, FEBRUARY, 1974
species of the genus Serratia has not been previously reported.
CASE REPoRT A 64-year-old man underwent aortic and mitral valve replacement on June 19, 1970. After operation he developed a wound infection at the lower end of the sternum which was treated by debridement, cauterization and local measures. Drainage persisted and in June, 1971, after culture revealed Enterobacter organisms, doxycycline was given orally for ten days, with some clinical improvement. In September, 1971, Enterobacter organisms were cultured again, and doxycycline therapy was reinstituted. Drainage persisted and two days prior to admission, the patient complained of cough, fever and weakness, and 1 ml of serosanguinous fluid was aspirated from the wound but was not cultured. Administration of tetracycline was resumed but the fever and symptoms persisted and the patient was readmitted on March 31, 1972. Physical examination on admission revealed an irregular pulse rate of 88/min; respirations, 16/min; blood pressure 110/60 mm Hg, and temperature, 39.4444 C·. The conjunctivae were free of petechiae. The neck veins were distended and showed a positive hepatojugular reflex. There were rAles and rhonchi at the lung bases. Examination of the heart revealed cardiomegaly with the point of maximum intensity (PMI) in the sixth intercostal space at the anterior axillary line. There was a blowing systolic murmur heard at the apex (grade 3/6) and a short harsh systolic murmur (grade 4/6) heard over the aortic area. The liver was palpable 2 em below the costal margin; the spleen was not enlarged. There was 2+ clubbing of the fingers. Administration of antibiotics was discontinued and blood cultures were obtained. Roentgenograms of the chest revealed an enlarged heart with prosthetic aortic and mitral valves and prominence of the pulmonary vasculature. An intravenous pyelogram showed an intrarenal mass suggestive of a cyst. Laboratory studies disclosed the following values: hematocrit, 32 percent; white blood cell count 7,5OO/mm3 , with 74 percent polymorphonuclear leukocytes, 20 percent lymphocytes and 6 percent monocytes; blood urea nitrogen (BUN), 16 mg/1oo ml; serum protein, 6.9 gm/ml; albumin, 3.1 gm/100 ml; alkaline phosphatase, 110 international units ( IU ); serum glutamic oxaloacetic transaminase (SGOT), 65 IU; and the urinalysis was normal. The latex-fixation test was positive in a dilution of 1/160. Daily temperature spikes to 38.8889 CO occurred, and blood cultures drawn on the sixth hospital day revealed the presence of Serratia. Intramuscular administration of gentamicin was begun and blood cultures drawn on April 13 and 14 again revealed this micro-organism. Twenty days after gentamicin therapy was begun, he became lethargic and less responsive. Blood cultures obtained on the 36th hospital day were again positive for Serratia. Repeated chest films showed cardiomegaly and congestive heart failure, without evidence of sternal osteomyelitis. On the 46th hospital day he became unresponsive, passed a tarry stool, developed hypotension and died. AUTOPSY FINDINGS
Autopsy findings revealed a healed midsternal incision with no evidence of infection, abscess formation, or osteomyelitis. A fibrous walled saccular false aneurysm 8 ern in its greatest diameter, was noted between the sternum and the anterior wall of the aorta. The inner wall had a granular fibrinous, shaggy and cobblestone appearance
MYCOTIC ANEURYSM 215
3. Section of aortic wall and adherent aneurysmal sac. Normally structured aortic wall is at left. Aneurysmal sac lining at right consistsof fibrous granulation tissue, fibrin and polymorphonuclear infiltrate (hematoxylin and eosin stain x FIGURE
FiGURE
1. Anterior view of heart with adherent opened an-
eurysmalsac. Communicationwith aorta is at left, with black suture material adjacent. (Fig I). This aneurysmal cyst communicated with the aorta via a I5-mm endothelialized hole, 5.5 cm above the aortic ring (Fig 2). Suture material was exposed at this level. This hole represents the upper end of the otherwise well-healed, aortotomy incision. Sections of the wall (Fig 3) revealed chronic inflammation with fibrosis, fibrin and polymorphonuclear leukocytes. The
48).
prosthetic valves were intact; there were no clots or evidence of infection either in the valve rings or on the valve surfaces. There were abscesses of both psoas muscles in which Gram-negative bacilli were seen on Gram stain. Postmortem culture of these abscesses grew Proteus morgan;; and Serratia. A simple renal retention cyst was noted in the kidney. DISCUSSION
FIGURE 2. Sagittal section through aortic wall and aneurysmal sac. Looseblack silk suture material is seen in opening. Aortic valve prosthesis is at left lower margin. Note shaggy and fibrinous character of aneurysmal sac lining.
216 MEYERS, SHAH, LEFKOWITZ
The differentiation of the cause of sustained bacteremia in a patient with prosthetic cardiac valves is a difficult diagnostic problem. In this patient, species of Serratia genus were isolated on four occasions 21 months after surgery and persisted in the presence of adequate antimicrobial therapy. Sande et al' suggest that infection occurring 60 days after prosthetic valve surgery is consistent with infection of the prosthesis. However, when extracardiac sources of infection exist such as sternal infection, the incidence of valvular involvement is markedly diminished. Gram-negative bacteremia in their series (9/13 events) occurred early in each patient's course and was associated with extravalvular infection. Gram-positive bacteremia occurred late in 10 of 11 patients who had prosthetic valve infection.
CHEST, 65: 2, FEBRUARY, 1974
Mycotic aneurysms of the ascending aorta were not a rare event before the availability of antibiotic therapy" and usually followed bacterial endocarditis of the aortic valve, with rupture into a sinus of Valsalva. Since 1941 infections in this part of the aorta are uncommon and involvement with Gram-negative species other than Sahnonella is very rare. 9-l t Mycotic aneurysms of the ascending aorta have been described recently in patients with an infected sternotomy site,I2 a congenital aortic ventricular tunnelt" and following infection of the suture line after aortic valvuIotomy.v In all of these cases surgical repair was lifesaving. The micro-organisms isolated were all Gram-positive: Staphylococcus aureus, Micrococcus, and Sarcinea lutea, respectively. Salmonellae usually group C are the most common Gram-negative organisms isolated from mycotic aneurysms at any site in the aorta. n •I6 Species of Serratia genus have been implicated in Gram-negative septicemia, necrotizing pneumonia, urinary tract infections and bacterial endocarditis,11-19 Reviews of Serratia bacteremia did not record this organism associated with mycotic aneurysms.w A wound infection persisting for a years suggested sternal osteomyelitis, although the wound healed during his hospital stay. Repeated roentgenograms of the chest did not reveal evidence of sternal osteomyelitis or widening of the mediastinum. At necropsy the aneurysm did not involve the sternum, nor was there pathologic evidence of osteomyelitis. It is possible that osteomyelitis finally healed, but the aneurysm progressed because of the suture material. The aneurysm arose from the suture line of the aortotomy site as in the case described by Lopez et al. 14 This patient with sustained bacteremia secondary to Serratia species was suspected of having bacterial involvement of the prosthetic valves, since no other obvious sources of infection were found. Treatment of prosthetic-valve endocarditis should consist of antimicrobial therapy and in most cases intervention by operation. Mycotic aneurysms of the ascending aorta must be treated with antibiotics and operation for cure.IO.ll.13.14 Sustained bacteremia with either Gram. positive or negative micro-organisms occurring more than 60 days after cardiac surgery should lead to an exhaustive search for either prosthetic-valve endocarditis or an intravascular mycotic lesion. Since Gram-negative bacillus infection of prosthetic valves occurs, although rarely,20 their persistence in the bloodstream should suggest an intravascular but extracardiac focus. Repeated chest x-ray films never suggested an aortic aneurysm in this patient. Angiography would have demonstrated this lesion. It is suggested that aortography should be included in the diagnostic work-up of patients with recurrent Gram-negative bacteremia in which an extravalvular source of infection is suspected.
valve endocarditis. J Thorac Cardiovasc Surg 60:540-548, 1970
3 Yeh TJ, Anabtawi IN, Cornett VE, et al: Bacterial endocarditis following open heart surgery. Ann Thorac Surg 3:29-36, 1967
4 Wehr KL, McCall CE: Infection of prosthetic valves. South Med J 65:1224-1228,1972 5 Olcies JE, Viroslav J, Williams TW Jr: Endocarditis after cardiac valvular replacement. Chest 59:198-202, 1971 6 Watanakunakonn C, Hamburger M: StaphylococCt18 epidermidis endocarditis complicating a Starr-Edwards prosthesis. Arch Intern Med 126:1014-1018, 1970 7 Goldswerg HG, Matsen JM, Castaeda AR: HemophUus aphrophaus endocarditis as a patient with mitral valve prosthesis. Case report and review of literature. J Thorac Cardiovasc Surg 63:408-411,1972 8 StauHer JL, Goldmann J: Bacterial endocarditis due to Actinobacillus actinomycetemcomitaf18 in a patient with a prosthetic aortic valve. Calif Med 117:59-63, 1972 9 Bennet DE: Primary mycotic aneurysms of the aorta. Arch Surg 94:758-765, 1967 10 CIiH MM, Soulen RL, Firestone AJ: Mycotic aneurysm: A challenge and a clue. Review of ten-year experience. Arch Intern Med 126:977-982, 1970 11 Blum L, Keefer EBC: Clinical entity of cryptogenic mycotic aneurysms. JAMA 188:505-508, 1964 12 Lillehei LW, Todd DB, Levy MT, et al: Partial cardio-
pulmonary bypass hypothermia and total circulatory arrest: A life saving technique for ruptured aortic aneurysms, ruptured left ventricle and other complicated pathology. J Thorac Cardiovasc Surg 58:530-543, 1969 13 Mulder DC, Johnson BL: Mycotic aneurysm of the aortic
root and infected valve treated by excisionand homograft valve replacement. Ann Thorac Surg 9:253-257,1970 14 Lopez GA, Dobell ARC: Mycotic aneurysm of ascending aorta due to Sarcina lutea. Ann Thorac Surg 13:607-611, 1972 15 Meade RH, Moran JM: Salmonella arteritis: Pre-operative diagnosis and cure of Salmonella typhimurlum aortic aneurysm. N Engl J Med 281 :310-312, 1969 16 Tillotson JR, Lerner AM: Mycotic aneurysm and endo-
carditis. Two uncommon complications of Salmonella infection in the same patient. Am J Cardiol 18:267-273, 1966 17 Sanders CV Ir, Luby ]P, Johanson NG Jr, et al: Serratia marcescem infections from inhalation therapy medications: Nosocomial out break. Ann Intern Med 73:15-21, 1970
18 Dodson WH: Serratiamarcescens septicemia. Arch Intern Med 121:145-150,1965
JE III: Serratia marcescem endocarditis. Arch Intern Med 125:1038-1040, 1970
19 Williams JC Jr, Johnson 1 Sande MA, Johnson WO, Hood EW, et al: Sustained
bacteremia in patients with prosthetic cardiac valves. N Engl J Med 286:1067-1070,1972 2 Block PC, DeSanctis RN, Weinberg AN, et al: Prosthetic
CHEST, 65: 2, FEBRUARY, 1974
20 Lerner PL, Weinstein L: Infective endocarditis in the antibiotic era. N Engl J Med 274:199-206, 259-266,323331, 1966
MYCOTIC ANEURYSM 217
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17
18
tachycardia initiated and terminated by a single electrical stimulus. Am J Cardiol24:37-48, 1969 Kitchen JG, Goldreyer BN: Demand pacemaker for refractory supraventricular tachycardia. N Engl J Med 287 :596-599, 1972 Kramer DH, Moss AJ: Permanent percutaneous atrial pacing from the coronary vein. Circulation 42:427-436, 1970 Moss AJ, Rivers RJ, Cooper M: Long-term pervenous atrial pacing from the proximal portion of the coronary vein. JAMA 209:543-545, 1969 Nepodono RJ, Cannon E, Zaroff L: Two observations regarding pervenous atrial pacing from the coronary sinus. J ElectrocardioI4:275-278, 1971
Mycotic Aneurysm of the Ascending Aorta Secondary to Serratia Infection: Differentiation from Prosthetic Valve Endeeerditis" Burt R. Meyers, M.D., Rashmikant Shah, M.D., and Martin Lefkowitz, M.D.
Twenty-one months after prosthetic aortic and mitral valve replacement, a 64-year-old man developed bacteremia secondary to a Serratia infection. Intensive investigation failed to reveal the origin of infection and gentamicin therapy did not eradicate the organisms from the bloodstream. The patient died. Postmortem examination revealed a large mycotic aneurysm arising from the aortotomy site but no evidence of prosthetic valve endocarditis. Late occurring bacteremia following valve replacement is discussed. Aortography may be necessary to deUneate this problem.
and fungal endocarditis in patients with B acterial prosthetic cardiac valves may respond to antibiotic therapy alone but generally requires surgery with valve replacement for cure.':" Sande et all recently reported 22 patients with prosthetic cardiac valves who had sustained bacteremia and suggested a way of differentiating valvular involvement from other causes. We recently treated a patient with prosthetic aortic and mitral valves who developed sustained Serratia bacteremia. This was secondary to a mycotic aneurysm of the ascending aorta, which could not be clinically differentiated from bacterial endocarditis. Mycotic aneurysms in this area are uncommon and involvement with the ·From the Division of Infectious Diseases Department of Medicine, The Mount Sinai School of M;;dicine of the City University of New York, New York, N.Y., and the Department of Pathology, Grasslands Hospital, Valhalla, N.Y. Reprint requests: Dr. Meyers, Mount Sinai Hospital, lOOth Street and Fifth Avenue, New York: City 10029
CHEST, 65: 2, FEBRUARY, 1974
species of the genus Serratia has not been previously reported.
CASE REPoRT A 64-year-old man underwent aortic and mitral valve replacement on June 19, 1970. After operation he developed a wound infection at the lower end of the sternum which was treated by debridement, cauterization and local measures. Drainage persisted and in June, 1971, after culture revealed Enterobacter organisms, doxycycline was given orally for ten days, with some clinical improvement. In September, 1971, Enterobacter organisms were cultured again, and doxycycline therapy was reinstituted. Drainage persisted and two days prior to admission, the patient complained of cough, fever and weakness, and 1 ml of serosanguinous fluid was aspirated from the wound but was not cultured. Administration of tetracycline was resumed but the fever and symptoms persisted and the patient was readmitted on March 31, 1972. Physical examination on admission revealed an irregular pulse rate of 88/min; respirations, 16/min; blood pressure 110/60 mm Hg, and temperature, 39.4444 C·. The conjunctivae were free of petechiae. The neck veins were distended and showed a positive hepatojugular reflex. There were rAles and rhonchi at the lung bases. Examination of the heart revealed cardiomegaly with the point of maximum intensity (PMI) in the sixth intercostal space at the anterior axillary line. There was a blowing systolic murmur heard at the apex (grade 3/6) and a short harsh systolic murmur (grade 4/6) heard over the aortic area. The liver was palpable 2 em below the costal margin; the spleen was not enlarged. There was 2+ clubbing of the fingers. Administration of antibiotics was discontinued and blood cultures were obtained. Roentgenograms of the chest revealed an enlarged heart with prosthetic aortic and mitral valves and prominence of the pulmonary vasculature. An intravenous pyelogram showed an intrarenal mass suggestive of a cyst. Laboratory studies disclosed the following values: hematocrit, 32 percent; white blood cell count 7,5OO/mm3 , with 74 percent polymorphonuclear leukocytes, 20 percent lymphocytes and 6 percent monocytes; blood urea nitrogen (BUN), 16 mg/1oo ml; serum protein, 6.9 gm/ml; albumin, 3.1 gm/100 ml; alkaline phosphatase, 110 international units ( IU ); serum glutamic oxaloacetic transaminase (SGOT), 65 IU; and the urinalysis was normal. The latex-fixation test was positive in a dilution of 1/160. Daily temperature spikes to 38.8889 CO occurred, and blood cultures drawn on the sixth hospital day revealed the presence of Serratia. Intramuscular administration of gentamicin was begun and blood cultures drawn on April 13 and 14 again revealed this micro-organism. Twenty days after gentamicin therapy was begun, he became lethargic and less responsive. Blood cultures obtained on the 36th hospital day were again positive for Serratia. Repeated chest films showed cardiomegaly and congestive heart failure, without evidence of sternal osteomyelitis. On the 46th hospital day he became unresponsive, passed a tarry stool, developed hypotension and died. AUTOPSY FINDINGS
Autopsy findings revealed a healed midsternal incision with no evidence of infection, abscess formation, or osteomyelitis. A fibrous walled saccular false aneurysm 8 ern in its greatest diameter, was noted between the sternum and the anterior wall of the aorta. The inner wall had a granular fibrinous, shaggy and cobblestone appearance
MYCOTIC ANEURYSM 215
3. Section of aortic wall and adherent aneurysmal sac. Normally structured aortic wall is at left. Aneurysmal sac lining at right consistsof fibrous granulation tissue, fibrin and polymorphonuclear infiltrate (hematoxylin and eosin stain x FIGURE
FiGURE
1. Anterior view of heart with adherent opened an-
eurysmalsac. Communicationwith aorta is at left, with black suture material adjacent. (Fig I). This aneurysmal cyst communicated with the aorta via a I5-mm endothelialized hole, 5.5 cm above the aortic ring (Fig 2). Suture material was exposed at this level. This hole represents the upper end of the otherwise well-healed, aortotomy incision. Sections of the wall (Fig 3) revealed chronic inflammation with fibrosis, fibrin and polymorphonuclear leukocytes. The
48).
prosthetic valves were intact; there were no clots or evidence of infection either in the valve rings or on the valve surfaces. There were abscesses of both psoas muscles in which Gram-negative bacilli were seen on Gram stain. Postmortem culture of these abscesses grew Proteus morgan;; and Serratia. A simple renal retention cyst was noted in the kidney. DISCUSSION
FIGURE 2. Sagittal section through aortic wall and aneurysmal sac. Looseblack silk suture material is seen in opening. Aortic valve prosthesis is at left lower margin. Note shaggy and fibrinous character of aneurysmal sac lining.
216 MEYERS, SHAH, LEFKOWITZ
The differentiation of the cause of sustained bacteremia in a patient with prosthetic cardiac valves is a difficult diagnostic problem. In this patient, species of Serratia genus were isolated on four occasions 21 months after surgery and persisted in the presence of adequate antimicrobial therapy. Sande et al' suggest that infection occurring 60 days after prosthetic valve surgery is consistent with infection of the prosthesis. However, when extracardiac sources of infection exist such as sternal infection, the incidence of valvular involvement is markedly diminished. Gram-negative bacteremia in their series (9/13 events) occurred early in each patient's course and was associated with extravalvular infection. Gram-positive bacteremia occurred late in 10 of 11 patients who had prosthetic valve infection.
CHEST, 65: 2, FEBRUARY, 1974
Mycotic aneurysms of the ascending aorta were not a rare event before the availability of antibiotic therapy" and usually followed bacterial endocarditis of the aortic valve, with rupture into a sinus of Valsalva. Since 1941 infections in this part of the aorta are uncommon and involvement with Gram-negative species other than Sahnonella is very rare. 9-l t Mycotic aneurysms of the ascending aorta have been described recently in patients with an infected sternotomy site,I2 a congenital aortic ventricular tunnelt" and following infection of the suture line after aortic valvuIotomy.v In all of these cases surgical repair was lifesaving. The micro-organisms isolated were all Gram-positive: Staphylococcus aureus, Micrococcus, and Sarcinea lutea, respectively. Salmonellae usually group C are the most common Gram-negative organisms isolated from mycotic aneurysms at any site in the aorta. n •I6 Species of Serratia genus have been implicated in Gram-negative septicemia, necrotizing pneumonia, urinary tract infections and bacterial endocarditis,11-19 Reviews of Serratia bacteremia did not record this organism associated with mycotic aneurysms.w A wound infection persisting for a years suggested sternal osteomyelitis, although the wound healed during his hospital stay. Repeated roentgenograms of the chest did not reveal evidence of sternal osteomyelitis or widening of the mediastinum. At necropsy the aneurysm did not involve the sternum, nor was there pathologic evidence of osteomyelitis. It is possible that osteomyelitis finally healed, but the aneurysm progressed because of the suture material. The aneurysm arose from the suture line of the aortotomy site as in the case described by Lopez et al. 14 This patient with sustained bacteremia secondary to Serratia species was suspected of having bacterial involvement of the prosthetic valves, since no other obvious sources of infection were found. Treatment of prosthetic-valve endocarditis should consist of antimicrobial therapy and in most cases intervention by operation. Mycotic aneurysms of the ascending aorta must be treated with antibiotics and operation for cure.IO.ll.13.14 Sustained bacteremia with either Gram. positive or negative micro-organisms occurring more than 60 days after cardiac surgery should lead to an exhaustive search for either prosthetic-valve endocarditis or an intravascular mycotic lesion. Since Gram-negative bacillus infection of prosthetic valves occurs, although rarely,20 their persistence in the bloodstream should suggest an intravascular but extracardiac focus. Repeated chest x-ray films never suggested an aortic aneurysm in this patient. Angiography would have demonstrated this lesion. It is suggested that aortography should be included in the diagnostic work-up of patients with recurrent Gram-negative bacteremia in which an extravalvular source of infection is suspected.
valve endocarditis. J Thorac Cardiovasc Surg 60:540-548, 1970
3 Yeh TJ, Anabtawi IN, Cornett VE, et al: Bacterial endocarditis following open heart surgery. Ann Thorac Surg 3:29-36, 1967
4 Wehr KL, McCall CE: Infection of prosthetic valves. South Med J 65:1224-1228,1972 5 Olcies JE, Viroslav J, Williams TW Jr: Endocarditis after cardiac valvular replacement. Chest 59:198-202, 1971 6 Watanakunakonn C, Hamburger M: StaphylococCt18 epidermidis endocarditis complicating a Starr-Edwards prosthesis. Arch Intern Med 126:1014-1018, 1970 7 Goldswerg HG, Matsen JM, Castaeda AR: HemophUus aphrophaus endocarditis as a patient with mitral valve prosthesis. Case report and review of literature. J Thorac Cardiovasc Surg 63:408-411,1972 8 StauHer JL, Goldmann J: Bacterial endocarditis due to Actinobacillus actinomycetemcomitaf18 in a patient with a prosthetic aortic valve. Calif Med 117:59-63, 1972 9 Bennet DE: Primary mycotic aneurysms of the aorta. Arch Surg 94:758-765, 1967 10 CIiH MM, Soulen RL, Firestone AJ: Mycotic aneurysm: A challenge and a clue. Review of ten-year experience. Arch Intern Med 126:977-982, 1970 11 Blum L, Keefer EBC: Clinical entity of cryptogenic mycotic aneurysms. JAMA 188:505-508, 1964 12 Lillehei LW, Todd DB, Levy MT, et al: Partial cardio-
pulmonary bypass hypothermia and total circulatory arrest: A life saving technique for ruptured aortic aneurysms, ruptured left ventricle and other complicated pathology. J Thorac Cardiovasc Surg 58:530-543, 1969 13 Mulder DC, Johnson BL: Mycotic aneurysm of the aortic
root and infected valve treated by excisionand homograft valve replacement. Ann Thorac Surg 9:253-257,1970 14 Lopez GA, Dobell ARC: Mycotic aneurysm of ascending aorta due to Sarcina lutea. Ann Thorac Surg 13:607-611, 1972 15 Meade RH, Moran JM: Salmonella arteritis: Pre-operative diagnosis and cure of Salmonella typhimurlum aortic aneurysm. N Engl J Med 281 :310-312, 1969 16 Tillotson JR, Lerner AM: Mycotic aneurysm and endo-
carditis. Two uncommon complications of Salmonella infection in the same patient. Am J Cardiol 18:267-273, 1966 17 Sanders CV Ir, Luby ]P, Johanson NG Jr, et al: Serratia marcescem infections from inhalation therapy medications: Nosocomial out break. Ann Intern Med 73:15-21, 1970
18 Dodson WH: Serratiamarcescens septicemia. Arch Intern Med 121:145-150,1965
JE III: Serratia marcescem endocarditis. Arch Intern Med 125:1038-1040, 1970
19 Williams JC Jr, Johnson 1 Sande MA, Johnson WO, Hood EW, et al: Sustained
bacteremia in patients with prosthetic cardiac valves. N Engl J Med 286:1067-1070,1972 2 Block PC, DeSanctis RN, Weinberg AN, et al: Prosthetic
CHEST, 65: 2, FEBRUARY, 1974
20 Lerner PL, Weinstein L: Infective endocarditis in the antibiotic era. N Engl J Med 274:199-206, 259-266,323331, 1966
MYCOTIC ANEURYSM 217