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Mycotic aneurysm of the left main coronary artery producing acute coronary occlusion and purulent pericarditis
International Journal of Cardiology 114 (2007) e81 – e82 www.elsevier.com/locate/ijcard
Letter to the Editor
Mycotic aneurysm of the left main coronary artery producing acute coronary occlusion and purulent pericarditis Kenneth Westover a , Bruce Benedick b,⁎ a
b
Stanford University School of Medicine, Medical Scientist Training Program, Stanford, CA 94305, United States Stanford University School of Medicine, Department of Medicine, 770 Welch Road #100, Palo Alto, CA 94304, United States Received 22 April 2006; accepted 29 April 2006 Available online 21 July 2006
Keywords: Mycotic aneurysm; Coronary artery aneurysm; Purulent pericarditis; Tamponade
1. Case report A 64-year-old gentleman presented to the emergency department with a 2-day history of pleuritic chest pain that radiated to his left arm. Upon evaluation his EKG and cardiac enzymes were unremarkable and the pain was unrelieved with nitroglycerin. His white blood cell count was elevated to 18,000 and his erythrocyte sedimentation rate was high. Because of recurrent, yet atypical chest pain and fluctuating non-specific ECG changes over the next 24 h, selective angiography was performed revealing diffuse yet only moderate coronary artery disease and an unusual 1 cm aneurysm in the distal left main coronary artery (Fig. 1A). Akinesis of the free anterior wall of the left ventricle due to occlusion of a large ramus of the coronary artery was also noted, but reperfusion was not attempted because the occluded ramus was in close proximity to this large coronary aneurysm and there was no evidence of ongoing ischemia. One day later the patient had a fever with a maximum of 38.5 °C, the only fever of his entire clinical course, which was asymptomatic and of short duration. Later that day he developed crushing substernal chest pain with acute anterior ST elevation and underwent emergent repeat cardiac catheterization. Total occlusion at the ostium of the left anterior descending coronary artery and additional moderate stenosis at the ostium of the left circumflex coronary artery
⁎ Corresponding author. E-mail address: [email protected] (B. Benedick). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.04.059
was now present in addition to a marked enlargement of the previously observed aneurysm (Fig. 1B). High risk angioplasty and stent placement at the ostium of the left anterior descending artery were performed, yielding in an excellent angiographic result (Fig. 1C). After a period of cardiogenic shock the patient slowly recovered until on days 6–8 post-procedure he felt relatively well overall. A small, non-compressive pericardial effusion was observed by echocardiography although it was unchanged from an echocardiogram done on admission. Additionally, one of two blood cultures drawn at the time of the previously noted fever grew Staphylococcus aureus, despite the absence of fever. On day nine the patient suddenly became short of breath and, over the course of an hour, developed cardiogenic shock. Heart sounds were distant and echocardiography revealed a significantly increased, now large, pericardial effusion with evidence of compression. Emergent pericardiocentesis removed 500 cm3 of white, chalky, fluid and the patient expired despite aggressive resuscitation attempts due to progressive shock. Post-mortem examination revealed that the left main coronary aneurysm was filled with hemorrhagic thrombus and its walls contained atherosclerotic material seeded with heavy growth of S. aureus. The infection extended through the aneurysm wall and pericardial fat into the proximal myocardium. S. aureus colonies were also found along the extent of the now completely-thrombosed left anterior descending artery. An alternative primary source of infection, including endocarditis, was not found. The pericardium
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K. Westover, B. Benedick / International Journal of Cardiology 114 (2007) e81–e82
Fig. 1. Rapidly expanding aneurysm of the left main coronary artery. (A) Angiogram done at hospital admission reveals diffuse, mild atherosclerotic disease and an aneurysm of the left main coronary artery measuring ∼1cm in the largest dimension. (B) Angiogram done on hospital day 2 shows complete left anterior descending artery occlusion and doubling of aneurysm size. (C) Angiogram post complete left anterior descending artery stenting.
was involved with heavy growth of S. aureus and purulent fluid but no evidence of hemopericaridum. 2. Discussion Isolated coronary aneurysms are rare and the vast majority of these are due to atherosclerosis. Other causes include congenital malformation, Kawasaki's disease, trauma, dissection, complications of angioplasty, vasculitis, syphilis and other infections. Coronary aneurysms of the mycotic variety are extremely rare with approximately 20 cases recorded since the first report in 1812 [1]. All cases were associated with endocarditis or septicemia, with one exception where, like this case, no source of Infection was found at autopsy [2]. This case highlights the difficulty of diagnosing this unusual infectious etiology as the patient demonstrated few clinical signs of infectious disease, aside from a short-lived, low grade fever after his first myocardial infarction. It has been reported that mycotic aneurysms present with highly variable and often indolent symptoms with occasional sudden catastrophic deterioration in the patient's condition, often a result of coronary perforation or coronary ischemia [3,4]. Surgical treatment for this patient's aneurysm was entertained early on, but more conservative management was favored because of the patient's clinical improvement after stent placement and the feeling that this aneurysm would be better addressed after recovery from the current
episode. Had this aneurysm been diagnosed as mycotic prior to death, expedient surgical intervention would have been supported by the literature. Surgical treatment mycotic coronary aneurysms was first reported in 1970 with resection of an left anterior descending aneurysm 6months after initial diagnosis by thoracotomy in a 17-year-old patient. Since that time a total of eight cases utilizing various surgical approaches have been reported. One of these patients died after 11 months from a gastrointestinal bleed but the remaining seven were reported alive at the time of last follow up which varied from 28days to greater than 4years [4–6]. References [1] Osevala MA, Heleotis TL, DeJene BA. Successful treatment of a ruptured mycotic coronary artery aneurysm. Ann Thorac Surg 1999; 67:1780–2. [2] Safi Jr J, Castelli JB, Kalil-Filho R, Mansur AJ. Cryptogenic mycotic aneurysm of the right coronary artery. South Med J 1999;92:67–8. [3] Reece IJ, al Tareif H, Tolia J, Saeed FA. Mycotic aneurysm of the left anterior descending coronary artery after aortic endocarditis. A case report and brief review of the literature. Tex Heart Inst J 1994;21:231–5. [4] Pratt JW, Kukielka G, Brown DA. Repair of mycotic coronary aneurysm without cardiopulmonary bypass: case report. Heart Surg Forum 2004;7: E256–8. [5] Takahashi Y, Sasaki Y, Shibata T, Bito Y, Suehiro S. Successful surgical treatment of a mycotic right coronary artery aneurysm complicated by a fistula to the right atrium. Jpn J Thorac Cardiovasc Surg 2005;53:661–4. [6] Romaniv S, Vondracek V, Lindner J, et al. Mycotic aneurysm of the coronary artery. Cas Lek Cesk 2004;143:771–3.
Letter to the Editor
Mycotic aneurysm of the left main coronary artery producing acute coronary occlusion and purulent pericarditis Kenneth Westover a , Bruce Benedick b,⁎ a
b
Stanford University School of Medicine, Medical Scientist Training Program, Stanford, CA 94305, United States Stanford University School of Medicine, Department of Medicine, 770 Welch Road #100, Palo Alto, CA 94304, United States Received 22 April 2006; accepted 29 April 2006 Available online 21 July 2006
Keywords: Mycotic aneurysm; Coronary artery aneurysm; Purulent pericarditis; Tamponade
1. Case report A 64-year-old gentleman presented to the emergency department with a 2-day history of pleuritic chest pain that radiated to his left arm. Upon evaluation his EKG and cardiac enzymes were unremarkable and the pain was unrelieved with nitroglycerin. His white blood cell count was elevated to 18,000 and his erythrocyte sedimentation rate was high. Because of recurrent, yet atypical chest pain and fluctuating non-specific ECG changes over the next 24 h, selective angiography was performed revealing diffuse yet only moderate coronary artery disease and an unusual 1 cm aneurysm in the distal left main coronary artery (Fig. 1A). Akinesis of the free anterior wall of the left ventricle due to occlusion of a large ramus of the coronary artery was also noted, but reperfusion was not attempted because the occluded ramus was in close proximity to this large coronary aneurysm and there was no evidence of ongoing ischemia. One day later the patient had a fever with a maximum of 38.5 °C, the only fever of his entire clinical course, which was asymptomatic and of short duration. Later that day he developed crushing substernal chest pain with acute anterior ST elevation and underwent emergent repeat cardiac catheterization. Total occlusion at the ostium of the left anterior descending coronary artery and additional moderate stenosis at the ostium of the left circumflex coronary artery
⁎ Corresponding author. E-mail address: [email protected] (B. Benedick). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.04.059
was now present in addition to a marked enlargement of the previously observed aneurysm (Fig. 1B). High risk angioplasty and stent placement at the ostium of the left anterior descending artery were performed, yielding in an excellent angiographic result (Fig. 1C). After a period of cardiogenic shock the patient slowly recovered until on days 6–8 post-procedure he felt relatively well overall. A small, non-compressive pericardial effusion was observed by echocardiography although it was unchanged from an echocardiogram done on admission. Additionally, one of two blood cultures drawn at the time of the previously noted fever grew Staphylococcus aureus, despite the absence of fever. On day nine the patient suddenly became short of breath and, over the course of an hour, developed cardiogenic shock. Heart sounds were distant and echocardiography revealed a significantly increased, now large, pericardial effusion with evidence of compression. Emergent pericardiocentesis removed 500 cm3 of white, chalky, fluid and the patient expired despite aggressive resuscitation attempts due to progressive shock. Post-mortem examination revealed that the left main coronary aneurysm was filled with hemorrhagic thrombus and its walls contained atherosclerotic material seeded with heavy growth of S. aureus. The infection extended through the aneurysm wall and pericardial fat into the proximal myocardium. S. aureus colonies were also found along the extent of the now completely-thrombosed left anterior descending artery. An alternative primary source of infection, including endocarditis, was not found. The pericardium
e82
K. Westover, B. Benedick / International Journal of Cardiology 114 (2007) e81–e82
Fig. 1. Rapidly expanding aneurysm of the left main coronary artery. (A) Angiogram done at hospital admission reveals diffuse, mild atherosclerotic disease and an aneurysm of the left main coronary artery measuring ∼1cm in the largest dimension. (B) Angiogram done on hospital day 2 shows complete left anterior descending artery occlusion and doubling of aneurysm size. (C) Angiogram post complete left anterior descending artery stenting.
was involved with heavy growth of S. aureus and purulent fluid but no evidence of hemopericaridum. 2. Discussion Isolated coronary aneurysms are rare and the vast majority of these are due to atherosclerosis. Other causes include congenital malformation, Kawasaki's disease, trauma, dissection, complications of angioplasty, vasculitis, syphilis and other infections. Coronary aneurysms of the mycotic variety are extremely rare with approximately 20 cases recorded since the first report in 1812 [1]. All cases were associated with endocarditis or septicemia, with one exception where, like this case, no source of Infection was found at autopsy [2]. This case highlights the difficulty of diagnosing this unusual infectious etiology as the patient demonstrated few clinical signs of infectious disease, aside from a short-lived, low grade fever after his first myocardial infarction. It has been reported that mycotic aneurysms present with highly variable and often indolent symptoms with occasional sudden catastrophic deterioration in the patient's condition, often a result of coronary perforation or coronary ischemia [3,4]. Surgical treatment for this patient's aneurysm was entertained early on, but more conservative management was favored because of the patient's clinical improvement after stent placement and the feeling that this aneurysm would be better addressed after recovery from the current
episode. Had this aneurysm been diagnosed as mycotic prior to death, expedient surgical intervention would have been supported by the literature. Surgical treatment mycotic coronary aneurysms was first reported in 1970 with resection of an left anterior descending aneurysm 6months after initial diagnosis by thoracotomy in a 17-year-old patient. Since that time a total of eight cases utilizing various surgical approaches have been reported. One of these patients died after 11 months from a gastrointestinal bleed but the remaining seven were reported alive at the time of last follow up which varied from 28days to greater than 4years [4–6]. References [1] Osevala MA, Heleotis TL, DeJene BA. Successful treatment of a ruptured mycotic coronary artery aneurysm. Ann Thorac Surg 1999; 67:1780–2. [2] Safi Jr J, Castelli JB, Kalil-Filho R, Mansur AJ. Cryptogenic mycotic aneurysm of the right coronary artery. South Med J 1999;92:67–8. [3] Reece IJ, al Tareif H, Tolia J, Saeed FA. Mycotic aneurysm of the left anterior descending coronary artery after aortic endocarditis. A case report and brief review of the literature. Tex Heart Inst J 1994;21:231–5. [4] Pratt JW, Kukielka G, Brown DA. Repair of mycotic coronary aneurysm without cardiopulmonary bypass: case report. Heart Surg Forum 2004;7: E256–8. [5] Takahashi Y, Sasaki Y, Shibata T, Bito Y, Suehiro S. Successful surgical treatment of a mycotic right coronary artery aneurysm complicated by a fistula to the right atrium. Jpn J Thorac Cardiovasc Surg 2005;53:661–4. [6] Romaniv S, Vondracek V, Lindner J, et al. Mycotic aneurysm of the coronary artery. Cas Lek Cesk 2004;143:771–3.