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Rapidly Progressing Mycotic Aortic Aneurysm Masquerading As Acute Coronary Syndrome
Canadian Journal of Cardiology 29 (2013) 1742.e17e1742.e20 www.onlinecjc.ca
Case Report
Rapidly Progressing Mycotic Aortic Aneurysm Masquerading As Acute Coronary Syndrome Lovely Chhabra, MD,a Mihaela A. Kruger, MD,b Gayatri Kuraganti, MD,a Rami Eltibi, MD,b Suresh Mamidala, MD,a Rishi Bajaj, MD,a Akhila Belur, MD,a Alwyn Rapose, MD,c and Joseph Hannan, MDb a b
Department of Internal Medicine, Saint Vincent Hospital and University of Massachusetts Medical School, Worcester, Massachusetts, USA
Department of Cardiovascular Medicine, Saint Vincent Hospital and University of Massachusetts Medical School, Worcester, Massachusetts, USA c
Department of Infectious Diseases, Saint Vincent Hospital and University of Massachusetts Medical School, Worcester, Massachusetts, USA
ABSTRACT
RESUM E
Mycotic aortic aneurysms are rare. The most common cause of a mycotic aortic aneurysm is bacterial seeding in a diseased or injured aortic intima with subsequent arteritis. Because the clinical presentation of mycotic aortic aneurysms can be quite variable, the diagnosis hence can often be quite challenging. We herewith report an interesting case study in which the patient with a mycotic aortic aneurysm presented with the clinical picture masquerading as an acute coronary syndrome. The scenario reiterates the fact that despite the availability of accurate noninvasive imaging techniques, strong clinical suspicion might be imperative for the diagnosis of mycotic aneurysms.
vrismes mycotiques de l’aorte sont rares. La cause la plus Les ane quente de l’ane vrisme mycotique de l’aorte est l’ensemencement fre rien dans l’intima de l’aorte pathologique ou atteinte suivi d’une bacte rite. Puisque le tableau clinique des ane vrismes mycotiques de arte rablement varier, le diagnostic peut donc souvent l’aorte peut conside ritable de fi. Nous rapportons une e tude de cas constituer un ve ressante dans laquelle le patient ayant un ane vrisme mycotique de inte l’aorte montrait faussement l’aspect clinique d’un syndrome coronario rappelle qu’en de pit de la disponibilite de narien aigu. Le sce cises, une forte suspicion techniques d’imagerie non effractives pre clinique pourrait être essentielle pour poser le diagnostic des vrismes mycotiques. ane
Case Report A 75-year-old man with history of coronary artery disease, multiple previous coronary interventions, and anemia presented with chest pain and dyspnea. Five weeks earlier, he had undergone a diagnostic cardiac catheterization in evaluation of recurrent atypical chest pain. This revealed nonobstructive coronary artery disease with widely patent stents in the left anterior descending and left circumflex coronary arteries. Two weeks later, he was rehospitalized with purulent pericardial tamponade associated with staphylococcus aureus bacteremia, for which he underwent urgent pericardiocentesis followed by a surgical pericardiotomy and a 4-week course of intravenous antibiotic therapy. During the latest admission (approximately 3 weeks after pericardiotomy), he presented with recurrent chest pain. He
was afebrile, hemodynamically stable, and had normal oxygen saturation. An electrocardiogram showed diffuse precordial T-wave inversions, suggestive of an acute coronary syndrome (Fig. 1A and B). Initial cardiac biomarkers were negative (troponin < 0.03 ng/mL). Except for findings of chronic anemia, hemogram and comprehensive metabolic panel were unremarkable. In the emergency room, a chest computed tomography (CT) scan using a pulmonary embolism protocol did not reveal evidence of acute pulmonary embolism. Followup troponin T was positive at 0.3 ng/mL. A 2-dimensional echocardiogram revealed newly depressed left ventricular systolic function. Subsequent diagnostic cardiac catheterization showed significant ostial circumflex and left anterior descending artery stenosis (Fig. 1, C and D; Video 1 , view video online). Left ventriculogram revealed a new large saccular aneurysmal dilatation of the ascending thoracic aorta and confirmed reduced left ventricular systolic function (Fig. 1, E and F; Video 2 , view video online). In light of the findings of the left ventriculogram, the CT scan of the chest was reassessed more comprehensively for other cardiopulmonary abnormalities which then confirmed the presence of a large mycotic aneurysm of the ascending thoracic aorta,
Received for publication May 14, 2013. Accepted August 26, 2013. Corresponding author: Dr Chhabra, 285 Plantation Street, # 813, Worcester, Massachusetts 01604, USA. Tel.: þ1-508-667-5052; fax: þ1-888598-6647. E-mail: [email protected] See page 1742.e20 for disclosure information.
0828-282X/$ - see front matter Ó 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.08.010
1742.e18
Canadian Journal of Cardiology Volume 29 2013
Figure 1. (A) Precordial leads (V1-V6) of the admission electrocardiogram show diffuse ST-depression and T-wave inversions. (B) Electrocardiogram from the previous hospitalization was largely unremarkable. (C) Left ventriculogram showing dilatation of the ascending thoracic aorta (arrow), suspicious for a mycotic aneurysm. (D) Previous left ventriculogram (5 weeks earlier) reveals a normal thoracic aorta. (E) Cardiac catheterization showing significant ostial circumflex and left anterior descending artery stenosis (arrow). (F) Cardiac catheterization performed 5 weeks earlier shows normal-calibre left coronaries.
externally compressing the pulmonary trunk and the left coronary circulation (Fig. 2). He underwent an urgent open surgical aneurysm resection, aortic reconstruction, and coronary artery bypass grafting of the left anterior descending artery
using a saphenous vein graft with apparent relief of cardiac ischemia. He initially exhibited a good clinical recovery; unfortunately, on postoperative day 3, he sustained a large ischemic stroke with CT scan demonstration of significant midline shift
Chhabra et al. Mycotic Aneurysm: A Diagnostic Challenge
1742.e19
Figure 2. (A, B) Sagittal views of computed tomography scan of the chest show a large mycotic aortic aneurysm compressing the pulmonary artery and the left anterior descending coronary artery. (C, D) Transverse views show a mycotic aortic aneurysm compressing the left coronary circulation and the pulmonary artery.
and transtentorial herniation. He was then maintained on comfort-care measures only and expired shortly thereafter. Discussion Mycotic aortic aneurysms are very rare. The term ‘mycotic’ is a misnomer and is actually used to describe an infected aneurysm regardless of its etiology (and not specifically a fungal aneurysm as the name would imply). Some experts reserve this term for aneurysms that develop when material originating in the heart causes arterial wall infection and subsequently dilation. The risk factors for the development of a mycotic aneurysm include arterial injury (mostly resulting from invasive monitoring, cardiac catheterization, or coronary interventions), preceding infection (typically involving bacteremia), atherosclerosis, old age, and immunosuppression.1,2 The most common cause of an infected aortic aneurysm is bacterial seeding in a diseased or injured aortic intima with subsequent arteritis.1 The intima is usually highly resistant to infection, but when diseased, it allows bacterial passing through into deeper layers of the arterial wall. Staphylococcus aureus and Salmonella are the most commonly revealed bacteria on blood cultures,3-5 but other bacteria such as
staphylococcus epidermidis and streptococcus pneumoniae have been reported. Fungal aneurysms are very rare and usually occur in patients with diabetes mellitus, HIV, and immunosuppression. The clinical spectrum, diagnosis, and management of mycotic aortic aneurysms are described in the Supplementary Material. In summary, our case represents an extremely rare presentation of a rapidly progressing infected aneurysm, masquerading as acute coronary syndrome, secondary to external compression of the left coronary circulation. The diagnosis was in fact quite challenging because the patient lacked any systemic signs of infection and moreover, a major oversight occurred on the initial read of CT chest angiography. The patient unfortunately died of a massive stroke despite appropriate aggressive management measures being implemented when the correct diagnosis was established. Our case underscores the importance of considering uncommon conditions while evaluating common clinical presentations. Thus, despite the availability of accurate noninvasive imaging techniques, strong clinical suspicion might often be required for the diagnosis of mycotic aneurysms.
1742.e20
Disclosures The authors have no conflicts of interest to disclose. References 1. Isselbacher EM. Diseases of the aorta. In: Braunwald’s Heart Disease. Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: Saunders Elsevier, 2008:1486e7. 2. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;34:900-8. 3. Moneta GL, Taylor LM Jr, Yeager RA, et al. Surgical treatment of infected aortic aneurysm. Am J Surg 1998;175:396-9.
Canadian Journal of Cardiology Volume 29 2013 4. Mukherjee JT, Nautiyal A, Labib SB. Mycotic aneurysms of the ascending aorta in the absence of endocarditis. Tex Heart Inst J 2012;39: 692-5. 5. Malouf JF, Chandrasekaran K, Orszulak TA. Mycotic aneurysms of the thoracic aorta: a diagnostic challenge. Am J Med 2003;115:489-96.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/ 10.1016/j.cjca.2013.08.010.
Case Report
Rapidly Progressing Mycotic Aortic Aneurysm Masquerading As Acute Coronary Syndrome Lovely Chhabra, MD,a Mihaela A. Kruger, MD,b Gayatri Kuraganti, MD,a Rami Eltibi, MD,b Suresh Mamidala, MD,a Rishi Bajaj, MD,a Akhila Belur, MD,a Alwyn Rapose, MD,c and Joseph Hannan, MDb a b
Department of Internal Medicine, Saint Vincent Hospital and University of Massachusetts Medical School, Worcester, Massachusetts, USA
Department of Cardiovascular Medicine, Saint Vincent Hospital and University of Massachusetts Medical School, Worcester, Massachusetts, USA c
Department of Infectious Diseases, Saint Vincent Hospital and University of Massachusetts Medical School, Worcester, Massachusetts, USA
ABSTRACT
RESUM E
Mycotic aortic aneurysms are rare. The most common cause of a mycotic aortic aneurysm is bacterial seeding in a diseased or injured aortic intima with subsequent arteritis. Because the clinical presentation of mycotic aortic aneurysms can be quite variable, the diagnosis hence can often be quite challenging. We herewith report an interesting case study in which the patient with a mycotic aortic aneurysm presented with the clinical picture masquerading as an acute coronary syndrome. The scenario reiterates the fact that despite the availability of accurate noninvasive imaging techniques, strong clinical suspicion might be imperative for the diagnosis of mycotic aneurysms.
vrismes mycotiques de l’aorte sont rares. La cause la plus Les ane quente de l’ane vrisme mycotique de l’aorte est l’ensemencement fre rien dans l’intima de l’aorte pathologique ou atteinte suivi d’une bacte rite. Puisque le tableau clinique des ane vrismes mycotiques de arte rablement varier, le diagnostic peut donc souvent l’aorte peut conside ritable de fi. Nous rapportons une e tude de cas constituer un ve ressante dans laquelle le patient ayant un ane vrisme mycotique de inte l’aorte montrait faussement l’aspect clinique d’un syndrome coronario rappelle qu’en de pit de la disponibilite de narien aigu. Le sce cises, une forte suspicion techniques d’imagerie non effractives pre clinique pourrait être essentielle pour poser le diagnostic des vrismes mycotiques. ane
Case Report A 75-year-old man with history of coronary artery disease, multiple previous coronary interventions, and anemia presented with chest pain and dyspnea. Five weeks earlier, he had undergone a diagnostic cardiac catheterization in evaluation of recurrent atypical chest pain. This revealed nonobstructive coronary artery disease with widely patent stents in the left anterior descending and left circumflex coronary arteries. Two weeks later, he was rehospitalized with purulent pericardial tamponade associated with staphylococcus aureus bacteremia, for which he underwent urgent pericardiocentesis followed by a surgical pericardiotomy and a 4-week course of intravenous antibiotic therapy. During the latest admission (approximately 3 weeks after pericardiotomy), he presented with recurrent chest pain. He
was afebrile, hemodynamically stable, and had normal oxygen saturation. An electrocardiogram showed diffuse precordial T-wave inversions, suggestive of an acute coronary syndrome (Fig. 1A and B). Initial cardiac biomarkers were negative (troponin < 0.03 ng/mL). Except for findings of chronic anemia, hemogram and comprehensive metabolic panel were unremarkable. In the emergency room, a chest computed tomography (CT) scan using a pulmonary embolism protocol did not reveal evidence of acute pulmonary embolism. Followup troponin T was positive at 0.3 ng/mL. A 2-dimensional echocardiogram revealed newly depressed left ventricular systolic function. Subsequent diagnostic cardiac catheterization showed significant ostial circumflex and left anterior descending artery stenosis (Fig. 1, C and D; Video 1 , view video online). Left ventriculogram revealed a new large saccular aneurysmal dilatation of the ascending thoracic aorta and confirmed reduced left ventricular systolic function (Fig. 1, E and F; Video 2 , view video online). In light of the findings of the left ventriculogram, the CT scan of the chest was reassessed more comprehensively for other cardiopulmonary abnormalities which then confirmed the presence of a large mycotic aneurysm of the ascending thoracic aorta,
Received for publication May 14, 2013. Accepted August 26, 2013. Corresponding author: Dr Chhabra, 285 Plantation Street, # 813, Worcester, Massachusetts 01604, USA. Tel.: þ1-508-667-5052; fax: þ1-888598-6647. E-mail: [email protected] See page 1742.e20 for disclosure information.
0828-282X/$ - see front matter Ó 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.08.010
1742.e18
Canadian Journal of Cardiology Volume 29 2013
Figure 1. (A) Precordial leads (V1-V6) of the admission electrocardiogram show diffuse ST-depression and T-wave inversions. (B) Electrocardiogram from the previous hospitalization was largely unremarkable. (C) Left ventriculogram showing dilatation of the ascending thoracic aorta (arrow), suspicious for a mycotic aneurysm. (D) Previous left ventriculogram (5 weeks earlier) reveals a normal thoracic aorta. (E) Cardiac catheterization showing significant ostial circumflex and left anterior descending artery stenosis (arrow). (F) Cardiac catheterization performed 5 weeks earlier shows normal-calibre left coronaries.
externally compressing the pulmonary trunk and the left coronary circulation (Fig. 2). He underwent an urgent open surgical aneurysm resection, aortic reconstruction, and coronary artery bypass grafting of the left anterior descending artery
using a saphenous vein graft with apparent relief of cardiac ischemia. He initially exhibited a good clinical recovery; unfortunately, on postoperative day 3, he sustained a large ischemic stroke with CT scan demonstration of significant midline shift
Chhabra et al. Mycotic Aneurysm: A Diagnostic Challenge
1742.e19
Figure 2. (A, B) Sagittal views of computed tomography scan of the chest show a large mycotic aortic aneurysm compressing the pulmonary artery and the left anterior descending coronary artery. (C, D) Transverse views show a mycotic aortic aneurysm compressing the left coronary circulation and the pulmonary artery.
and transtentorial herniation. He was then maintained on comfort-care measures only and expired shortly thereafter. Discussion Mycotic aortic aneurysms are very rare. The term ‘mycotic’ is a misnomer and is actually used to describe an infected aneurysm regardless of its etiology (and not specifically a fungal aneurysm as the name would imply). Some experts reserve this term for aneurysms that develop when material originating in the heart causes arterial wall infection and subsequently dilation. The risk factors for the development of a mycotic aneurysm include arterial injury (mostly resulting from invasive monitoring, cardiac catheterization, or coronary interventions), preceding infection (typically involving bacteremia), atherosclerosis, old age, and immunosuppression.1,2 The most common cause of an infected aortic aneurysm is bacterial seeding in a diseased or injured aortic intima with subsequent arteritis.1 The intima is usually highly resistant to infection, but when diseased, it allows bacterial passing through into deeper layers of the arterial wall. Staphylococcus aureus and Salmonella are the most commonly revealed bacteria on blood cultures,3-5 but other bacteria such as
staphylococcus epidermidis and streptococcus pneumoniae have been reported. Fungal aneurysms are very rare and usually occur in patients with diabetes mellitus, HIV, and immunosuppression. The clinical spectrum, diagnosis, and management of mycotic aortic aneurysms are described in the Supplementary Material. In summary, our case represents an extremely rare presentation of a rapidly progressing infected aneurysm, masquerading as acute coronary syndrome, secondary to external compression of the left coronary circulation. The diagnosis was in fact quite challenging because the patient lacked any systemic signs of infection and moreover, a major oversight occurred on the initial read of CT chest angiography. The patient unfortunately died of a massive stroke despite appropriate aggressive management measures being implemented when the correct diagnosis was established. Our case underscores the importance of considering uncommon conditions while evaluating common clinical presentations. Thus, despite the availability of accurate noninvasive imaging techniques, strong clinical suspicion might often be required for the diagnosis of mycotic aneurysms.
1742.e20
Disclosures The authors have no conflicts of interest to disclose. References 1. Isselbacher EM. Diseases of the aorta. In: Braunwald’s Heart Disease. Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: Saunders Elsevier, 2008:1486e7. 2. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;34:900-8. 3. Moneta GL, Taylor LM Jr, Yeager RA, et al. Surgical treatment of infected aortic aneurysm. Am J Surg 1998;175:396-9.
Canadian Journal of Cardiology Volume 29 2013 4. Mukherjee JT, Nautiyal A, Labib SB. Mycotic aneurysms of the ascending aorta in the absence of endocarditis. Tex Heart Inst J 2012;39: 692-5. 5. Malouf JF, Chandrasekaran K, Orszulak TA. Mycotic aneurysms of the thoracic aorta: a diagnostic challenge. Am J Med 2003;115:489-96.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/ 10.1016/j.cjca.2013.08.010.