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PATIENT STORY

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A 36-year-old man was admitted to the hospital with signs and symptoms of sepsis. He had a history of intravenous drug abuse as well as hepatitis B and C. He was discovered to have a left forearm abscess at an intravenous drug access site, as well as septic arthritis of the left hip with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.

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He underwent incision and drainage of the left hip and conservative management of the left forearm. A computed tomographic arteriogram (CTA) of the abdomen for abdominal pain showed inflammation around the distal abdominal aorta consistent with aortitis (Figure 35-1). Although his clinical course improved, his abdominal pain persisted and a repeat CTA 1 week later showed a large false aneurysm of the distal aorta (Figure 35-2).

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Options were discussed and he underwent successful endovascular repair of the aorta (Figures 35-3 and 35-4) and was discharged eventually on long-term antibiotics.

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FIGURE 35-1

Computed tomographic (CT) scan with periaortic inflammation consistent with aortitis (blue arrow).

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FIGURE 35-2

Distal aortic mycotic false aneurysm 1 week later (blue arrow).

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FIGURE 35-3

Aortogram demonstrating distal aortic false aneurysm (blue arrow) and involvement of the iliac vessels.

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FIGURE 35-4

Successful aortic endograft placement, resolving the false aneurysm.

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EPIDEMIOLOGY

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  • Infectious aortitis represents a rare etiology of aortic aneurysm with one of the largest reviews revealing that 2.8% of 673 consecutive abdominal aortic aneurysm (AAA) patients presented with infectious aortitis as the etiology, including locations in the thoracic and abdominal aortas.1

  • The disease is significantly more devastating than traditional aneurysmal disease with a large proportion of patients with a mycotic aneurysm (19%-48%) presenting for the first time with rupture.1,2, and 3

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ETIOLOGY OR PATHOPHYSIOLOGY

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  • The term mycotic is actually a misnomer for infectious aortitis since most aortic infections are not secondary to a fungal pathogen. Many organisms have been implicated with S aureus being the most common.

  • Others include Streptococcus pneumoniae, Listeria monocytogenes, Pseudomonas aeruginosa, Morganella morganii, Pasteurella multocida, and Salmonella species.4,5,6,7,8, and 9

  • Infections in native vessels are most commonly the result of seeding from a remote source or infections in an immunocompromised host. Infections also occur in previously placed prosthetic grafts, but this is a different disease entity and not the subject of this chapter.

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DIAGNOSIS

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Clinical Features

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