Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 375-377

Mycotic aortic aneurysm caused by Acinetobacter baumannii complex: A rare case


Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Date of Submission09-Jan-2021
Date of Acceptance19-Apr-2021
Date of Web Publication9-Dec-2021

Correspondence Address:
Naveen Rajendra
Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_8_21

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  Abstract 


Mycotic aneurysms are uncommon, difficult to treat, and fatal. These aneurysms caused by Acinetobacter baumannii complex are not documented. We present the case of a 20-year-old female who presented with pain abdomen and vomiting with on and off episodes of fever. This woman had a history of postpartum cardiomyopathy for 12 months and chronic kidney disease for 2 months, on medical treatment. She was diagnosed with an infrarenal aortic aneurysm with iliac extension caused by A. baumannii complex and left hydronephrosis. She was successfully treated with surgery followed by long-term antibiotics. There is no documented evidence of this organism to cause mycotic aneurysm. We also discuss about the course, investigations, and management of this case.

Keywords: Acinetobacter, mycotic aneurysm, surgery


How to cite this article:
Rajendra N, Sebastian JJ, Reddy A, Kumar A, Ayappan M K, Mathur K, Raju R. Mycotic aortic aneurysm caused by Acinetobacter baumannii complex: A rare case. Indian J Vasc Endovasc Surg 2021;8:375-7

How to cite this URL:
Rajendra N, Sebastian JJ, Reddy A, Kumar A, Ayappan M K, Mathur K, Raju R. Mycotic aortic aneurysm caused by Acinetobacter baumannii complex: A rare case. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jan 27];8:375-7. Available from: https://www.indjvascsurg.org/text.asp?2021/8/4/375/332056




  Introduction Top


Development of a mycotic aneurysm is uncommon but a fulminant process. It is potentially life threatening as it can lead to aortic aneurysm rupture, despite aggressive therapy. Staphylococcus aureus and Salmonella species are pathogens commonly associated with mycotic aneurysm development. We present a case of abdominal aortic mycotic aneurysm in a 20-year-old woman who presented with abdominal pain, vomiting and fever, caused by ACINETOBACTER BAUMANNII COMPLEX.


  Case Report Top


A 20-year-old female presented to the emergency department with a history of pain abdomen for 2 days and vomiting for 1 day. She gave a history of on and off fever associated with chills for 2 months. She was a known case of hypothyroidism, hypertension, and cardiomyopathy secondary to pregnancy and was on medical treatment. She was also diagnosed with chronic kidney disease for 2 months and was on medical treatment.

On admission, her vitals signs included pulse rate of 92/min, blood pressure of 144/88 mm Hg, respiratory rate of 19/min, and temperature of 100 F. On per abdomen examination, she had tenderness in the left lumbar region and left iliac fossa without any signs of guarding and rigidity.

Laboratory investigations showed a total leukocyte count of 6900/mm3, hemoglobin level of 10.4 g/dl, erythrocyte sedimentation rate (ESR) of 84 mm/h, C-reactive protein (CRP) of 4.2 mg/dl, blood urea of 23 mg/dl, and serum creatinine of 2.6 mg/dl. Contrast-enhanced computed tomography [Figure 1] of the abdomen and pelvis showed aneurysmal dilatation involving the infrarenal aorta, bilateral common and internal iliac artery with chronic thrombosis, multiple areas of parenchymal scarring in both kidneys, mild left hydroureteronephrosis with mild mural thickening, and narrowing of left ureter secondary to chronic periaortitis. Broad-spectrum antibiotics were started at diagnosis after blood cultures had been drawn.
Figure 1: Computed tomography aortogram showing aneurysmal lesions

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Given the diagnosis of infected/inflammatory “infrarenal aortic aneurysm with bilateral iliac artery aneurysm and chronic kidney disease,” she was taken up for surgery. Under general anesthesia, bilateral Double J stenting was done, followed by transabdominal approach to the aneurysm. The inflamed aneurysmal aortic wall was debrided and Rifampicin dipped bifurcated Dacron graft was used for aorta to left common iliac and right external iliac bypass followed by right graft to right internal iliac artery bypass [Figure 2]. The wall, plaques and debris were sent for culture and sensitivity.
Figure 2: Intra operative image showing aortobiliac bypass with graft extension to right internal iliac artery

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Postoperatively, the patient was closely monitored in the intensive care unit for 24 h and later transferred to the ward. The operative tissue culture grew Acinetobacter baumannii complex sensitive to several antibiotics including cefoperazone, ceftazidime, cefotaxime, ciprofloxacin, cefepime, gentamycin, levofloxacin, amikacin, and tetracycline. Blood cultures were negative. She recovered well and was ambulated by day 3 and was discharged on day 8 on ASA and long course of intravenous antibiotic as per the culture for 4 weeks followed by oral ciprofloxacin for 12 weeks, as recommended by the infectious diseases team.

At 1-month follow-up, she was clinically asymptomatic, her renal function was normal, her ESR was 24 mm/h, and CRP was 1.4 mg/dl, which were suggestive of reduction in the inflammatory response. She was advised for the double J stent removal after a month.


  Discussion Top


Mycotic aortic aneurysm is an uncommon disease that makes up 0.65% to 1.3% of all aortic aneurysms.[1] Microorganisms invade the aortic wall to cause mycotic aortic aneurysms. The mode of invasion may be via septic emboli, bacterial inoculation secondary to trauma, direct extension from adjacent infected fields like lymph nodes, or seeding of the vasa vasorum or of the intimal surface of a preexisting atherosclerotic plaque or aneurysm.[2],[3],[4],[5],[6],[7] Other predisposing factors include intravascular drug abuse, poor immunity, and iatrogenic causes such as catheterizations of the vessels for diagnostic or therapeutic purposes.[6]

Pathogens have been cultured from 46% to 74% of blood samples and 76% of tissue biopsy samples.[8],[9] The most frequent pathogens are S. aureus and Salmonella species,[10],[11],[12] but other organisms (e.g. Bacteroides species) have been occasionally reported as causative pathogens.[12],[13] The incidence of aneurysm rupture and mortality is higher with Gram-negative infections than with Gram-positive infections (84% vs. 10% for rupture and 84% vs. 50% for morality, respectively).[14]

In our patient, the source of the mycotic aneurysm remains unclear. Blood cultures were negative, with only the surgical tissue culture growing A. baumannii complex.

A. baumannii is a Gram-negative bacillus that is aerobic, pleomorphic, and nonmotile. An opportunistic pathogen, A. baumannii, has a high incidence among immunocompromised individuals, particularly those who have experienced a prolonged (>90 days) hospital stay.[15] It colonizes in the skin, respiratory, and oropharynx secretions of the infected individuals.[16] In recent years, it has been designated as a “red alert” human pathogen, generating alarm among the medical fraternity, arising largely from its extensive antibiotic resistance spectrum.[17]

The treatment of mycotic aortic aneurysm combines surgical intervention with intravenous antibiotics. Broad-spectrum antibiotics should be started as soon as there is clinical suspicion of a mycotic aortic aneurysm and can be tailored once cultures return.[2],[18] The gold standard for surgical treatment of infrarenal mycotic aortic aneurysms involves resection of the infected aorta along with extensive debridement of the surrounding periaortic tissue. Revascularization is performed by in situ reconstruction of the aorta or by aortic ligation and extra-anatomic bypass.[1],[19] There is no standardization regarding the conduit to choice. Superficial femoral veins, popliteal veins, cryopreserved arterial homografts, silver-coated Dacron grafts, or antibiotic-bonded grafts have all been tried.[20],[21]

Data regarding antibiotic-soaked grafts such as rifampin-soaked grafts remain mixed. In a canine model, rifampin-bonded gelatin-sealed polyester grafts were found to have significantly decreased rates of reinfection than silver/collagen-coated polyester grafts.[22]

To our knowledge, this is the first case of mycotic aneurysm caused by Acinetobacter baumannii complex. In the future, we hope that definitive treatment guidelines will be established for patients with mycotic aneurysm.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vallejo N, Picardo NE, Bourke P, Bicknell C, Cheshire NJ, Jenkins MP, et al. The changing management of primary mycotic aortic aneurysms. J Vasc Surg 2011;54:334-40.  Back to cited text no. 1
    
2.
Cartery C, Astudillo L, Deelchand A, Moskovitch G, Sailler L, Bossavy JP, et al. Abdominal infectious aortitis caused by Streptococcus pneumoniae: A case report and literature review. Ann Vasc Surg 2011;25:266.e9 -16.  Back to cited text no. 2
    
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Gornik HL, Creager MA. Aortitis. Circulation 2008;117:3039-51.  Back to cited text no. 3
    
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Cozijnsen L, Marsaoui B, Braam RL, Groenemeijer BE, van Hees BC, Kardux JJ, et al. Infectious aortitis with multiple mycotic aneurysms caused by Streptococcus agalactiae. Ann Vasc Surg 2013;27:975.e7-9.  Back to cited text no. 4
    
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Brown SL, Busuttil RW, Baker JD, Machleder HI, Moore WS, Barker WF. Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984;1:541-7.  Back to cited text no. 5
    
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Gomes MN, Choyke PL, Wallace RB. Infected aortic aneurysms. A changing entity. Ann Surg 1992;215:435-42.  Back to cited text no. 6
    
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Dawas K, Hicks RC. Pneumococcal aortitis causing aortic rupture. EJVES Extra 2003;6:70-2.  Back to cited text no. 7
    
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Müller BT, Wegener OR, Grabitz K, Pillny M, Thomas L, Sandmann W. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: Experience with anatomic and extra-anatomic repair in 33 cases. J Vasc Surg 2001;33:106-13.  Back to cited text no. 8
    
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Lee HL, Liu KH, Yang YJ, Kan CD. Bacteroidesfragilis aortic arch pseudoaneurysm: Case report with review. J Cardiothorac Surg 2008;3:29.  Back to cited text no. 9
    
10.
Johnson JR, Ledgerwood AM, Lucas CE. Mycotic aneurysm. New concepts in therapy. Arch Surg 1983;118:577-82.  Back to cited text no. 10
    
11.
Maeda H, Umezawa H, Goshima M, Hattori T, Nakamura T, Umeda T, et al. Primary infected abdominal aortic aneurysm: Surgical procedures, early mortality rates, and a survey of the prevalence of infectious organisms over a 30-year period. Surg Today 2011;41:346-51.  Back to cited text no. 11
    
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Malouf JF, Chandrasekaran K, Orszulak TA. Mycotic aneurysms of the thoracic aorta: A diagnostic challenge. Am J Med 2003;115:489-96.  Back to cited text no. 12
    
13.
Jarrett F, Darling RC, Mundth ED, Austen WG. Experience with infected aneurysms of the abdominal aorta. Arch Surg 1975;110:1281-6.  Back to cited text no. 13
    
14.
Montefour K, Frieden J, Hurst S, Helmich C, Headley D, Martin M, et al. Acinetobacter baumannii: An emerging multidrug-resistant pathogen in critical care. Crit Care Nurse 2008;28:15-25.  Back to cited text no. 14
    
15.
Sebeny PJ, Riddle MS, Petersen K. Acinetobacter baumannii skin and soft-tissue infection associated with war trauma. Clin Infect Dis 2008;47:444-9.  Back to cited text no. 15
    
16.
Cerqueira GM, Peleg AY. Insights into Acinetobacter baumannii pathogenicity. IUBMB Life 2011;63:1055-60.  Back to cited text no. 16
    
17.
Hollier LH, Money SR, Creely B, Bower TC, Kazmier FJ. Direct replacement of mycotic thoracoabdominal aneurysms. J Vasc Surg 1993;18:477-84.  Back to cited text no. 17
    
18.
Torsello G, Sandmann W, Gehrt A, Jungblut RM. In situ replacement of infected vascular prostheses with rifampin-soaked vascular grafts: Early results. J Vasc Surg 1993;17:768-73.  Back to cited text no. 18
    
19.
Robinson JA, Johansen K. Aortic sepsis: Is there a role for in situ graft reconstruction? J Vasc Surg 1991;13:677-82.  Back to cited text no. 19
    
20.
Bisdas T, Wilhelmi M, Haverich A, Teebken OE. Cryopreserved arterial homografts vs silver-coated Dacron grafts for abdominal aortic infections with intraoperative evidence of microorganisms. J Vasc Surg 2011;53:1274-810000.  Back to cited text no. 20
    
21.
Goëau-Brissonnière OA, Fabre D, Leflon-Guibout V, Di Centa I, Nicolas-Chanoine MH, Coggia M. Comparison of the resistance to infection of rifampin-bonded gelatin-sealed and silver/collagen-coated polyester prostheses. J Vasc Surg 2002;35:1260-3.  Back to cited text no. 21
    
22.
Smith JJ, Taylor PR. Endovascular treatment of mycotic aneurysms of the thoracic and abdominal aorta: The need for level I evidence. Eur J Vasc Endovasc Surg 2004;27:569-70.  Back to cited text no. 22
    


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