Case Study
Innominate artery injury from disseminated tuberculosis
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 704–706 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314523767 aan.sagepub.com
Oliver S Chow, Joe T Huang, Justin T Sambol, Paul J Bolanowski and Constantinos J Lovoulos
Abstract A 49-year-old man presented with chest pain and was found to have hemorrhage and drainage from a chest wound secondary to disseminated tuberculosis involving the sternum and ankle. He then developed acute hemorrhage from an innominate artery pseudoaneurysm originating just below a severely diseased sternoclavicular junction. A staged approach was used to manage his pathology given the life-threatening bleeding and his debilitated condition. He underwent endovascular stent grafting to exclude the pseudoaneurysm, followed by aggressive debridement of the affected sternal area.
Keywords Blood vessel prosthesis implantation, brachiocephalic trunk, mycobacterium tuberculosis, osteomyelitis, tuberculosis, osteoarticular, sternum
Introduction We present this unique case of disseminated tuberculosis with resultant ankle osteomyelitis, manubrial destruction, and an innominate artery pseudoaneurysm. Although exceedingly rare, disseminated tuberculosis can result in sternal osteomyelitis and pathologic fracture.1–3 To our knowledge, this is the first such case associated with vascular injury.
Case report A 49-year-old African American man with no past medical history presented to the emergency department complaining of chest pain, bleeding, and purulent drainage from his right chest after a fall. He had been in good health until one year prior to presentation, when he fell and injured his left ankle. Subsequently, he had numerous falls that he attributed to this injury. Upon further inquiry, he admitted to 9 kg of unintentional weight loss over the past year, subjective fevers, and a nonproductive cough over the past month. He was cachectic in appearance with a 1-cm ulcer over his right sternoclavicular region. The ulcer was inflamed and tender, but no bleeding or discharge was noted initially. An ulcer on his left lateral ankle with purulent
discharge was cultured and sent for an acid-fast bacilli test. Computed tomography revealed severe right sternoclavicular and manubrial bony destruction, pulmonary nodules, and cavitary lesions, along with axillary lymphadenopathy and subsegmental pulmonary emboli (Figure 1). Computed tomography of the lower extremity was suggestive of chronic osteomyelitis. The patient was admitted, underwent sampling of his leg ulcer and axillary nodes, and was empirically started on anti-tuberculin chemotherapy. During his hospitalization, he developed an episode of brisk bleeding from his right chest ulcer. A computed tomography-angiogram revealed a pseudoaneurysm originating from the innominate artery underneath the right sternoclavicular junction. The patient underwent an urgent angiogram which demonstrated a bovine arch and an innominate artery pseudoaneurysm between the common carotid arteries (Figure 2). Given the active bleeding, a decision
Rutgers New Jersey Medical School, Newark, NJ, USA Corresponding author: Constantinos J Lovoulos, 150 Bergen St., Suite F-102, Newark, NJ 07103, USA. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF FLORIDA Smathers Libraries on November 16, 2015
Chow et al.
705 and right vertebral arteries. There was retrograde filling of the right common carotid artery, demonstrating good collateral flow. The following day, the patient underwent debridement of his sternoclavicular junction with findings of significant clot content as well as severe bony destruction near the endograft. The entire wound was copiously irrigated with antibiotics, and a negativepressure wound therapy system was applied. The final pathological examination of the specimens obtained from the patient’s left foot, left below-knee-amputation, axillary lymph node, and clavicle all revealed acid-fast bacilli consistent with the diagnosis of disseminated tuberculosis, and cultures isolated Mycobacterium tuberculosis. With antituberculin therapy, he made a full recovery following the surgical procedures.
Discussion
Figure 1. Computed tomography showing pulmonary nodules and cavitary lesions with severe right sternoclavicular and manubrial bony destruction.
Figure 2. Angiogram demonstrating patient’s bovine arch and a pseudoaneurysm between the common carotid arteries.
was made to place a 9 mm 5 cm covered stent (Viabahn; Gore) across the area of injury to the innominate artery. The stent was deployed in a retrograde fashion across the origin of the right common carotid artery through a right brachial artery access. A completion angiogram confirmed exclusion of the pseudoaneurysm with preservation of the left common carotid
Sternal osteomyelitis secondary to tuberculosis is treated, as with other extrapulmonary manifestations of tuberculosis, using antituberculin therapy. There is some evidence that surgical debridement when there is considerable bony destruction is beneficial or even essential to cure.4 In our patient, given the uncontrolled hemorrhage from the innominate artery pseudoaneurysm, endovascular repair was chosen over an open intervention, which may have involved measures as extensive as cardiopulmonary bypass, deep hypothermia, and circulatory arrest in a severely debilitated patient. Once the patient was resuscitated and stabilized, efficient debridement of the involved musculoskeletal structures was performed. Negative-pressure wound therapy facilitated successful closure by secondary intention. Although graft infection was of significant concern, the benefit of controlling the active bleeding outweighed the risk of graft infection. A review of the literature revealed one report of tuberculosis graft infection in an elderly patient, but it is not clear whether the patient succumbed to this complication.5 This case represents an extraordinary presentation of disseminated tuberculosis, highlighting the complexity of the disease, and reiterating the need to consider aggressive debridement of localized disease with bony involvement. Additionally, we introduced the novel use of endovascular techniques as an adjunct in advanced cases.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from aan.sagepub.com at UNIV OF FLORIDA Smathers Libraries on November 16, 2015
706
Asian Cardiovascular & Thoracic Annals 23(6)
Conflicts of interest statement None declared.
References 1. McLellan DG, Philips KB, Corbett CE and Bronze MS. Sternal osteomyelitis caused by Mycobacterium tuberculosis: case report and review of the literature. Am J of Med Sci 2000; 319: 250–254. 2. Ouarssani A, Atoini F, Ait Lhou F and Idrissi Rguibi M. Sternal tuberculosis: report of 2 cases. Pan Afr Med J 2012; 11: 33.
3. Watts RA, Paice EW and White AG. Spontaneous fracture of the sternum and sternal tuberculosis. Thorax 1987; 42: 984–985. 4. Dutt AK, Moers D and Stead WW. Short-course chemotherapy for extrapulmonary tuberculosis. Nine years’ experience. Ann Intern Med 1986; 104: 7–12. 5. Marroni M, Cao P, Verzini F, Corneli P, Mazzola R and Stagni G. Thoracic aortic graft infection after disseminated tuberculosis. Lancet Infect Dis 2005; 5: 251.
Downloaded from aan.sagepub.com at UNIV OF FLORIDA Smathers Libraries on November 16, 2015
Innominate artery injury from disseminated tuberculosis
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 704–706 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314523767 aan.sagepub.com
Oliver S Chow, Joe T Huang, Justin T Sambol, Paul J Bolanowski and Constantinos J Lovoulos
Abstract A 49-year-old man presented with chest pain and was found to have hemorrhage and drainage from a chest wound secondary to disseminated tuberculosis involving the sternum and ankle. He then developed acute hemorrhage from an innominate artery pseudoaneurysm originating just below a severely diseased sternoclavicular junction. A staged approach was used to manage his pathology given the life-threatening bleeding and his debilitated condition. He underwent endovascular stent grafting to exclude the pseudoaneurysm, followed by aggressive debridement of the affected sternal area.
Keywords Blood vessel prosthesis implantation, brachiocephalic trunk, mycobacterium tuberculosis, osteomyelitis, tuberculosis, osteoarticular, sternum
Introduction We present this unique case of disseminated tuberculosis with resultant ankle osteomyelitis, manubrial destruction, and an innominate artery pseudoaneurysm. Although exceedingly rare, disseminated tuberculosis can result in sternal osteomyelitis and pathologic fracture.1–3 To our knowledge, this is the first such case associated with vascular injury.
Case report A 49-year-old African American man with no past medical history presented to the emergency department complaining of chest pain, bleeding, and purulent drainage from his right chest after a fall. He had been in good health until one year prior to presentation, when he fell and injured his left ankle. Subsequently, he had numerous falls that he attributed to this injury. Upon further inquiry, he admitted to 9 kg of unintentional weight loss over the past year, subjective fevers, and a nonproductive cough over the past month. He was cachectic in appearance with a 1-cm ulcer over his right sternoclavicular region. The ulcer was inflamed and tender, but no bleeding or discharge was noted initially. An ulcer on his left lateral ankle with purulent
discharge was cultured and sent for an acid-fast bacilli test. Computed tomography revealed severe right sternoclavicular and manubrial bony destruction, pulmonary nodules, and cavitary lesions, along with axillary lymphadenopathy and subsegmental pulmonary emboli (Figure 1). Computed tomography of the lower extremity was suggestive of chronic osteomyelitis. The patient was admitted, underwent sampling of his leg ulcer and axillary nodes, and was empirically started on anti-tuberculin chemotherapy. During his hospitalization, he developed an episode of brisk bleeding from his right chest ulcer. A computed tomography-angiogram revealed a pseudoaneurysm originating from the innominate artery underneath the right sternoclavicular junction. The patient underwent an urgent angiogram which demonstrated a bovine arch and an innominate artery pseudoaneurysm between the common carotid arteries (Figure 2). Given the active bleeding, a decision
Rutgers New Jersey Medical School, Newark, NJ, USA Corresponding author: Constantinos J Lovoulos, 150 Bergen St., Suite F-102, Newark, NJ 07103, USA. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF FLORIDA Smathers Libraries on November 16, 2015
Chow et al.
705 and right vertebral arteries. There was retrograde filling of the right common carotid artery, demonstrating good collateral flow. The following day, the patient underwent debridement of his sternoclavicular junction with findings of significant clot content as well as severe bony destruction near the endograft. The entire wound was copiously irrigated with antibiotics, and a negativepressure wound therapy system was applied. The final pathological examination of the specimens obtained from the patient’s left foot, left below-knee-amputation, axillary lymph node, and clavicle all revealed acid-fast bacilli consistent with the diagnosis of disseminated tuberculosis, and cultures isolated Mycobacterium tuberculosis. With antituberculin therapy, he made a full recovery following the surgical procedures.
Discussion
Figure 1. Computed tomography showing pulmonary nodules and cavitary lesions with severe right sternoclavicular and manubrial bony destruction.
Figure 2. Angiogram demonstrating patient’s bovine arch and a pseudoaneurysm between the common carotid arteries.
was made to place a 9 mm 5 cm covered stent (Viabahn; Gore) across the area of injury to the innominate artery. The stent was deployed in a retrograde fashion across the origin of the right common carotid artery through a right brachial artery access. A completion angiogram confirmed exclusion of the pseudoaneurysm with preservation of the left common carotid
Sternal osteomyelitis secondary to tuberculosis is treated, as with other extrapulmonary manifestations of tuberculosis, using antituberculin therapy. There is some evidence that surgical debridement when there is considerable bony destruction is beneficial or even essential to cure.4 In our patient, given the uncontrolled hemorrhage from the innominate artery pseudoaneurysm, endovascular repair was chosen over an open intervention, which may have involved measures as extensive as cardiopulmonary bypass, deep hypothermia, and circulatory arrest in a severely debilitated patient. Once the patient was resuscitated and stabilized, efficient debridement of the involved musculoskeletal structures was performed. Negative-pressure wound therapy facilitated successful closure by secondary intention. Although graft infection was of significant concern, the benefit of controlling the active bleeding outweighed the risk of graft infection. A review of the literature revealed one report of tuberculosis graft infection in an elderly patient, but it is not clear whether the patient succumbed to this complication.5 This case represents an extraordinary presentation of disseminated tuberculosis, highlighting the complexity of the disease, and reiterating the need to consider aggressive debridement of localized disease with bony involvement. Additionally, we introduced the novel use of endovascular techniques as an adjunct in advanced cases.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from aan.sagepub.com at UNIV OF FLORIDA Smathers Libraries on November 16, 2015
706
Asian Cardiovascular & Thoracic Annals 23(6)
Conflicts of interest statement None declared.
References 1. McLellan DG, Philips KB, Corbett CE and Bronze MS. Sternal osteomyelitis caused by Mycobacterium tuberculosis: case report and review of the literature. Am J of Med Sci 2000; 319: 250–254. 2. Ouarssani A, Atoini F, Ait Lhou F and Idrissi Rguibi M. Sternal tuberculosis: report of 2 cases. Pan Afr Med J 2012; 11: 33.
3. Watts RA, Paice EW and White AG. Spontaneous fracture of the sternum and sternal tuberculosis. Thorax 1987; 42: 984–985. 4. Dutt AK, Moers D and Stead WW. Short-course chemotherapy for extrapulmonary tuberculosis. Nine years’ experience. Ann Intern Med 1986; 104: 7–12. 5. Marroni M, Cao P, Verzini F, Corneli P, Mazzola R and Stagni G. Thoracic aortic graft infection after disseminated tuberculosis. Lancet Infect Dis 2005; 5: 251.
Downloaded from aan.sagepub.com at UNIV OF FLORIDA Smathers Libraries on November 16, 2015
