Case Study
Management of mycotic femoral artery aneurysm with two resistant organisms
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 742–744 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313490935 aan.sagepub.com
Man Fung Ho, Yiu-Che Chan and Stephen Wing-Keung Cheng
Abstract We report the management of a case of thigh abscess with ruptured left superficial femoral artery mycotic aneurysm in a 91-year-old woman with significant comorbidity. The abscess culture grew Escherichia coli and Acinetobacter baumannii. Vascular reconstruction was not performed because the foot was viable with a heavily contaminated wound. The thigh wound healed with the help of vacuum-assisted closure. This is the first report of a ruptured mycotic aneurysm of the superficial femoral artery associated with Escherichia coli and Acinetobacter baumannii infection. This case demonstrates that resection of a mycotic aneurysm without vascular continuity is feasible, especially in frail patients.
Keywords Aged, 80 and over, acinetobacter infections, aneurysm, false, escherichia coli infections, femoral artery, negative-pressure wound therapy
Introduction Mycotic pseudoaneurysms commonly arise from septic foci, with intimal disruption as a predisposing factor. The most common organisms causing mycotic pseudoaneurysms are methicillin-sensitive Staphylococcus aureus, Salmonella, Escherichia coli, Streptococcus, and Pseudomonas, and mixed growth is common.1–4 We report the successful treatment of a 91-year-old lady who had an emphysematous medial thigh muscle abscess associated with rupture of a proximal left superficial femoral artery mycotic aneurysm due to Escherichia coli and multidrug-resistant Acinetobacter baumannii.
Case report A 91-year-old, extremely frail, bed-bound lady with a fixed flexion deformity of the hips and knees and significant comorbidity of ischemic heart disease and chronic renal impairment, presented to the hospital with fever and delirium. The old peoples’ home staff discovered a progressively enlarging tender mass in her left thigh the day before, and referred her to the accident and emergency department. She was admitted under the Directorate of Orthopedics. There was no history of trauma, cannula or needle insertion.
The patient’s son said the mass has been there for about one week. She had no chest or urinary tract infection as potential septic foci. Clinical examination showed that the patient was septic and dehydrated. There was a large tender pulsatile mass in the left thigh, with clinical crepitus. Both feet were well perfused with full compliments of distal pulses palpable. A plain radiograph showed subcutaneous gas over the medial thigh, and an emergency computed tomography angiogram confirmed a 2.6-cm pseudoaneurysm from the proximal superficial femoral artery, with a 15 12cm intramuscular emphysematous abscess (Figure 1). After consulting the microbiologists, we started the patient on intravenous imipenem and cilastatin sodium, metronidazole, and vancomycin. She was resuscitated with fluids to optimize her condition. Emergency exploration of the left thigh showed a Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong Corresponding author: Yiu-Che Chan, Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14th Floor K Block, Queen Mary Hospital, Pokfulam Road, Hong Kong, China. Email: [email protected]
Downloaded from aan.sagepub.com at University of Sydney on May 1, 2015
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Figure 3. The left foot was well perfused postoperatively.
Figure 1. Emergency computed tomography showing soft tissue gas surrounding the superficial femoral artery pseudoaneurysm.
Figure 2. Perioperative photograph after draining the abscess, with a pseudoaneurysm from the proximal superficial femoral artery.
large infected hematoma in the left medial thigh (Figure 2). The superficial femoral artery proximal and distal to the abscess cavity was dissected out and controlled. The ruptured pseudoaneurysm was resected and oversewn with 2 layers of Prolene sutures. Pus and infected thrombus were drained. The wound was debrided and lavaged with copious amounts of hydrogen peroxide and normal saline solution. The wound was partially apposed, and the dead space was packed with gauze after a corrugated drain was inserted. The foot was well perfused at the end of procedure (Figure 3). A vacuum-assisted closure device was used in the ward to aid wound closure. The pseudoaneurysm wall was sent for culture and yielded multidrug-resistant Acinetobacter baumannii. However, a preoperative blood culture grew Escherichia coli. The wound healed slowly and there was no need for a subsequent operation. The leg was well perfused afterwards.
The patient did not receive any antibiotics prior to this surgical admission.
Discussion The superficial femoral artery is one of the most common sites of involvement by pseudoaneurysm, but the organism responsible may be elusive. In a review of 253 extrathoracic mycotic aneurysms, it was shown that the source of infection could not be identified in a quarter of the cases.5 The diagnosis is usually clinical, with a painful and pulsatile mass together with signs of sepsis. Our patient developed a mycotic pseudoaneurysm over the left superficial femoral artery without any history of sepsis, trauma, or groin puncture. A mycotic pseudoaneurysm can occur in native arteries when an atherosclerotic plaque is infected, especially in immunocompromised patients.3,4 Conventional treatment of mycotic aneurysms usually involves wide local debridement, resection of the infected artery, with or without revascularization via in-situ or extraanatomical bypass grafts, together with long-term antibiotic treatment.3,6 From experience with intravenous drug addicts who have septic groin pseudoaneurysms, it is possible not to revascularize without the consequence of ischemic limb loss.4 Vacuumassisted closure has achieved much success since its introduction in the 1990s for management of infected wounds, especially septic wounds that are not amendable to primary closure. The negative pressure promotes wound healing by encouraging local blood flow and granulation, with clearance of the inflammatory exudate and contaminants.7 Its use in vascular patients is not limited to those with diabetic wounds, but also applicable in patients with large wounds that cannot be closed primarily.7,8 We believe this is the first report of a patient who presented with emphysematous medial thigh muscle abscess associated with a ruptured superficial femoral artery mycotic aneurysm due to Escherichia coli and multidrug-resistant Acinetobacter baumannii.
Downloaded from aan.sagepub.com at University of Sydney on May 1, 2015
744
Asian Cardiovascular & Thoracic Annals 22(6)
Acinetobacter baumannii is an aerobic Gram-negative bacillus resistant to most antibiotics. It usually causes severe pneumonia or urinary tract infection in the immunocompromised, and is an important opportunistic and emerging pathogen that can lead to serious nosocomial infections.9 The global mortality in patients infected with Acinetobacter baumannii can be as high as 49%.10 Our patient was institutionalized and in an immunocompromised state, and thus would be susceptible to this organism. The surgical management of incision and drainage of the infected hematoma with ligation of the artery appeared to be effective in eradicating the sepsis without limb loss. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Ting AC and Cheng SW. Femoral pseudoaneurysms in drug addicts. World J Surg 1997; 21: 783–786. 2. Ponosh S, Brown MD and Sieunarine K. Pseudomonas aeruginosa infected aneurysm of the superficial femoral artery. ANZ J Surg 2004; 74: 613–615.
3. Chan YC, Morales JP and Taylor PR. The management of mycotic aortic aneurysms: is there a role for endoluminal treatment [Review]? Acta Chir Belg 2005; 105: 580–587. 4. Chan YC and Burnand KG. Management of septic groin complications and infected femoral false aneurysms in intravenous drug abusers. Br J Surg 2006; 93: 781–782. 5. Brown SL, Busuttil RW, Baker JD, Machleder HI, Moore WS and Barker WF. Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984; 1: 541–547. 6. Muller BT, Wegener OR, Grabitz K, Pillny M, Thomas L and 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: 106–113. 7. Chan YC, Nichol I, Evans GH and Stansby G. Managing the diabetic foot with the use of vacuum-assisted closure: a call for more studies. Int J Clin Pract 2006; 60: 256–257. 8. Dosluoglu HH, Loghmanee C, Lall P, Cherr GS, Harris LM and Dryjski ML. Management of early (
Management of mycotic femoral artery aneurysm with two resistant organisms
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 742–744 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313490935 aan.sagepub.com
Man Fung Ho, Yiu-Che Chan and Stephen Wing-Keung Cheng
Abstract We report the management of a case of thigh abscess with ruptured left superficial femoral artery mycotic aneurysm in a 91-year-old woman with significant comorbidity. The abscess culture grew Escherichia coli and Acinetobacter baumannii. Vascular reconstruction was not performed because the foot was viable with a heavily contaminated wound. The thigh wound healed with the help of vacuum-assisted closure. This is the first report of a ruptured mycotic aneurysm of the superficial femoral artery associated with Escherichia coli and Acinetobacter baumannii infection. This case demonstrates that resection of a mycotic aneurysm without vascular continuity is feasible, especially in frail patients.
Keywords Aged, 80 and over, acinetobacter infections, aneurysm, false, escherichia coli infections, femoral artery, negative-pressure wound therapy
Introduction Mycotic pseudoaneurysms commonly arise from septic foci, with intimal disruption as a predisposing factor. The most common organisms causing mycotic pseudoaneurysms are methicillin-sensitive Staphylococcus aureus, Salmonella, Escherichia coli, Streptococcus, and Pseudomonas, and mixed growth is common.1–4 We report the successful treatment of a 91-year-old lady who had an emphysematous medial thigh muscle abscess associated with rupture of a proximal left superficial femoral artery mycotic aneurysm due to Escherichia coli and multidrug-resistant Acinetobacter baumannii.
Case report A 91-year-old, extremely frail, bed-bound lady with a fixed flexion deformity of the hips and knees and significant comorbidity of ischemic heart disease and chronic renal impairment, presented to the hospital with fever and delirium. The old peoples’ home staff discovered a progressively enlarging tender mass in her left thigh the day before, and referred her to the accident and emergency department. She was admitted under the Directorate of Orthopedics. There was no history of trauma, cannula or needle insertion.
The patient’s son said the mass has been there for about one week. She had no chest or urinary tract infection as potential septic foci. Clinical examination showed that the patient was septic and dehydrated. There was a large tender pulsatile mass in the left thigh, with clinical crepitus. Both feet were well perfused with full compliments of distal pulses palpable. A plain radiograph showed subcutaneous gas over the medial thigh, and an emergency computed tomography angiogram confirmed a 2.6-cm pseudoaneurysm from the proximal superficial femoral artery, with a 15 12cm intramuscular emphysematous abscess (Figure 1). After consulting the microbiologists, we started the patient on intravenous imipenem and cilastatin sodium, metronidazole, and vancomycin. She was resuscitated with fluids to optimize her condition. Emergency exploration of the left thigh showed a Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong Corresponding author: Yiu-Che Chan, Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14th Floor K Block, Queen Mary Hospital, Pokfulam Road, Hong Kong, China. Email: [email protected]
Downloaded from aan.sagepub.com at University of Sydney on May 1, 2015
Ho et al.
743
Figure 3. The left foot was well perfused postoperatively.
Figure 1. Emergency computed tomography showing soft tissue gas surrounding the superficial femoral artery pseudoaneurysm.
Figure 2. Perioperative photograph after draining the abscess, with a pseudoaneurysm from the proximal superficial femoral artery.
large infected hematoma in the left medial thigh (Figure 2). The superficial femoral artery proximal and distal to the abscess cavity was dissected out and controlled. The ruptured pseudoaneurysm was resected and oversewn with 2 layers of Prolene sutures. Pus and infected thrombus were drained. The wound was debrided and lavaged with copious amounts of hydrogen peroxide and normal saline solution. The wound was partially apposed, and the dead space was packed with gauze after a corrugated drain was inserted. The foot was well perfused at the end of procedure (Figure 3). A vacuum-assisted closure device was used in the ward to aid wound closure. The pseudoaneurysm wall was sent for culture and yielded multidrug-resistant Acinetobacter baumannii. However, a preoperative blood culture grew Escherichia coli. The wound healed slowly and there was no need for a subsequent operation. The leg was well perfused afterwards.
The patient did not receive any antibiotics prior to this surgical admission.
Discussion The superficial femoral artery is one of the most common sites of involvement by pseudoaneurysm, but the organism responsible may be elusive. In a review of 253 extrathoracic mycotic aneurysms, it was shown that the source of infection could not be identified in a quarter of the cases.5 The diagnosis is usually clinical, with a painful and pulsatile mass together with signs of sepsis. Our patient developed a mycotic pseudoaneurysm over the left superficial femoral artery without any history of sepsis, trauma, or groin puncture. A mycotic pseudoaneurysm can occur in native arteries when an atherosclerotic plaque is infected, especially in immunocompromised patients.3,4 Conventional treatment of mycotic aneurysms usually involves wide local debridement, resection of the infected artery, with or without revascularization via in-situ or extraanatomical bypass grafts, together with long-term antibiotic treatment.3,6 From experience with intravenous drug addicts who have septic groin pseudoaneurysms, it is possible not to revascularize without the consequence of ischemic limb loss.4 Vacuumassisted closure has achieved much success since its introduction in the 1990s for management of infected wounds, especially septic wounds that are not amendable to primary closure. The negative pressure promotes wound healing by encouraging local blood flow and granulation, with clearance of the inflammatory exudate and contaminants.7 Its use in vascular patients is not limited to those with diabetic wounds, but also applicable in patients with large wounds that cannot be closed primarily.7,8 We believe this is the first report of a patient who presented with emphysematous medial thigh muscle abscess associated with a ruptured superficial femoral artery mycotic aneurysm due to Escherichia coli and multidrug-resistant Acinetobacter baumannii.
Downloaded from aan.sagepub.com at University of Sydney on May 1, 2015
744
Asian Cardiovascular & Thoracic Annals 22(6)
Acinetobacter baumannii is an aerobic Gram-negative bacillus resistant to most antibiotics. It usually causes severe pneumonia or urinary tract infection in the immunocompromised, and is an important opportunistic and emerging pathogen that can lead to serious nosocomial infections.9 The global mortality in patients infected with Acinetobacter baumannii can be as high as 49%.10 Our patient was institutionalized and in an immunocompromised state, and thus would be susceptible to this organism. The surgical management of incision and drainage of the infected hematoma with ligation of the artery appeared to be effective in eradicating the sepsis without limb loss. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Ting AC and Cheng SW. Femoral pseudoaneurysms in drug addicts. World J Surg 1997; 21: 783–786. 2. Ponosh S, Brown MD and Sieunarine K. Pseudomonas aeruginosa infected aneurysm of the superficial femoral artery. ANZ J Surg 2004; 74: 613–615.
3. Chan YC, Morales JP and Taylor PR. The management of mycotic aortic aneurysms: is there a role for endoluminal treatment [Review]? Acta Chir Belg 2005; 105: 580–587. 4. Chan YC and Burnand KG. Management of septic groin complications and infected femoral false aneurysms in intravenous drug abusers. Br J Surg 2006; 93: 781–782. 5. Brown SL, Busuttil RW, Baker JD, Machleder HI, Moore WS and Barker WF. Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984; 1: 541–547. 6. Muller BT, Wegener OR, Grabitz K, Pillny M, Thomas L and 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: 106–113. 7. Chan YC, Nichol I, Evans GH and Stansby G. Managing the diabetic foot with the use of vacuum-assisted closure: a call for more studies. Int J Clin Pract 2006; 60: 256–257. 8. Dosluoglu HH, Loghmanee C, Lall P, Cherr GS, Harris LM and Dryjski ML. Management of early (
