Huge Mycotic Aneurysm at the Celiac Trunk in a Patient With Severe Aortic Regurgitation Due to Infective Endocarditis

A 67-year-old female patient suffering from fever, general weakness, and dyspnea visited our emergency department (ER). She had no significant medical history.

With the results of elevated C-reactive protein (9.44 mg/dL) and brain natriuretic peptide (1,471 pg/mL), we performed transthoracic echocardiography (TTE) to evaluate the cause of symptoms. TTE showed a mobile echogenic mass at the aortic valve (AV) and severe aortic regurgitation (Figure A-1); then a >1 cm-sized vegetation and prolapse of the non-coronary cusp of the AV was found (Figure A-2,A-3). An empirical antibiotic agent (Ceftriaxone and gentamicin) was administrated immediately and this was changed to ampicillin following blood culture (Streptococcus mitis). For treating aortic regurgitation and infective endocarditis (IE), we performed an AV replacement (9^th hospital day). During the smooth recovery from surgery, the patient complained of severe epigastric pain on the 15^th postoperative day. A huge mycotic aneurysm (5.8×4.2×4.6 cm) that originated from the celiac trunk was found by using abdominopelvic computed tomography (APCT) (Figure B-1,B-2; Supplementary Movie 1); this aneursym did not appear on the pre-operative scan taken in the ER (Figure B-3). We decided to coil-embolize the celiac trunk to reduce the mycotic aneurysm (Figure C-1,C-2); however, the blood flow still existed a week later. An additional thrombin injection was therefore made into the mycotic aneurysm (Figure C-3,C-4; Supplementary Movie 2). As a result of this further treatment, the patient was discharged without any epigastric discomfort.

Figure.

(A-1) Transthoracic echocardiography, (A-2,A-3) transesophgeal echocardiography image of infective endocarditis and severe aortic regurgitation. (B-1,B-2) Abdominal CT image of celiac artery mycotic aneurysm (McA) and (B-3) CT of pre-operative state. (C-1,C-2) Image of coil embolization for celiac artery and (C-3,C-4) thrombin injection to a mycotic aneurysm.

Mycotic aneurysms associated with IE are caused by septic embolization of vegetation and infection that has spread throughout the vessel wall.¹ The development of a mycotic aneurysm caused by IE may be associated with a delayed diagnosis and caused by a low virulence microorganism.² However, factors associated with the size of an aneurysm are unknown. Delayed presentation because of a low virulence pathogen and anticoagulation during surgery may influence the size of the aneurysm. Furthermore, the location of the aneurysm, which in this case was surrounded by relatively soft tissue, could affect the size. In addition, it was thought that this case of mycotic aneurysm evolved within 9 days because surgical intervention was performed on the 9^th hospital day after APCT in the ER. Although the celiac artery mycotic aneurysm in this case was large and grew rapidly, we could still safely treat it using coiling and a thrombin injection. This case highlights the potential vascular complication of IE and the need for physician awareness.

Acknowledgment

The Soonchunhyang University Research Fund supported this work. All authors appreciated Il Joong Kim and Hwa Suk Koh for efforts in imaging.

Disclosures

The authors declare no conflicts of interest.

Supplementary Files

Supplementary Movie 1. Celiac mycotic aneurysm in APCT.

Supplementary Movie 2. Pre- and post-procedure angiography.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-20-1226

References

• 1.   Chambers HF, Bayer AS. Native-valve infective endocarditis. N Engl J Med 2020; 383: 567–576.
• 2.   Gonzalez I, Sarria C, Lopez J, Vilacosta I, San Roman A, Olmos C, et al. Symptomatic peripheral mycotic aneurysms due to infective endocarditis: A contemporary profile. Medicine (Baltimore) 2014; 93: 42–52.