469 lines
28 KiB
Markdown
469 lines
28 KiB
Markdown
---
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title: "Mycotic Aneurysm"
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docid: "20616d0a-7e0b-48d9-9be9-1af29e3dd6da"
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authors:
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- key: "ee6ece9d-ad74-458c-a8df-11628ae7f879"
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value: "Arzu Canan, MD"
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- key: "3d1e4c57-c1cf-4c89-b0f0-5d82b29a31e1"
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value: "Suhny Abbara, MD, FACR, MSCCT, FNASCI"
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- key: "501b57b9-1723-4b1e-b21e-d4516655fac8"
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value: "Sanjeeva P. Kalva, MD, FSIR, FCIRSE"
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breadcrumbs:
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-
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name: "Cardiac"
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slug: "cardiac"
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treeNodeId: "fa90100b-619c-430e-8074-b5b9789bab39"
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-
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "5c92cf4f-e9d5-4059-9c13-22255c51c121"
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-
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name: "Aorta"
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slug: "aorta"
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treeNodeId: "4d206a6b-1a82-467c-9199-0df25ab749d7"
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-
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name: "Mycotic Aneurysm"
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slug: "mycotic-aneurysm"
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treeNodeId: null
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category: "Cardiac"
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documentVersionId: "8f0b7338-cf37-4f0c-ad92-25741a515b79"
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imageCount: 18
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lastUpdated: "11/20/24"
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pageDescription: "Mycotic Aneurysm"
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pageKeywords: "Cardiac, Diagnosis, Aorta, Mycotic Aneurysm"
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pageTitle: "Mycotic Aneurysm | STATdx"
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enhancedTitle: "Mycotic Aneurysm"
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type: "DX"
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references: true
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ddx: true
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cases: 1
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breadcrumbs:
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- "Cardiac"
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- "Diagnosis"
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- "Aorta"
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- "Mycotic Aneurysm"
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---
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# KEY FACTS
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- ## Terminology
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- Aneurysm arising from infection of arterial wall, usually bacterial
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- ## Imaging
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- Rapidly growing focal saccular aneurysm arising eccentrically from aortic wall
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- Periaortic soft tissue stranding, edema, and fluid
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- Adjacent vertebral body or psoas abnormalities due to spread of infection
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- Increased uptake of labeled leukocytes at site of aneurysm
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- ## Top Differential Diagnoses
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- Atherosclerotic aneurysm
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- Inflammatory aneurysm
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- Contained rupture
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- Aortoenteric fistula
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- ## Pathology
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- Bacterial aortitis most commonly caused by *Salmonella* or *Staphylococcus aureus*
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- Primary mycotic aneurysm arises from distant, unknown, or remote source of infection
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- Secondary mycotic aneurysm arises from specific source of infection
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- ## Clinical Issues
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- Fever, signs of sepsis
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- Positive blood cultures in most cases
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- Surgical resection/grafting following antibiotic therapy
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- ## Diagnostic Checklist
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- Contrast-enhanced CTA or MRA with delayed images for evaluation
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- Labeled leukocyte scan if indeterminate CTA and MRA
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# TERMINOLOGY
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- ## Synonyms
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- Infectious aneurysm (more appropriate term)
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- ## Definitions
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- Aneurysm arising from infection of arterial wall, usually bacterial
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# IMAGING
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- ## General Features
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- ### Best diagnostic clue
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- Rapidly growing saccular aneurysm arising eccentrically from aortic wall
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- ### Location
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- Anywhere in aorta or other vessels
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- Tends to occur at major branch points of aorta
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- ### Size
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- Variable
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- ### Morphology
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- Usually saccular with focal involvement of artery
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- Periaortic inflammation, abscess, mass
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- Periaortic gas
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- Adjacent vertebral body abnormalities due to spread of infection
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- ## Radiographic Findings
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- ### Radiography
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- May reveal increased size of aorta
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- Lytic or sclerotic areas in adjacent bone
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- ## CT Findings
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- ### NECT
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- Periaortic soft tissue stranding, edema, and fluid are frequent
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- Periaortic gas
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- Adjacent vertebral body or psoas abnormalities due to spread of infection
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- Periaortic, high-attenuation fluid if ruptured
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- Bacterial aortitis is rarely calcified
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- Syphilitic aortitis shows curvilinear calcifications
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- ### CECT
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- ≥ 1 saccular aneurysm(s) arising from aortic wall, usually focal
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- Lobular contours of aneurysm
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- Enhancement of periaortic soft tissue
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- Rim enhancement in case of abscess
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- ### CTA
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- Saccular, eccentric aneurysms of variable size
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- Enhancing periaortic soft tissue or abscess
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- ## MR Findings
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- ### T1WI
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- Periaortic low signal intensity in nonenhanced MR
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- Aortic and periaortic enhancement following gadolinium, especially evident on fat-suppressed images
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- Rim enhancement in case of abscess
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- Adjacent bone abnormality if contiguous infection
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- ### T2WI
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- Periaortic high signal intensity on fat-suppressed T2WI
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- Contrast-enhanced MRA
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- ≥ 1 saccular aneurysm(s) arising from aortic wall
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- Effacement of wall with possible leakage at rupture site
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- In addition to MRA, delayed source images need to be analyzed to identify areas of enhancement
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- ## Ultrasonographic Findings
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- ### Grayscale ultrasound
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- Useful in children or if superficial arteries are involved
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- Focal, eccentric pseudoaneurysm
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- Perivascular soft tissue or abscess
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- ### Color Doppler
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- Flow within aneurysm with typical yin-yang configuration
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- ## Echocardiographic Findings
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- ### Echocardiogram
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- Used to rule out endocarditis as potential source of septic emboli
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- ## Angiographic Findings
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- Conventional
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- Focal, saccular aneurysm
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- Irregularity of luminal surface
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- ## Nuclear Medicine Findings
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- ### Labeled leukocyte scintigraphy
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- Increased uptake at site of aneurysm
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- ## Imaging Recommendations
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- ### Best imaging tool
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- Contrast-enhanced CT/CTA
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- Labeled leukocyte scintigraphy
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- ### Protocol advice
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- Obtain delayed images during contrast-enhanced CTA or MRA
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- Review adjacent bones
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# DIFFERENTIAL DIAGNOSIS
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- ## Atherosclerotic Aneurysm
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- Slow growing
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- More often fusiform
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- Often calcified
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- No enhancement of aortic wall
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- ## Inflammatory Aneurysm
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- Distal aorta and iliac involvement
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- Thick rind of soft tissue around aorta
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- Uniform, rim-like aortic wall enhancement on contrast CT/MR
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- Fusiform aneurysm
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- Retroperitoneal fibrosis
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- ## Contained Rupture
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- Focal disruption or gap in aortic wall
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- High attenuation in wall or in periphery of aneurysm
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- Lack of enhancement
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- ## Aortoenteric Fistula
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- Most involve duodenum
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- Periaortic soft tissue with periaortic gas
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- Active contrast material extravasation or pseudoaneurysm
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- Presents as gastrointestinal bleed
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- ## Surgical material
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- History of prior surgery
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- Hyperdense on NECT
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- Bacterial aortitis most commonly caused by *Salmonella* or *Staphylococcus aureus*
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- Syphilitic aortitis involves ascending aorta but spares aortic sinus: Ascending aorta most common location
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- Routes of infection
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- Most often caused by seeding of existing lesion (atheroma or aneurysm) via vasa vasorum
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- Direct extension from infection in vessel wall, i.e., bacterial endocarditis
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- Invasion of aortic wall by extravascular contiguous infection, such as spinal infection or intraabdominal abscess
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- Lymphatic spread
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- *Burkholderia pseudomallei* (causing melioidosis), endemic in Southeast Asia and Northern Australia, is increasingly recognized as agent causing aortitis and mycotic aneurysms
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- ### Associated abnormalities
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- Endocarditis
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- Spinal or retroperitoneal infection
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- Intraabdominal infection
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- ## Staging, Grading, & Classification
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- Classification system
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- Primary mycotic aneurysm arises from distant, unknown, or remote source of infection
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- Secondary mycotic aneurysm arises from specific source of infection
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- Bacterial endocarditis (intravascular spread)
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- Tuberculosis (contiguous spread)
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- ## Gross Pathologic & Surgical Features
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- Bacterial aneurysm
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- Noncalcified saccular aneurysm
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- Thinning of aortic wall with periaortic inflammatory changes
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- Syphilitic aneurysm
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- Calcified lesion
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- Tree bark appearance when atheroma develops in infected areas
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- ## Microscopic Features
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- Loss of intima and destruction of internal elastic lamina
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- Varying degrees of destruction of media
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- Bacteria present on histology
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- Common bacteria: *Pseudomonas*, *Clostridium*, *Salmonella*, *Streptococcus*, *Aspergillus*
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# CLINICAL ISSUES
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- ## Presentation
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- ### Most common signs/symptoms
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- Fever, signs of sepsis
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- Symptoms vary greatly
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- Nonspecific findings
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- Low-grade fever
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- Localized pain
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- Positive blood cultures
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- Blood cultures are negative in 25% of cases
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- ## Demographics
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- ### Epidemiology
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- 0.7-2.6% of all aortic aneurysms
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- Increased risk in
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- Intravenous drug abusers
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- Patients with history of bacterial endocarditis
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- Occurs in 2% of patients with infective endocarditis
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- Most common location is intracranial
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- Rupture more easily and associated with poor prognosis
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- Immunocompromised patients
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- Patients with vascular prostheses (valves, grafts)
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- ## Natural History & Prognosis
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- Nearly always fatal if untreated
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- Acute rupture/hemorrhage seen in 75%
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- Mortality rate estimated at 67%
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- ## Treatment
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- Surgical resection/grafting following antibiotic therapy
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- May need extraanatomic bypass grafting
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- Endovascular repair in some cases
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# DIAGNOSTIC CHECKLIST
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- ## Consider
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- Contrast-enhanced CTA or MRA with delayed images for evaluation
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- Labeled leukocyte scan if CTA and MRA are indeterminate
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- ## Image Interpretation Pearls
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- Focal, eccentric aneurysm of aorta
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- Enhancing periaortic soft tissue
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- Rim enhancement of periaortic abscess
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- ## Reporting Tips
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- Include location, size, and involvement of branch vessels
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- Check for and report extent of contiguous infection
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a1eb2f8e-cf67-4cad-84d1-41c6f82b7d53
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## References
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# Selected References
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1. [Calderón-Parra J et al: Epidemiology and risk factors of mycotic aneurysm in patients with infective endocarditis and the impact of its rupture in outcomes. Analysis of a national prospective cohort. Open Forum Infect Dis. 11(3):ofae121, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38500574%5Bpmid%5D)
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1. [Wyss TR et al: Infective native aortic aneurysm: a Delphi consensus document on treatment, follow up, and definition of cure. Eur J Vasc Endovasc Surg. 67(4):654-61, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38097164%5Bpmid%5D)
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1. [Wu H et al: Mycotic aneurysm secondary to melioidosis in China: a series of eight cases and a review of literature. PLoS Negl Trop Dis. 14(8):e0008525, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32785225%5Bpmid%5D)
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1. [Haidar GM et al: "In situ" endografting in the treatment of arterial and graft infections. J Vasc Surg. 65(6):1824-9, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28359717%5Bpmid%5D)
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1. [Sörelius K et al: Endovascular treatment of mycotic aortic aneurysms: a paradigm shift. J Cardiovasc Surg (Torino). 58(6):870-4, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28627863%5Bpmid%5D)
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1. [Deipolyi AR et al: Imaging findings, diagnosis, and clinical outcomes in patients with mycotic aneurysms: single center experience. Clin Imaging. 40(3):512-6, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27133696%5Bpmid%5D)
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1. [Murphy DJ et al: Cross-sectional imaging of aortic infections. Insights Imaging. 7(6):801-18, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27761883%5Bpmid%5D)
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1. [Uchida N et al: In situ replacement for mycotic aneurysms on the thoracic and abdominal aorta using rifampicin-bonded grafting and omental pedicle grafting. Ann Thorac Surg. 93(2):438-42, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22054654%5Bpmid%5D)
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1. [Iida H et al: Bacteremia causes mycotic aneurysm of the aortic arch in 110 days. Ann Thorac Surg. 83(5):1874-6, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17462421%5Bpmid%5D)
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1. [Taylor CF et al: Treatment options for primary infected aorta. Ann Vasc Surg. 21(2):225-7, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17349369%5Bpmid%5D)
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1. [Froeschl M et al: Ruptured mycotic pseudoaneurysm of the thoracic aorta. Cardiovasc Pathol. 15(2):116-8, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16533702%5Bpmid%5D)
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1. [Kerzmann A et al: Infected abdominal aortic aneurysm treated by in situ replacement with cryopreserved arterial homograft. Acta Chir Belg. 106(4):447-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=17017707%5Bpmid%5D)
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1. [Lee KH et al: Stent-graft treatment of infected aortic and arterial aneurysms. J Endovasc Ther. 13(3):338-45, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16784321%5Bpmid%5D)
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1. [Palanichamy N et al: Mycotic pseudo-aneurysm of the ascending thoracic aorta after cardiac transplantation. J Heart Lung Transplant. 25(6):730-3, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16730580%5Bpmid%5D)
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1. [Ting AC et al: Endovascular stent graft repair for infected thoracic aortic pseudoaneurysms--a durable option? J Vasc Surg. 44(4):701-5, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16930927%5Bpmid%5D)
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1. [Gonzalez-Fajardo JA et al: Endovascular repair in the presence of aortic infection. Ann Vasc Surg. 19(1):94-8, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15714375%5Bpmid%5D)
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1. [Ting AC et al: Surgical treatment of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta. Am J Surg. 189(2):150-4, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15720981%5Bpmid%5D)
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1. [Malouf JF et al: Mycotic aneurysms of the thoracic aorta: a diagnostic challenge. Am J Med. 115(6):489-96, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=14563506%5Bpmid%5D)
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1. [Cina CS et al: Ruptured mycotic thoracoabdominal aortic aneurysms: a report of three cases and a systematic review. J Vasc Surg. 33(4):861-7, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11296343%5Bpmid%5D)
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1. [Locati P et al: Salmonella mycotic aneurysms: traditional and "alternative" surgical repair with arterial homograft. Minerva Cardioangiol. 47(1-2):31-7, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10356939%5Bpmid%5D)
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1. [Long R et al: Tuberculous mycotic aneurysm of the aorta: review of published medical and surgical experience. Chest. 115(2):522-31, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10027455%5Bpmid%5D)
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1. [Fichelle JM et al: Infected infrarenal aortic aneurysms: when is in situ reconstruction safe? J Vasc Surg. 17(4):635-45, 1993](http://www.ncbi.nlm.nih.gov/pubmed/?term=8464080%5Bpmid%5D)
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## Differential diagnosis
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### Dilated Aorta
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DDX:9daee273-f1e9-4cf9-a979-8990a9b82e40
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### Dilated Aorta
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DDX:bb8315f3-0893-4f17-aaf6-343fd5419b8e
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## Cases
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- {'cases': [{'authors': [{'key': 'bee1f359-33fb-4cba-9e6b-ed1ca1842439', 'value': 'Jeffrey S. Ross, MD'}], 'caseVersionId': 'cf6a6efe-995c-4a18-9cb2-5f3395aae678', 'description': "Variant case of a rare mycotic aneurysm presumably from extension from the adjacent thoracic osteomyelitis. The patient's hemoptysis was from the additional complication of an aortobronchial fistula. Patient was emergently treated with a covered stent within the descending aorta.\n\nCTA study of the thorax (#1-8) shows typical appearance of a midthoracic disc space infection with collapse of the disc space and endplate destruction (arrow, #1). Midline sagittal image (#1) also shows adjacent soft tissue mass within the posterior mediastinum (open arrows, #1). The contrast-enhanced images show a large, irregular, enhancing lesion consistent with pseudoaneurysm (open arrows, #2-5) within the posterior mediastinum that displaces the aorta anteriorly (curved arrows, #3-5). The vertebral body destruction from the osteomyelitis (arrows, #3-5) and the extension into the prevertebral soft tissues and mediastinum is seen on the axial views. Coronal images (#6-8) show the pseudoaneurysm (arrows) and the surrounding inflammatory mass as well as the disc space centered bony destruction (open arrow, #8).\n\nOblique aortogram shows contrast extravasating into the pseudoaneurysm with a broad neck (arrows, #9,10).", 'history': 'Presented with massive hemoptysis; history of back pain.', 'imagePoolId': 'd5da4f47-3ed7-4e07-9c88-8dcf8bb6ae26', 'name': 'Aortic vertebral fistula and aortobronchial fistula', 'teachingPoint': None, 'demographics': '59 Years old male'}], 'caseType': 'variant', 'name': 'VARIANT'}
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## Images
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### Selected Images
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*Axial CECT of the abdominal aorta shows periaortic, low-density soft tissue <img src='img/arrows/WC.png'/> with rim enhancement <img src='img/arrows/WS.png'/> of the aortic wall, which is consistent with an infected aortic wall and periaortic abscess.*
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*Axial CECT of the abdominal aorta shows periaortic, low-density soft tissue <img src='img/arrows/WC.png'/> with rim enhancement <img src='img/arrows/WS.png'/> of the aortic wall, which is consistent with an infected aortic wall and periaortic abscess.*
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*Axial CECT of the aorta in the same patient shows an area of focal, small luminal outpouching (pseudoaneurysm) <img src='img/arrows/WO.png'/> of the left lateral wall of the aorta with associated periaortic soft tissue swelling <img src='img/arrows/WS.png'/>, consistent with a mycotic aneurysm.*
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*Oblique CTA reconstruction in the same patient shows 2 focal contrast outpouchings consistent with mycotic pseudoaneurysms <img src='img/arrows/WS.png'/> affecting the lateral wall of the abdominal aorta.*
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*Coronal CTA of the aortoiliac arteries in the same patient following infrarenal aortic resection shows that the lower extremities are now perfused via a right axillary-femoral artery bypass graft <img src='img/arrows/WS.png'/> and cross-femoral bypass graft <img src='img/arrows/WO.png'/>. Note the absence of resected infrarenal aorta.*
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*Axial CTA of the abdominal aorta shows a focal, eccentric pseudoaneurysm <img src='img/arrows/WS.png'/> affecting the juxtarenal abdominal aorta <img src='img/arrows/WO.png'/>. Note the minimal periaortic soft tissue.*
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*Oblique CTA of the abdominal aorta in the same patient shows a focal, eccentric pseudoaneurysm <img src='img/arrows/WS.png'/>. There is no significant soft tissue adjacent to the pseudoaneurysm. This patient had bacteremia and spinal infection (not shown). Surgical resection of the aorta confirmed the mycotic nature of the pseudoaneurysm.*
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*Axial CTA of the thoracic aorta shows a focal, eccentric pseudoaneurysm <img src='img/arrows/WS.png'/> arising from the anterior wall of the ascending aorta with associated periaortic soft tissue <img src='img/arrows/WO.png'/>.*
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*Oblique CTA of the thoracic aorta in the same patient shows a focal, eccentric pseudoaneurysm <img src='img/arrows/WS.png'/> along the anterior wall of the ascending aorta with associated low-density soft tissue <img src='img/arrows/WO.png'/>. These features are consistent with a mycotic aneurysm.*
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*Axial CTA of the abdomen shows a pseudoaneurysm <img src='img/arrows/WS.png'/> arising from a branch of the superior mesenteric artery. Note the perianeurysmal soft tissue <img src='img/arrows/WC.png'/>.*
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*Coronal CTA in the same patient confirms the pseudoaneurysm <img src='img/arrows/WS.png'/> arising from a branch of the superior mesenteric artery. This was secondary to a septic embolus from valvular vegetations in a 30-year-old man with endocarditis secondary to intravenous drug abuse.*
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### Additional Images
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*Oblique CTA shows a saccular aortic aneurysm <img src='img/arrows/WO.png'/> with peripheral mural thrombus <img src='img/arrows/WS.png'/>. Mycotic aneurysms are usually saccular and involve a focal arterial segment. Infection weakens the arterial wall and allows for the aneurysm formation.*
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*Axial CECT shows a saccular aortic aneurysm <img src='img/arrows/WO.png'/> with mural thrombus.*
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*Axial CECT shows the saccular aneurysm <img src='img/arrows/WO.png'/> with mural thrombus <img src='img/arrows/WC.png'/> arising from the abdominal aorta <img src='img/arrows/WS.png'/>. Mycotic aneurysms typically involve a diseased segment of the arterial wall.*
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*Oblique MRA shows multiple small pseudoaneurysms <img src='img/arrows/WS.png'/> following the ascending aortic aneurysm repair. Also note the enhancing soft tissue <img src='img/arrows/WO.png'/> surrounding the aneurysms.*
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*Axial NECT shows a saccular outpouching <img src='img/arrows/WO.png'/> from the abdominal aorta <img src='img/arrows/WS.png'/>. This eccentric saccular appearance is typical of a mycotic aneurysm.*
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*Axial CECT shows a pseudoaneurysm <img src='img/arrows/WO.png'/> and periaortic soft tissue <img src='img/arrows/WS.png'/> following surgical repair of an ascending aortic aneurysm.*
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*Axial CECT shows a saccular aortic aneurysm <img src='img/arrows/WO.png'/> with mural thrombus and periaortic soft tissue <img src='img/arrows/WS.png'/>.*
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*Coronal CTA shows a saccular aortic aneurysm <img src='img/arrows/WO.png'/> arising from the lateral wall of the abdominal aorta. Mycotic aneurysms account for ≤ 2.6% of all aortic aneurysms. There is an increased risk for this type of aneurysm in intravenous drug abusers, immunocompromised patients, and in cases of bacterial endocarditis.*
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