Mycotic Hepatic Artery Aneurysm Causing Quinckeʼs Triad: Does It Still Exist?

Abstract

Mycotic aneurysm of hepatic artery is a rare but recognized complication of bacterial endocarditis. It accounts for 0.1% of arterial aneurysms and 20% of visceral aneurysms. With the widespread use of effective antibiotics, the incidence of mycotic aneurysms has declined. Currently, most of the hepatic artery aneurysms are primary and likely due to medial degeneration or atherosclerosis. Allthough most hepatic artery aneurysms are asymptomatic, when they present, 80% of patients will have right upper quadrant pain. The combination of abdominal pain, hemobilia and obstructive jaundice, referred to as Quincke's triad, is observed in less than one-third of patients. We report a rare case of a 47year-old male who presented with severe right upper quadrant pain, coffee ground emesis, fever and jaundice of 5 days. A month ago he was treated for aortic valve endocarditis requiring aortic valve replacement and antibiotic therapy. His medical history is significant for hepatitis C infection and illicit drug use. He denies any recent trauma, hepato-biliary procedures or similar episodes in the past. Physical exam disclosed diffuse abdominal tenderness. Laboratory studies revealed leukocyte count of 13000/mL,hemoglobin of 8.8 g/dl, alanine transaminase of 195 IU/L,aspartate transaminase of 127 IU/L, alkaline phosphate of 398 U/L and total/direct bilirubin of 5.8/3 mg/dL. Computed tomography (CT) of abdomen showed a hepatic artery aneurysm and a high density material in the gallbladder lumen suggestive of hemorrhage. CT angiography of the abdomen confirmed a 3.2 x 2.6x2.4 cm proximal right hepatic artery aneurysm (Fig 1,3). Patient underwent successful angiographic coil embolization by interventional radiology using 15 coils (Fig 2).Following the procedure, hemoglobin level remained stable and liver profile normalized over the course of 7 days. Patient was then discharged on antibiotics.Figure 1Figure 3Figure 2Mycotic hepatic artery aneurysm is an unusual pathology in the antibiotic era. Heightened awareness is required to diagnose this entity in high risk patients with recent or remote history of endocarditis, particularly in the setting of a gastrointestinal hemorrhage.The gold standard test is conventional angiography which provides accurate location, size, and shape of the aneurysm. Early recognition and prompt surgical or radiological intervention will avoid the very high mortality associated with the expected rupture of these aneurysms.