MYCOTIC PULMONARY ARTERY ANEURYSM SECONDARY TO SEPTIC EMBOLI: A POTENTIALLY LIFE-THREATENING COMPLICATION OF INFECTIVE ENDOCARDITIS

Abstract

SESSION TITLE: Systemic Diseases with Deceptive Pulmonary ManifestationsSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 12:25 pm - 01:25 pmINTRODUCTION: A mycotic aneurysm is the dilation of an arterial wall due to infection. Common risk factor includes intravenous drug use and congenital heart disease. Patients may present with shortness of breath, chest pain, and hemoptysis (1). The incidence of mycotic aneurysms of the artery is 1-3 % of all causes of the arterial aneurysm, and it rarely involves s pulmonary artery (1). Mycotic pulmonary artery aneurysm is a rare but potentially life-threatening clinical entity. The reported mortality is 50-100 %; therefore, early diagnosis and treatment are critical for optimum outcomes (2).CASE PRESENTATION: A 37-year-old female with a medical history of intravenous heroin use presented with chest pain, shortness of breath, and daily fevers for two weeks. On arrival, the patient heart rate was 124 beats/minute; other vital signs were normal. Her physical examination revealed a holosystolic murmur at the left lower sternal border. Laboratory examination revealed a white cell count of 15000 (normal range 4500 to 1100 cells/mcL), hemoglobin of 8.0 g/dl, and a platelet count of 270000 (normal range 150,000 to 450,000 cells/mcL). The patient was started empirically on vancomycin for suspected infective endocarditis (IE). Subsequently, she was diagnosed with tricuspid valve IE on an echocardiogram ( see figure 1). Her Blood cultures revealed the growth of methicillin-resistant Staphylococcus aureus (MRSA). On day 3 of admission, the patient started having brisk non-massive hemoptysis and worsening shortness of breath. CT angiogram chest revealed several segmental pulmonary artery mycotic aneurysmal dilatations and multiple cavitary nodules throughout the lungs (figure 2). Conservative management was recommended by pulmonology for mycotic pulmonary artery aneurysms as hemoptysis was non-massive and resolved spontaneously. She was subsequently discharged to rehab with six weeks of IV vancomycin.DISCUSSION: Mycotic Aneurysms caused by IE occur primarily in the intracranial arteries, followed by visceral arteries and arteries of the upper and lower extremities (3). Mycotic pulmonary artery aneurysm due to right-sided infective endocarditis is a very rare entity. Staphylococcus and Streptococcus species are the most common culprits. The imaging modality of choice for detecting mycotic pulmonary artery aneurysms is CTA. Treatment strategies include surgical interventions or conservative management with intravenous antibiotics. The conservative approach is used in patients with no emergency symptoms or massive hemoptysis, while surgical interventions are reserved for massive hemoptysis and hemodynamic instability (1,2,3). Surgical options include aneurysmectomy, lobectomy, and embolotherapy.CONCLUSIONS: Mycotic pulmonary artery aneurysm is a rare clinical entity with very high mortality and morbidity. Timely diagnosis is critical to prevent life-threatening complications such as vessel rupture.Reference #1: Mikroulis D, Chrysafis I, Fotakis S, Pneumatikos I, Papaioannou V. Hemoptysis Due to a Mycotic Pulmonary Artery Aneurysm in an Injecting Drug User. Thorac Cardiovasc Surg. 2012;62(05):453-5.Reference #2: Iki Y, Hata A, Fukuyama M et al. Successful Conservative Treatment of Mycotic Pulmonary Artery Aneurysms Caused by MRSA Bacteremia. Pediatrics. 2019;144(5).Reference #3: Baddour L, Wilson W, Bayer A et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications. Circulation. 2015;132(15):1435-86.DISCLOSURES: No relevant relationships by Haris AsifNo relevant relationships by Arshan KhanNo relevant relationships by Maria Riasat SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: A mycotic aneurysm is the dilation of an arterial wall due to infection. Common risk factor includes intravenous drug use and congenital heart disease. Patients may present with shortness of breath, chest pain, and hemoptysis (1). The incidence of mycotic aneurysms of the artery is 1-3 % of all causes of the arterial aneurysm, and it rarely involves s pulmonary artery (1). Mycotic pulmonary artery aneurysm is a rare but potentially life-threatening clinical entity. The reported mortality is 50-100 %; therefore, early diagnosis and treatment are critical for optimum outcomes (2). CASE PRESENTATION: A 37-year-old female with a medical history of intravenous heroin use presented with chest pain, shortness of breath, and daily fevers for two weeks. On arrival, the patient heart rate was 124 beats/minute; other vital signs were normal. Her physical examination revealed a holosystolic murmur at the left lower sternal border. Laboratory examination revealed a white cell count of 15000 (normal range 4500 to 1100 cells/mcL), hemoglobin of 8.0 g/dl, and a platelet count of 270000 (normal range 150,000 to 450,000 cells/mcL). The patient was started empirically on vancomycin for suspected infective endocarditis (IE). Subsequently, she was diagnosed with tricuspid valve IE on an echocardiogram ( see figure 1). Her Blood cultures revealed the growth of methicillin-resistant Staphylococcus aureus (MRSA). On day 3 of admission, the patient started having brisk non-massive hemoptysis and worsening shortness of breath. CT angiogram chest revealed several segmental pulmonary artery mycotic aneurysmal dilatations and multiple cavitary nodules throughout the lungs (figure 2). Conservative management was recommended by pulmonology for mycotic pulmonary artery aneurysms as hemoptysis was non-massive and resolved spontaneously. She was subsequently discharged to rehab with six weeks of IV vancomycin. DISCUSSION: Mycotic Aneurysms caused by IE occur primarily in the intracranial arteries, followed by visceral arteries and arteries of the upper and lower extremities (3). Mycotic pulmonary artery aneurysm due to right-sided infective endocarditis is a very rare entity. Staphylococcus and Streptococcus species are the most common culprits. The imaging modality of choice for detecting mycotic pulmonary artery aneurysms is CTA. Treatment strategies include surgical interventions or conservative management with intravenous antibiotics. The conservative approach is used in patients with no emergency symptoms or massive hemoptysis, while surgical interventions are reserved for massive hemoptysis and hemodynamic instability (1,2,3). Surgical options include aneurysmectomy, lobectomy, and embolotherapy. CONCLUSIONS: Mycotic pulmonary artery aneurysm is a rare clinical entity with very high mortality and morbidity. Timely diagnosis is critical to prevent life-threatening complications such as vessel rupture. Reference #1: Mikroulis D, Chrysafis I, Fotakis S, Pneumatikos I, Papaioannou V. Hemoptysis Due to a Mycotic Pulmonary Artery Aneurysm in an Injecting Drug User. Thorac Cardiovasc Surg. 2012;62(05):453-5. Reference #2: Iki Y, Hata A, Fukuyama M et al. Successful Conservative Treatment of Mycotic Pulmonary Artery Aneurysms Caused by MRSA Bacteremia. Pediatrics. 2019;144(5). Reference #3: Baddour L, Wilson W, Bayer A et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications. Circulation. 2015;132(15):1435-86. DISCLOSURES: No relevant relationships by Haris Asif No relevant relationships by Arshan Khan No relevant relationships by Maria Riasat