Mycotic Supra-Cœliac Aortic Aneurysm due to Anaerobic Infection

Abstract

A 72-year-old lady was admitted to hospital with a history of severe back pain. It had developed after the patient underwent a radical hysterectomy for grade III endometrial adenocarcinoma, 3 months earlier. This had been complicated by a vesico-vaginal fistula. On admission, the patient appeared flushed and in pain, the abdomen was tender with no signs of peritonism. She was tachycardic and apyrexial. Laboratory investigations revealed a haemoglobin of 8.5 g/dl, a white cell count of 21.3 £ 10 l with a neutrophilia and a C-reactive protein level of 217 mg/l. A plain lumbar radiograph the month before the patient’s admission was normal. She then had an intravenous contrast enhanced CTscan, which demonstrated the presence of a large false aneurysm of the supra-cœliac aorta surrounded by haematoma (Fig. 1). The patient underwent urgent repair via a thoracoabdominal approach. A false aneurysm was found above the cœliac axis. Aortic clamps were applied above the diaphragm and below the renal arteries. The warm ischaemia time was 42 min and the aorta was trimmed back to healthy borders at the level of diaphragm above, and just above the cœliac origin below. In situ arterial reconstruction was then achieved using a gelatin coated knitted Dacron graft, wrapped in a gentamicin-impregnated fleece. Postoperatively, the patient was commenced on intravenous antibiotics. Cultures of the aneurysmal wall and surrounding haematoma grew anaerobic Gram negative bacilli, identical to that obtained following culture of the vaginal discharge which had led to the diagnosis of the vesicovaginal fistula 2 months earlier. Histological examination demonstrated the same organism in the aortic wall with no evidence of malignant infiltration. The patient was initially commenced on intravenous vancomycin and tazocin with an intraoperative dose of gentamicin. On postoperative day 6 the antibiotics were changed to intravenous ciprofloxacin and metronidazole according to organism sensitivity and we continued those for a total period of 6 weeks. Inflammatory markers returned to normal after antibiotic therapy. Six months after surgery, she is asymptomatic with normal inflammatory markers. Urologists are planning a repair of the vesico-vaginal fistula. EJVES Extra 8, 15–16 (2004) doi: 10.1016/j.ejvsextra.2004.05.011, available online at http://www.sciencedirect.com on