RUPTURED GASTRIC DUODENAL ARTERY FROM MYCOTIC ANEURYSM DUE TO CANDIDA ENDOCARDITIS

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mycotic aneurysms refers to the irreversible vascular dilations caused by weakening and destruction of the vessel intimal wall by an invasive organism. Due to the advent of early treatment with antibiotics, mycotic aneurysms are quite rare, constituting only about 1-3% of all arterial aneurysms. We present a case of a 64 year old intravenous (IV) drug user who was admitted for candida endocarditis and developed hemorrhagic shock due to a ruptured gastric duodenal artery from a mycotic aneurysm. CASE PRESENTATION: A 64 year old male with a history of IV drug use and chronic steroid use for erythrodermic psoriasis presented with fevers for several days. In the emergency department, he was febrile to 101.9 degrees Fahrenheit, tachycardic to 120 beats per minute, and hypotensive to 88/46 mmHg. Blood cultures were drawn and he was started on IV fluids, broad-spectrum antibiotics, and vasopressor support for septic shock. His cultures were positive for candida fungemia. He had a transthoracic echocardiogram (TTE) which revealed a focal thickening on the anterior mitral valve leaflet which prompted a transesophageal echocardiogram (TEE). TEE confirmed a small, mobile vegetation on the anterior mitral valve leaflet consistent with endocarditis. Furthermore, his hospitalization was complicated by hemorrhagic shock with computed tomography of the abdomen revealing a large hematoma from a ruptured gastric duodenal artery requiring massive transfusion and emergent embolization for resolution of the bleed. The cause of the arterial bleed was found to be due to a mycotic aneurysm. DISCUSSION: Mycotic aneurysm is a rare phenomenon only constituting about 1-3% of all visceral aneurysms. They were first described by Dr. William Osler as aneurysms associated with bacterial or fungal endocarditis which had the appearance of a “fresh fungus vegetation” 2. Although mycotic aneurysms were initially thought to be due only to infective endocarditis, emerging literature revealed that these aneurysms can develop as a result of any hematogenous spread, lymphatic spread, contiguous extension, or direct inoculation. The initial presenting signs and symptoms of mycotic aneurysms constitute a febrile illness that eventually leads to fulminant sepsis. If left untreated, 20% of mycotic aneurysms will rupture leading to massive hemorrhage. Treatment of mycotic aneurysms includes antibiotic therapy, removal of the source of infection, and surgical or endovascular repair of the aneurysm itself. Endovascular intervention has been a successful intervention for mycotic aneurysms with a 2-year survival rate of 75%. CONCLUSIONS: Clinicians should recognize the risk of developing mycotic aneurysms and possible rupture as a complication of infective endocarditis with the mainstay of treatment being early antibiotic administration, removal of the source of infection, and surgical or endovascular repair of the mycotic aneurysm. Reference #1: Parkhurst GF, Dekcer JP. Bacterial aortitis and mycotic aneurysm of the aorta; a report of twelve cases. Am J Pathol. 1955;31(5):821-835. Reference #2: Gomes MN, Choyke PL. Infected aortic aneurysms: CT diagnosis. J Cardiovasc Surg (Torino). 1992;33(6):684-689. Reference #3: Sörelius Karl, Mani Kevin, Björck Martin, et al. Endovascular Treatment of Mycotic Aortic Aneurysms. Circulation. 2014;130(24):2136-2142. doi:10.1161/CIRCULATIONAHA.114.009481 DISCLOSURES: No relevant relationships by Everardo Arias Torres, source=Web Response No relevant relationships by Tim Cheng, source=Web Response No relevant relationships by Richard Lee, source=Web Response No relevant relationships by George Nasr, source=Web Response