Central MessageClostridium septicum aortitis is a rare and lethal disease associated with underlying malignancy.See Commentary on page 9.A-76-year-old previously healthy woman without medication use presented with paraplegia after awakening. Furthermore, she reported currently regressing back pain for the past 2 days. Findings of the physical examination confirmed paraplegia with preserved sense of proprioception and vibration. There were no clinical signs of myonecrosis. Computed tomography of the aorta revealed periaortic gas at the level of seventh thoracic vertebra (Figure 1, A, white arrow) and thickened aortic wall (Figure 1, B, black arrowheads), suggesting infectious aortitis. In addition, a mass in the transverse colon was found. The patient was referred 12 hours after the onset of paraplegia to our clinic for surgery. Magnetic resonance imaging of the spine revealed obstruction of the left ninth and tenth anterior segmental medullary arteries (Figure 1, C, white arrows) and a well-demarcated anterior spinal cord infarction extending from the seventh thoracic vertebra to the medullary cone (Figure 1, D, white arrowheads), confirming anterior spinal artery syndrome (ASAS).Figure 1Computed tomography of the descending aorta showing periaortic gas (A, white arrow) and thickened aortic wall (B, black arrowheads). Magnetic resonance imaging of the spine showing obstruction of the left ninth and tenth anterior segmental medullary arteries (C, white arrows) and demarcated spinal cord infarction (D, white arrowheads). Computed tomography of the descending aorta showing contained aortic rupture after 3-month (E, black arrow) and 1-year (F, black arrow) follow-up.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Due to poor neurologic prognosis, the patient declined aortic surgery. Spinal fluid drainage as salvage therapy did not result in neurologic improvement. Blood cultures confirmed Clostridium septicum bacteremia, and empirical antibiotics were adapted to life-long therapy with metronidazole. Follow-up imaging after 3 months (Figure 1, E, black arrow) and 1 year (Figure 1, F, black arrow) showed contained aortic rupture. The patient died 1 year after the diagnosis due to infective endocarditis of the aortic valve. The classical presentation of ASAS consists of acute back pain and paraplegia. It is caused by the occlusion of the largest anterior segmental medullary artery (artery of Adamkiewicz), primarily in acute aortic syndrome. Secondary causes include thoracoabdominal aortic surgery and interventions.1Weidauer S. Nichtweiß M. Hattingen E. Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features.Neuroradiology. 2015; 57: 241-257Crossref PubMed Scopus (71) Google Scholar,2Yogendranathan N. Herath H.M.M.T.B. Jayamali W.D. Matthias A.T. Pallewatte A. Kulatunga A. A case of anterior spinal cord syndrome in a patient with unruptured thoracic aortic aneurysm with a mural thrombus.BMC Cardiovasc Disord. 2018; 18: 48Crossref PubMed Scopus (7) Google Scholar Infectious etiologies of ASAS are rare, and C septicum aortitis is associated with underlying gastrointestinal or hematologic malignancy.3Ranchal P. Ferin A. Gupta R. Malekan R. Goldberg J. Laskowski I. et al.Clostridium septicum aortitis: a kiss of the devil.J Card Surg. 2020; 35: 514-517Crossref PubMed Scopus (7) Google Scholar Although the prognosis of C septicum aortitis is poor, emergent aortic surgery and restoration of the spinal perfusion are essential.4Seder C.W. Kramer M. Long G. Uzieblo M.R. Shanley C.J. Bove P. Clostridium septicum aortitis: report of two cases and review of the literature.J Vasc Surg. 2009; 49: 1304-1309Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Clostridium septicum aortitis is a rare and lethal disease associated with underlying malignancy. Clostridium septicum aortitis is a rare and lethal disease associated with underlying malignancy. See Commentary on page 9. See Commentary on page 9. A-76-year-old previously healthy woman without medication use presented with paraplegia after awakening. Furthermore, she reported currently regressing back pain for the past 2 days. Findings of the physical examination confirmed paraplegia with preserved sense of proprioception and vibration. There were no clinical signs of myonecrosis. Computed tomography of the aorta revealed periaortic gas at the level of seventh thoracic vertebra (Figure 1, A, white arrow) and thickened aortic wall (Figure 1, B, black arrowheads), suggesting infectious aortitis. In addition, a mass in the transverse colon was found. The patient was referred 12 hours after the onset of paraplegia to our clinic for surgery. Magnetic resonance imaging of the spine revealed obstruction of the left ninth and tenth anterior segmental medullary arteries (Figure 1, C, white arrows) and a well-demarcated anterior spinal cord infarction extending from the seventh thoracic vertebra to the medullary cone (Figure 1, D, white arrowheads), confirming anterior spinal artery syndrome (ASAS). Due to poor neurologic prognosis, the patient declined aortic surgery. Spinal fluid drainage as salvage therapy did not result in neurologic improvement. Blood cultures confirmed Clostridium septicum bacteremia, and empirical antibiotics were adapted to life-long therapy with metronidazole. Follow-up imaging after 3 months (Figure 1, E, black arrow) and 1 year (Figure 1, F, black arrow) showed contained aortic rupture. The patient died 1 year after the diagnosis due to infective endocarditis of the aortic valve. The classical presentation of ASAS consists of acute back pain and paraplegia. It is caused by the occlusion of the largest anterior segmental medullary artery (artery of Adamkiewicz), primarily in acute aortic syndrome. Secondary causes include thoracoabdominal aortic surgery and interventions.1Weidauer S. Nichtweiß M. Hattingen E. Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features.Neuroradiology. 2015; 57: 241-257Crossref PubMed Scopus (71) Google Scholar,2Yogendranathan N. Herath H.M.M.T.B. Jayamali W.D. Matthias A.T. Pallewatte A. Kulatunga A. A case of anterior spinal cord syndrome in a patient with unruptured thoracic aortic aneurysm with a mural thrombus.BMC Cardiovasc Disord. 2018; 18: 48Crossref PubMed Scopus (7) Google Scholar Infectious etiologies of ASAS are rare, and C septicum aortitis is associated with underlying gastrointestinal or hematologic malignancy.3Ranchal P. Ferin A. Gupta R. Malekan R. Goldberg J. Laskowski I. et al.Clostridium septicum aortitis: a kiss of the devil.J Card Surg. 2020; 35: 514-517Crossref PubMed Scopus (7) Google Scholar Although the prognosis of C septicum aortitis is poor, emergent aortic surgery and restoration of the spinal perfusion are essential.4Seder C.W. Kramer M. Long G. Uzieblo M.R. Shanley C.J. Bove P. Clostridium septicum aortitis: report of two cases and review of the literature.J Vasc Surg. 2009; 49: 1304-1309Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Commentary: Knowledge-based wisdomJTCVS TechniquesVol. 13PreviewThe authors describe a 76-year-old woman with sudden onset of back pain and paraplegia. Computed tomography imaging suggested aortitis with periaortic gas, whereas magnetic resonance imaging confirmed anterior spinal cord infarction due to the obstruction of 2 anterior segmental medullary arteries.1 The authors presume that the aortitis was due to Clostridum septicum originating from a tumor of the colon. This report adds to a limited number of C speticum case reports as cited by the authors and corroborates the poor prognosis with or without operative intervention. Full-Text PDF Open Access