Hospital: Hospital Clínic Universitari.
Ciudad:
Nº:
Aut@r o Autores: C. Biosca, S. Busó, R. Dosdá, M. De La Cruz, M. Aparisi, J. Mogort.,
Presentación:
An 80-year-old male with a history of B-CLL and hepatic artery aneurysm, went to the emergency department for a pulsatile and painful epigastric tumor. He had previously been admitted for fever of unknown origin with positive culture for Salmonella. The last control of PET-CT showed hypermetabolism of the aneurysm suggestive of an active infectious process (mycotic aneurysm). CT was performed showing a giant hepatic artery aneurysm, with growth compared to the previous control. The lesion presented a mural thrombus and thick, irregular walls, with internal calcifications that had focal disruptions through which contrast leaked, remaining contained by soft perivascular inflammatory tissue. These findings were suggestive of mycotic aneurysm with signs of impending rupture. Surgical exeresis of the aneurysm was performed and the diagnosis was confirmed.
Discusión:
Infectious or mycotic aneurysms in the visceral arteries are infrequent, with the aorta and the peripheral ones being more susceptible. The causative agents are usually Staphylococcus and Streptococcus. There are several mechanisms: a) hematogenous dissemination of septic microemboli in an artery or preexisting aneurysm, b) previous intimal defect infection, c) contiguous involvement by septic focus, d) direct inoculation. They are associated with factors like intravenous drugs, immunosuppression and invasive procedures. The clinic is non-specific, in addition to fever, the classic triad presents in only one third of cases, including epigastric pain, hemobilia, and obstructive jaundice. Almost 30% can break and manifest with hypovolemic shock.Early diagnosis is important, because of its ability to evolve to rupture, fulminant sepsis and death. Currently CT is the test of choice. Radiological findings include thickening and irregularity of the vascular wall, which can enhance contrast and present intramural calcifications, as well as perivascular inflammatory changes. Signs of imminent rupture are of special importance, such as growth, focal discontinuity of intramural calcium compared with previous CT scans and the hyperattenuating crescent sign in unenhanced CT images.
Conclusión:
Infectious or mycotic aneurysms in the visceral arteries are infrequent, with the aorta and the peripheral ones being more susceptible. The causative agents are usually Staphylococcus and Streptococcus. There are several mechanisms: a) hematogenous dissemination of septic microemboli in an artery or preexisting aneurysm, b) previous intimal defect infection, c) contiguous involvement by septic focus, d) direct inoculation. They are associated with factors like intravenous drugs, immunosuppression and invasive procedures. The clinic is non-specific, in addition to fever, the classic triad presents in only one third of cases, including epigastric pain, hemobilia, and obstructive jaundice. Almost 30% can break and manifest with hypovolemic shock.Early diagnosis is important, because of its ability to evolve to rupture, fulminant sepsis and death. Currently CT is the test of choice. Radiological findings include thickening and irregularity of the vascular wall, which can enhance contrast and present intramural calcifications, as well as perivascular inflammatory changes. Signs of imminent rupture are of special importance, such as growth, focal discontinuity of intramural calcium compared with previous CT scans and the hyperattenuating crescent sign in unenhanced CT images.
Bibliografía:
– Lee W-K, Mossop PJ, Little AF, Fitt GJ, Vrazas JI, Hoang JK, et al. Infected (mycotic) aneurysms: spectrum of imaging appearances and management. Radiographics. 2008 Dec,28(7):1853–68. – Kim J, Rha SE, Chun HJ, Kim YS, Oh SN, Lee YJ, et al. Giant aneury