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A giant pseudoaneurysm of the forearm as unusual complication of bacterial endocarditis.

Arcopinto M, Russo T, Ruvolo A, Cittadini A, Saccà L, Napoli R - Case Rep Vasc Med (2013)

Bottom Line: A 59-year-old man with fever was diagnosed with endocarditis due to Streptococcus bovis.Surgical intervention with the removal of multiple, sterile clots from the hematoma was performed, and the multiple lacerations of the artery detected were corrected.This is the first case reporting rupture of the radial artery as a complication of infective endocarditis.

View Article: PubMed Central - PubMed

Affiliation: Department of Translational Medical Sciences, School of Medicine, Federico II University, 5 Via Sergio Pansini, 80131 Napoli, Italy.

ABSTRACT
A 59-year-old man with fever was diagnosed with endocarditis due to Streptococcus bovis. Two weeks after antibiotic therapy was started, he presented with red and painful swelling of the forearm without any sign of systemic inflammation. A giant hematoma connected to the radial artery was detected with ultrasound. Surgical intervention with the removal of multiple, sterile clots from the hematoma was performed, and the multiple lacerations of the artery detected were corrected. This is the first case reporting rupture of the radial artery as a complication of infective endocarditis.

No MeSH data available.


Related in: MedlinePlus

(a) Color Doppler imaging showing mild-to-moderate mitral regurgitation; (b) three-chamber apical view showing vegetation on distal third of mitral anterior leaflet; (c) echography of anterior aspect of right forearm showing color Doppler imaging of radial artery refueling perivascular blood collection.
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fig1: (a) Color Doppler imaging showing mild-to-moderate mitral regurgitation; (b) three-chamber apical view showing vegetation on distal third of mitral anterior leaflet; (c) echography of anterior aspect of right forearm showing color Doppler imaging of radial artery refueling perivascular blood collection.

Mentions: A 59-year-old man with no history of major diseases was admitted to the hospital for the presence of fever during the previous 8 weeks, asthenia, myoarthralgia, and abdominal pain. Before being hospitalized, the patient was prescribed an offhand antibiotic therapy (amoxicillin 2 g/die for five days) without any improvement of his symptoms. On arrival, the physical examination performed showed no clear sign of disease, except for a mild systolic murmur detectable at the cardiac apex. Body temperature was between 37.5 and 38.7°C during the day, heart rate was 90 bpm, respiration rate 20/min, and blood pressure 130/80 mmHg. Blood check showed mild neutrophilic leukocytosis, high C-reactive protein and fibrinogen. Chest radiogram and urinalysis were normal. During the following days, three consecutive venous blood samples were taken one day apart from each other for culture. In these blood cultures Streptococcus bovis, was constantly present. Transthoracic echocardiography showed vegetations on the anterior leaflet of the distal third of the mitral valve, associated with moderate regurgitation. According to modified Duke criteria [2], diagnosis of bacterial endocarditis was established and treatment with ceftriaxone (2 g IV, daily), based on actual bacterial susceptibility, was started and continued for the following 4 weeks. Right from the first week of treatment, the blood cultures were negative, fever disappeared, and the clinical conditions improved. The patient was then discharged. Two weeks after diagnosis, the patient returned to the hospital with a giant, red, and painful swelling on the anterior side of the left forearm (about 10 × 12 cm). This swelling appeared suddenly and was associated with rise in body temperature for a few days. No signs of ischemia in the left hand were present. Laboratory data showed an increase of inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), whereas two consecutive blood cultures were negative for germs. A major trauma as a possible explanation of the forearm swelling was easily ruled out with careful patient's interview. An echography of the forearm was performed and an ~8 cm, low-echogenic, blood collection connected with the radial artery was clearly visible (Figure 1). On the basis of the results of the antibiotic testing on the Streptococcus bovis isolated in the original blood culture, medical therapy was upgraded with Gentamicin, 1 mg/kg every 8 hours. To stop the refueling of the pseudoaneurysm by the artery, since the surgical support was not immediately available, two consecutive 20-minute compressions of the forearm were applied, but the results were unsatisfactory. Therefore, the patient underwent surgery for diagnostic and therapeutic purposes. During the surgery, after the incision of the brachial fascia, a big clot was evident. Several lacerations on different sides of radial artery were also visible, providing possible explanation for the blood extravasation. No vegetations or other major abnormalities of the arterial wall were found. The vessel integrity was then reconstructed with excision of the damaged segments and primary end-to-end anastomosis of the mobilized extremities with application of 6-0 prolene sutures was performed (Figure 2). Microbiological examination of the tissues removed showed complete sterility. After two additional weeks of antibiotic treatment, medical therapy was discontinued and a strict follow-up was planned. Thereafter, the patient has been checked several times till a year later and no recurrence of systemic or local signs or symptoms has been detected. Radial arterial patency and hand hemodynamics have been assessed through serial ultrasound examinations of ulnar and radial arteries. As S. bovis is known to be associated to colonic neoformations, we carried out also a screening colonoscopy, and four adenomatosis masses were removed from the gut.


A giant pseudoaneurysm of the forearm as unusual complication of bacterial endocarditis.

Arcopinto M, Russo T, Ruvolo A, Cittadini A, Saccà L, Napoli R - Case Rep Vasc Med (2013)

(a) Color Doppler imaging showing mild-to-moderate mitral regurgitation; (b) three-chamber apical view showing vegetation on distal third of mitral anterior leaflet; (c) echography of anterior aspect of right forearm showing color Doppler imaging of radial artery refueling perivascular blood collection.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3794644&req=5

fig1: (a) Color Doppler imaging showing mild-to-moderate mitral regurgitation; (b) three-chamber apical view showing vegetation on distal third of mitral anterior leaflet; (c) echography of anterior aspect of right forearm showing color Doppler imaging of radial artery refueling perivascular blood collection.
Mentions: A 59-year-old man with no history of major diseases was admitted to the hospital for the presence of fever during the previous 8 weeks, asthenia, myoarthralgia, and abdominal pain. Before being hospitalized, the patient was prescribed an offhand antibiotic therapy (amoxicillin 2 g/die for five days) without any improvement of his symptoms. On arrival, the physical examination performed showed no clear sign of disease, except for a mild systolic murmur detectable at the cardiac apex. Body temperature was between 37.5 and 38.7°C during the day, heart rate was 90 bpm, respiration rate 20/min, and blood pressure 130/80 mmHg. Blood check showed mild neutrophilic leukocytosis, high C-reactive protein and fibrinogen. Chest radiogram and urinalysis were normal. During the following days, three consecutive venous blood samples were taken one day apart from each other for culture. In these blood cultures Streptococcus bovis, was constantly present. Transthoracic echocardiography showed vegetations on the anterior leaflet of the distal third of the mitral valve, associated with moderate regurgitation. According to modified Duke criteria [2], diagnosis of bacterial endocarditis was established and treatment with ceftriaxone (2 g IV, daily), based on actual bacterial susceptibility, was started and continued for the following 4 weeks. Right from the first week of treatment, the blood cultures were negative, fever disappeared, and the clinical conditions improved. The patient was then discharged. Two weeks after diagnosis, the patient returned to the hospital with a giant, red, and painful swelling on the anterior side of the left forearm (about 10 × 12 cm). This swelling appeared suddenly and was associated with rise in body temperature for a few days. No signs of ischemia in the left hand were present. Laboratory data showed an increase of inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), whereas two consecutive blood cultures were negative for germs. A major trauma as a possible explanation of the forearm swelling was easily ruled out with careful patient's interview. An echography of the forearm was performed and an ~8 cm, low-echogenic, blood collection connected with the radial artery was clearly visible (Figure 1). On the basis of the results of the antibiotic testing on the Streptococcus bovis isolated in the original blood culture, medical therapy was upgraded with Gentamicin, 1 mg/kg every 8 hours. To stop the refueling of the pseudoaneurysm by the artery, since the surgical support was not immediately available, two consecutive 20-minute compressions of the forearm were applied, but the results were unsatisfactory. Therefore, the patient underwent surgery for diagnostic and therapeutic purposes. During the surgery, after the incision of the brachial fascia, a big clot was evident. Several lacerations on different sides of radial artery were also visible, providing possible explanation for the blood extravasation. No vegetations or other major abnormalities of the arterial wall were found. The vessel integrity was then reconstructed with excision of the damaged segments and primary end-to-end anastomosis of the mobilized extremities with application of 6-0 prolene sutures was performed (Figure 2). Microbiological examination of the tissues removed showed complete sterility. After two additional weeks of antibiotic treatment, medical therapy was discontinued and a strict follow-up was planned. Thereafter, the patient has been checked several times till a year later and no recurrence of systemic or local signs or symptoms has been detected. Radial arterial patency and hand hemodynamics have been assessed through serial ultrasound examinations of ulnar and radial arteries. As S. bovis is known to be associated to colonic neoformations, we carried out also a screening colonoscopy, and four adenomatosis masses were removed from the gut.

Bottom Line: A 59-year-old man with fever was diagnosed with endocarditis due to Streptococcus bovis.Surgical intervention with the removal of multiple, sterile clots from the hematoma was performed, and the multiple lacerations of the artery detected were corrected.This is the first case reporting rupture of the radial artery as a complication of infective endocarditis.

View Article: PubMed Central - PubMed

Affiliation: Department of Translational Medical Sciences, School of Medicine, Federico II University, 5 Via Sergio Pansini, 80131 Napoli, Italy.

ABSTRACT
A 59-year-old man with fever was diagnosed with endocarditis due to Streptococcus bovis. Two weeks after antibiotic therapy was started, he presented with red and painful swelling of the forearm without any sign of systemic inflammation. A giant hematoma connected to the radial artery was detected with ultrasound. Surgical intervention with the removal of multiple, sterile clots from the hematoma was performed, and the multiple lacerations of the artery detected were corrected. This is the first case reporting rupture of the radial artery as a complication of infective endocarditis.

No MeSH data available.


Related in: MedlinePlus