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Symptomatic peripheral mycotic aneurysms due to infective endocarditis: a contemporary profile.

González I, Sarriá C, López J, Vilacosta I, San Román A, Olmos C, Sáez C, Revilla A, Hernández M, Caniego JL, Fernández C - Medicine (Baltimore) (2014)

Bottom Line: In conclusion, we found that SPMAs were a rare complication of IE that developed only in left-sided IE, and especially in native valves.Surgical and endovascular treatments were safe and effective.Mortality was high in those cases treated only with antibiotics.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Internal Medicine-Infectious Diseases (IG, C Sarriá, C Sáez, MH) and Radiology (JLC), Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, Madrid; Instituto de Ciencias del Corazón (ICICOR) (JL, ASR, AR), Hospital Clínico Universitario. Valladolid; and Instituto Cardiovascular (IV, CO, CF), Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IDISSC), Universidad Complutense de Madrid, Madrid; Spain.

ABSTRACT
Peripheral mycotic aneurysms (PMAs) are a relatively rare but serious complication of infective endocarditis (IE). We conducted the current study to describe and compare the current epidemiologic, microbiologic, clinical, diagnostic, therapeutic, and prognostic characteristics of patients with symptomatic PMAs (SPMAs). A descriptive, comparative, retrospective observational study was performed in 3 tertiary hospitals, which are reference centers for cardiac surgery. From 922 definite IE episodes collected from 1996 to 2011, 18 patients (1.9%) had SPMAs. Because all SPMAs developed in left-sided IE, we performed a comparative study between 719 episodes of left-sided IE without SPMAs and 18 episodes with SPMAs. We found a higher frequency of intravenous drug abuse, native valve IE, intracranial bleeding, septic emboli, multiple embolisms, and IE diagnostic delay >30 days in patients with SPMAs than in patients without SPMAs. The causal microorganisms were gram-positive cocci (n =10), gram-negative bacilli (n = 2), gram-positive bacilli (n = 3), Bartonella henselae (n = 1), Candida albicans (n = 1), and negative culture (n = 1). The median IE diagnosis delay was 15 days (interquartile range [IQR], 13-33 d) in the case of high-virulence microorganisms versus 45 days (IQR, 30-240 d) in the case of low- to medium-virulence microorganisms. Twelve SPMAs were intracranial and 6 were extracranial. In 10 cases (8 intracranial and 2 extracranial), SPMAs were the initial presentation of IE; the remaining cases developed symptoms during or after finishing parenteral antibiotic treatment. The initial diagnosis of intracranial SPMAs was made by computed tomography (CT) or magnetic resonance imaging in 6 unruptured aneurysms and by angiography in 6 ruptured aneurysms. The initial test in extracranial SPMAs was Doppler ultrasonography in limbs, CT in liver, and coronary angiography in heart. Four (3 intracranial, 1 extracranial) of 7 (6 intracranial, 1 extracranial) patients treated only with antibiotics died. Surgical resection was performed in 7 (3 intracranial, 4 extracranial) and endovascular repair in 4 (3 intracranial, 1 extracranial) patients; all of them survived. In conclusion, we found that SPMAs were a rare complication of IE that developed only in left-sided IE, and especially in native valves. Intracranial hemorrhage, embolism, multiple embolisms, and diagnostic delay of IE were more common in patients with SPMAs. The microbiologic profile was diverse, but microorganisms of low-medium virulence were predominant, and had a greater delayed diagnosis of IE than those caused by microorganisms of high virulence. SPMAs were often the initial presentation of IE. The most common location of SPMAs was intracranial. Noninvasive radiologic imaging techniques were the initial imaging test in intracranial unruptured SPMAs and in most extracranial SPMAs. Surgical and endovascular treatments were safe and effective. Endovascular treatment could be the first line of treatment in selected cases. Mortality was high in those cases treated only with antibiotics.

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Related in: MedlinePlus

Popliteal aneurysm in a patient with infective endocarditis.
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Figure 4: Popliteal aneurysm in a patient with infective endocarditis.

Mentions: Two extracranial SPMAs were the initial presentation of IE, 1 in the popliteal artery with pain and palpable throbbing mass, and another located in the liver with abdominal pain secondary to hematoma and hepatic ischemia due to aneurysm rupture (Figures 2 and 3). The other extracranial SPMAs did not rupture. Three began to show symptoms during parenteral antibiotic therapy: 1 in the ulnar artery, 1 in the humeral artery, and 1 in both popliteal arteries with peripheral neuropathy and painful pulsatile masses (Figure 2 and 4). The patient with SPMA located in the coronary artery developed an acute coronary syndrome with acute pulmonary edema 3 weeks after finishing IE treatment (see Figure 2). Two of 8 patients who developed SPMAs during hospitalization still had fever in the second week of antibiotic treatment.


Symptomatic peripheral mycotic aneurysms due to infective endocarditis: a contemporary profile.

González I, Sarriá C, López J, Vilacosta I, San Román A, Olmos C, Sáez C, Revilla A, Hernández M, Caniego JL, Fernández C - Medicine (Baltimore) (2014)

Popliteal aneurysm in a patient with infective endocarditis.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4616324&req=5

Figure 4: Popliteal aneurysm in a patient with infective endocarditis.
Mentions: Two extracranial SPMAs were the initial presentation of IE, 1 in the popliteal artery with pain and palpable throbbing mass, and another located in the liver with abdominal pain secondary to hematoma and hepatic ischemia due to aneurysm rupture (Figures 2 and 3). The other extracranial SPMAs did not rupture. Three began to show symptoms during parenteral antibiotic therapy: 1 in the ulnar artery, 1 in the humeral artery, and 1 in both popliteal arteries with peripheral neuropathy and painful pulsatile masses (Figure 2 and 4). The patient with SPMA located in the coronary artery developed an acute coronary syndrome with acute pulmonary edema 3 weeks after finishing IE treatment (see Figure 2). Two of 8 patients who developed SPMAs during hospitalization still had fever in the second week of antibiotic treatment.

Bottom Line: In conclusion, we found that SPMAs were a rare complication of IE that developed only in left-sided IE, and especially in native valves.Surgical and endovascular treatments were safe and effective.Mortality was high in those cases treated only with antibiotics.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Internal Medicine-Infectious Diseases (IG, C Sarriá, C Sáez, MH) and Radiology (JLC), Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, Madrid; Instituto de Ciencias del Corazón (ICICOR) (JL, ASR, AR), Hospital Clínico Universitario. Valladolid; and Instituto Cardiovascular (IV, CO, CF), Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IDISSC), Universidad Complutense de Madrid, Madrid; Spain.

ABSTRACT
Peripheral mycotic aneurysms (PMAs) are a relatively rare but serious complication of infective endocarditis (IE). We conducted the current study to describe and compare the current epidemiologic, microbiologic, clinical, diagnostic, therapeutic, and prognostic characteristics of patients with symptomatic PMAs (SPMAs). A descriptive, comparative, retrospective observational study was performed in 3 tertiary hospitals, which are reference centers for cardiac surgery. From 922 definite IE episodes collected from 1996 to 2011, 18 patients (1.9%) had SPMAs. Because all SPMAs developed in left-sided IE, we performed a comparative study between 719 episodes of left-sided IE without SPMAs and 18 episodes with SPMAs. We found a higher frequency of intravenous drug abuse, native valve IE, intracranial bleeding, septic emboli, multiple embolisms, and IE diagnostic delay >30 days in patients with SPMAs than in patients without SPMAs. The causal microorganisms were gram-positive cocci (n =10), gram-negative bacilli (n = 2), gram-positive bacilli (n = 3), Bartonella henselae (n = 1), Candida albicans (n = 1), and negative culture (n = 1). The median IE diagnosis delay was 15 days (interquartile range [IQR], 13-33 d) in the case of high-virulence microorganisms versus 45 days (IQR, 30-240 d) in the case of low- to medium-virulence microorganisms. Twelve SPMAs were intracranial and 6 were extracranial. In 10 cases (8 intracranial and 2 extracranial), SPMAs were the initial presentation of IE; the remaining cases developed symptoms during or after finishing parenteral antibiotic treatment. The initial diagnosis of intracranial SPMAs was made by computed tomography (CT) or magnetic resonance imaging in 6 unruptured aneurysms and by angiography in 6 ruptured aneurysms. The initial test in extracranial SPMAs was Doppler ultrasonography in limbs, CT in liver, and coronary angiography in heart. Four (3 intracranial, 1 extracranial) of 7 (6 intracranial, 1 extracranial) patients treated only with antibiotics died. Surgical resection was performed in 7 (3 intracranial, 4 extracranial) and endovascular repair in 4 (3 intracranial, 1 extracranial) patients; all of them survived. In conclusion, we found that SPMAs were a rare complication of IE that developed only in left-sided IE, and especially in native valves. Intracranial hemorrhage, embolism, multiple embolisms, and diagnostic delay of IE were more common in patients with SPMAs. The microbiologic profile was diverse, but microorganisms of low-medium virulence were predominant, and had a greater delayed diagnosis of IE than those caused by microorganisms of high virulence. SPMAs were often the initial presentation of IE. The most common location of SPMAs was intracranial. Noninvasive radiologic imaging techniques were the initial imaging test in intracranial unruptured SPMAs and in most extracranial SPMAs. Surgical and endovascular treatments were safe and effective. Endovascular treatment could be the first line of treatment in selected cases. Mortality was high in those cases treated only with antibiotics.

Show MeSH
Related in: MedlinePlus