Ann Thorac Surg 2000;70:966-968
© 2000 The Society of Thoracic Surgeons
Case report
Endarteritis and false aneurysm complicating aortic coarctation
Messaoud Idir, MDa,b,c,
Rocco Denisi, MDa,b,c,
Marie Parrens, MDa,b,c,
Raymond Roudaut, MDa,b,c,
Claude Deville, MDa,b,c
a Services de Cardiologie, CHU de Bordeaux, Pessac, France
b Division of d’Anatomo–Pathologie, CHU de Bordeaux, Pessac, France
c Division of de Chirurgie Cardiaque, Hopital Cardiologique, CHU de Bordeaux, Pessac, France
Address reprint requests to Dr Roudaut, Hôpital Cardiologique du Haut-Lévêque, Avenue de Magellan, 33604 Pessac, France
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Abstract
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We report a tricky case of endocarditis because of the localization, aortic coarctation, and the pathogenic bacteria Actinobacillus actinomycetemcomitans. Furthermore, we underline the leading role of transesophageal echocardiography in the diagnosis of aortic endarteritis. First, aortitis was treated with antibiotics and, second, successfully operated on.
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Introduction
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The diagnosis of aortic coarctation (AC) is generally made during infancy. The untreated course tends to be complicated by hypertension, aortic aneurysm, cardiac failure and, rarely, endarteritis. We report an unusual case that presented for the first time in middle age, with Actinobacillus actinomycetemcomitans endarteritis after the site of the aorta stricture associated with a false aneurysm. In this case, the findings of transesophageal echocardiography (TEE) were crucial to the diagnosis. Endarteritis was treated with antibiotics and then successfully operated on.
A 30-year-old man with suspected endocarditis was referred to our hospital for a TEE examination. He had a history of persistent fever, a weight loss of 8 kg in 1 month, lack of appetite and asthenia with a soft cardiac murmur. He had a medical history of mild hypertension, nephretic colic, and repetitive urinary infections. He smoked 20 cigarettes per day for 14 years. There was no history of chronic alcohol abuse.
One month before his admission to the hospital, he presented with an infection of the upper respiratory tract. He was treated by Cefatrizine for one week and then by amoxicillin associated to Clavulanic acid for another week. Two weeks later his general state was not much better.
On examination, he was found to have a temperature of 38°C. He had an atypical systolic murmur heard most strongly over the left subclavian area. Femoral pulses were weak, and his blood pressure was 160/80 mm Hg in the upper limb and 110/60 in the lower limb. An electrocardiogram showed a 70 beats/min sinus rhythm and an incomplete right-bundle branch block. Chest x-ray did not reveal any abnormality. Transthoracic echocardiography was normal at the level of the heart, but detected an isthmus stricture of the descending aorta.
The TEE examination revealed a vibrating echo, evocative of a vegetation, associated with a poststenotic dilatation just distal to the coarcted segment (Figs 1 and 2) . No evidence of valve lesion or septal defect were present. The AC was confirmed by magnetic resonance imaging, which evidenced a poststrictural flow void, indicative of marked constriction (Fig 3). The significant laboratory data included 19,000/mm3 leukocytes with a neutrophil count of 16,500/mm3, and an inflammatory syndrome characterized by an erythrocyte sedimentation rate of 55 mm, fibrinogen 7.8 g/L and CRP 75 mg/L. Cytobacteriological study of urine sample was negative.
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Fig 1. TEE 0° at the level of the aortic isthmus illustrating the coarcted segment with a vibrating echo evocative of a vegetation (arrow) and a poststenotic dilatation.
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Fig 2. TEE view M mode recording of the vegetation illustrating a vibrating echo protruding in the aortic lumen.
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Fig 3. Magnetic resonance imaging of the AC with poststenotic flow void, indicative of a marked constriction.
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Fourteen days after the blood samples were taken, eight successive blood cultures revealed a gram-negative bacillus identified as Actinobacillus actinomycetemcomitans. Endarteritis was diagnosed, and after antibiotic sensitivity testing, the patient was treated with a course of Cefotaxime and Gentamycin for 3 weeks and then for a further 2 months with Ciprofloxacine. Apyrexia was obtained after 4 days treatment. Clinical, biological and TEE supervision showed a regression of the infection. A decayed tooth was extracted to avoid any recurrence of endocarditis.
Three months after the diagnosis, and after a left wide thoracotomy and under an extracorporeal circulation was instituted between the left atrium and the external iliac artery, the surgeons performed a resection of the constricted aortic segment 2 cm under the left subclavian artery and 1 cm under the stricture. All 7 cm of the descending aorta were replaced by a 20-mm-diameter Dacron tube. Clamping delay was 31 minutes. Macroscopic examination of the operative piece (Fig 4) revealed a false aneurysm corresponding to the poststenotic dilatation communicating with the aortic lumen by a small hole. On microscopic examination, the intima was thickened and the media was dissociated by bunches of fibrosis at the site of the AC. Inflammatory seeping of neutrophils was noted in some places associated with some necrotic foci in the media and adventitia. Bacteriologic cultures were negative. Postoperatively, the patient felt well. TEE study did not show any abnormality at the level of the Dacron tube.
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Fig 4. Anatomical specimen: longitudinal section of the resected aortic segment showing the mycotic aneurysm (MA) just distal to the aortic coarctation (AC).
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Comment
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In AC, endocarditis or endarteritis are rare, although a few cases have been reported. The incidence of infective endocarditis (IE) in AC was 6 of 72 cases (8%) on autopsy in the study of Rose [1]. It involved the aortic valve in all cases, and in two patients there was a jet lesion distal to the AC. We report a tricky case of Actinobacillus actinomycetemcomitans (Aa) endarteritis in the site of the AC. It is a germ of the HACEK group (Hemophilus parainfluenzae=H, Actinobacillus actinomycetemcomitans=A, Cardiobacterium hominis=C, Eikenella corrodens=E, Kingella kingae=K). These germs are most commonly present in the mouth and the upper respiratory tract. Their growth is fastidious, and they need a growing environment enriched by CO2 [2]. The infection was thought to have spread from the respiratory tract.
The second complication during the course of IE is mycotic aneurysm (MA). A case of MA was observed after subacute endocarditis in a child with AC, just distal to the coarcted site, who died during surgical treatment [3]. Two children were reported with MA and AC just distal to the coarctation, which was diagnosed by angiography [4]. MA of the aorta is an unusual complication of arterial infection associated with high morbidity and mortality. The operative treatment and the length of antimicrobial therapy remain controversial.
There are two different surgical techniques: extraanatomic or in situ reconstruction [5]. The operative option is usually made according to the surgeon’s preference. In situ reconstruction of the aorta with allograft material after excising the entire infected tissue is the preferable surgical treatment for MA located at the side of the AC. It might reduce the late postoperative infection rate and improve survival in these high-risk patients [6]. Our patient underwent an operation when the infection was well controlled after 3 months of efficient antimicrobial therapy. The resected segment of the descending aorta was replaced by a Dacron tube without any infection recurrence.
To conclude, TEE represents a major advance in the investigation of endocarditis and also of the thoracic aorta. It was shown to be superior to transthoracic echocardiography. TEE is not usually performed in AC, but it is particularly suited for detecting such complications as endarteritis and aneurysm, as in the present case. It is a valuable diagnostic tool because it can influence the prognosis by enabling early diagnosis and management.
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References
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Rose A.G. Infective endocarditis complicating congenital heart disease. S Afr Med J 1978;53:739-743.[Medline]
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Kaplan A.H., Weber D.J., Oddone E.Z., Perfect J.R. Infection due to Actinobacillus actinomycetemcomitans. Rev Infect Dis 1989;11:46-63.[Medline]
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Sanyal S.K., Jadish K.R., Thapar M.K., Saxena H.M. Mycotic aneurysm following subacute bacterial endocarditis in a child with coarctation of the aorta. Indian J Pediatr 1973;40:410-415.[Medline]
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Garcia E.J., Maroto E., Rivera R., Maroto C., Delgado J., Fermosal J. Mycotic aneurysms of the aorta in patients with aortic coarctation. Presentation of 2 cases and review of the literature. Rev Esp Cardiol 1982;35:571-575.[Medline]
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Pasic M. Mycotic aneurysm of the aorta evolving surgical concept. Ann. Thorac. Surg. 1996;61:1053-1054.[Free Full Text]
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Knosalla C., Weng Y., Yankah C., Hofmeister J., Hetzer R. Using allograft material to treat mycotic aneurysms of the thoracic aorta. Ann. Thorac. Surg. 1996;61:1146-1152.[Abstract/Free Full Text]
Accepted for publication November 29, 1999.
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