Mycotic aneurysm is an established condition first identified in 1885 by Sir William Osler. It is linked to malignant endocarditis. With prevalence of 0.7–2.6% of all cases of aortic aneurysms, it is associated with a significant rate of mortality and morbidity. Physicians should be highly cautious, as diagnosis and effective treatment for this condition are difficult. The following is a case report of a 13-year-old pediatric patient diagnosed with mycotic aneurysm. Before an adequate treatment plan could be developed and implemented, patient’s status worsened swiftly and was ultimately terminal. This case is the sole instance of this condition evidenced in the last ten years in Saudi Arabia.
A 13-year-old, not known to have had any previous medical or surgical problems, presented to the Emergency Department (ER) with a two-week history of fever, shortness of breath, a dry cough, chills, and night sweats. One week prior to presentation, he had experienced orthopnea, palpitations, and central chest pain. On initial physical examination, the patient blood pressure was 110/50 mmHg, and he was tachycardic (147 beats/min.), febrile (39°C), and tachypneic (55 breath/min). Oxygen saturation (97%) was enabled by use of a 10 L facial mask. A chest examination revealed scattered crepitation and a gallop rhythm with pansystolic and early diastolic murmurs (grade 4/6 with thrill). An abdominal examination revealed a tender liver; however, there was no palpable mass or organomegaly. Blood analysis revealed leukocytosis (white blood cell count, 16.3/
Initially, the patient was admitted from the ER to the pediatric medical ward. Later at the same day, when he showed signs of respiratory distress, he was transferred to the pediatric intensive care unit (PICU) for further management. In the PICU, the patient was kept on bilevel positive airway pressure and steroids. Consequently, the patient was started on Furosemide (20 mg/8 h), dobutamine (10 mcg/kg/min), and antibiotics; ceftriaxone was started immediately in the ER. Later, at the same day, broad-spectrum antibiotics were added (Vancomycin and Gentamycin) as a treatment of bacterial endocarditis, until any result of blood culture and sensitivity testing is established. All medications were given intravenously. An echocardiography was performed immediately, which indicated evidence of heart failure and infective endocarditis, with suspected mycotic aortic aneurysm (Figure
Modified short access view at the level of the aortic root showing large mycotic pseudoaneurysm.
Urgent electrocardiogram- (ECG-) synchronized intravenous (IV) contrast-enhanced multidetector computed tomography (MDCT) imaging of the heart and aorta was subsequently performed, demonstrating a sizable aortic root paravalvular mycotic pseudoaneurysm with internal vegetation (Figures
Coronal maximum intensity projection of the aorta (Ao) demonstrating a paravalvular mycotic pseudoaneurysm arising from the aortic root (arrow).
Coronal maximum intensity projection computed tomography of the aorta (Ao) showing a paravalvular mycotic pseudoaneurysm stemming from the aortic root (arrow).
The patient was scheduled for surgical intervention on the following day (aortic aneurysm excision and graft replacement), with a plan of cleaning and debridement of the aortic valve and root, followed by reconstruction with aortic homograft. Unfortunately, the patient developed arrhythmia, hypotension, and shock hours later, with subsequent desaturation and cardiac arrest (≤2 minutes). Cardiopulmonary resuscitation (CPR) was applied for 20 minutes, but there was no response and the patient died. Autopsy was intended to be taken in order to confirm the diagnosis, but, unfortunately, parents refused it.
Mycotic aneurysm of the aorta, especially with a thoracic element, rarely occurs in children and it can result in mortality subsequent to intervention delay [
In this case, diagnosis of infective endocarditis was delayed until patient’s clinical presentation. It is possible that the patient had a previously undiagnosed congenital heart condition, leading to infective endocarditis and ultimately the development of a mycotic aortic aneurysm. To confirm this diagnosis, we utilized a noninvasive ECG-synchronized IV contrast-enhanced cardiac MDCT, which has been shown to be efficacious in assessing infective endocarditis [
Even though the patient received antibiotic and anticardiac failure treatment as soon as the diagnosis was suspected, it seems that patient’s situation was deteriorating, which may have been avoided if the root cause had been determined earlier. Despite no clear established cause of mortality, it is considered probable that the patient experienced a ruptured mycotic aortic aneurysm, resulting in hypovolemic shock, as indicated by desaturation, hypotension, and cardiac arrest. Another possible cause, such as sepsis, was eliminated, as the patient was taking appropriate antibiotic medication. Unfortunately, autopsy has not been done which could have confirmed findings on imaging and confirmed the definite cause of death (probably rupture, but coronary embolism from a vegetation is also an option); however, parents refused it.
This case emphasizes the critical importance of prompt diagnosis followed by rapid surgical treatment in patients with mycotic aortic aneurysm in order to avoid patient mortality. Research indicates that the standard approach for mycotic aneurysm is rapid surgical treatment accompanied by longitudinal antibiotic treatment in order to limit widespread infection and to accomplish cardiovascular stability. The most important message from this case is not to delay diagnosis and high-risk surgery, which all need to be done simultaneously in the same day at least instead of doing things step-by-step to prevent rupture and mortality.
The authors declare that they have no competing interests.
Dr. Noran Mohammed Abu-Ouf participated in collection the essential patients information, which is needed in drafting the article, revising it critically for the important intellectual content. Dr. Ahmad Azhar reviewed and edited the whole case report.
The authors would like sincerely to acknowledge Dr. Amr Mohammad Ajlan (Assistant Professor and Consultant Cardiothoracic Radiology, King Abdulaziz University, Jeddah, Saudi Arabia) for reviewing the MRI images.