INTRODUCTION: Mycotic pulmonary artery aneurysms (PAAs) and pseudo-aneurysms are rare. Diagnosis and management of these lesions can be difficult. We present a case of mycotic aneurysm in a 25 yr old with persistent hemoptysis and successful coil embolization with complete recovery.
CASE PRESENTATION: A 25 y/o healthy professional soccer player presented with 13 days of cough, fevers, and shortness of breath. He was diagnosed with a viral URI but returned 72 hours later with worsening symptoms. Blood cultures grew Staphlococcus Aureus. He was admitted for IV antibiotic therapy. He did use alcohol but had no smoking history and denied any prior intravenous drug use. On exam he was diaphoretic but afebrile. A holosystolic murmur heard best at the apex with a mid-systolic click was present. Lower extremity exam revealed diffuse pinpoint erythematous papules bilaterally. WBC count was 11.9 with 81% granulocytes. A CXR showed diffuse patchy infiltrates bilaterally. A non-contrast CT scan of the chest showed multifocal pneumonia with cavitation compatible with septic emboli. TEE showed a dense vegetation of the tricuspid valve. A diagnosis of staphylococcus aureus tricuspid valve endocarditis with septic emboli was made and he was started on IV vancomycin. Forty eight hours later he had an episode of frank hemoptysis (400ml), was intubated, and underwent emergent bronchoscopy. Fresh clotted blood was found in his airway with no active bleeding. He remained intubated for the next 14 days with recurrent hemoptysis with no apparent source on repeat bronchoscopy. He had a repeat contrast chest CT demonstrating a pseudo-aneurysm in the distal right pulmonary artery felt to be mycotic in nature. He successfully underwent coil embolization of the lesion with resolution of his hemoptysis and was discharged 2 days later.
DISCUSSIONS: Pulmonary artery aneurysms (PAAs) and pseudo-aneurysms are rare and can be congenital or acquired. Causes include congenital malformations, trauma, vasculitis, neoplasm, and infection. Mycotic PAAs are most frequently caused by fungi or pyogenic bacteria with Staphlococcus and Salmonella being the two most common causes. The mechanism appears to be endovascular seeding through hematogenous dissemination from the site of infection. This is perhaps most commonly seen in patients with a history of IV drug use and endocarditis. Presentation is non-specific and diagnosis can be difficult. The most common manifestations include hemoptysis, dyspnea, chest pain, cough, and an abnormal CXR. Patients whose lesions have arterio-venous communication with right to left shunt physiology may also exhibit cyanosis, clubbing, or CNS manifestations due to emboli. Lesions often appear as a pulmonary nodule(s) in the lung parenchyma. Proximal aneurysms may be mistaken for enlarged pulmonary vasculature, hilar adenopathy, or dilation of the aortic root. Diagnosis is made definitively by pulmonary angiography, CT of the chest with contrast, or MRI. A feeding vessel may or may not be seen. PAA must always be considered in the differential for pulmonary nodules as biopsy can cause massive bleeding. Treatment includes therapy for the underlying infection and prompt intervention. Early coil embolization has been employed since the 1970's and is currently the most common treatment modality. Other therapies include aneurysmectomy, vascular ligation, banding, pneumonectomy, and lobectomy. The treatment used depends on the location, type of aneurysm, and clinical scenario. Our patient underwent successful coil embolization and returned to playing professional soccer 18 months later.
CONCLUSION: Mycotic PAAs and pseudo-aneurysms can present as lung nodules on chest CT. If these studies are not done with contrast it is difficult to discern the vascular nature of the lesions. Failure to consider PAA in the appropriate context can delay diagnosis and put the patient at risk for major bleeding or possible biopsy of the lesion. Patients who are successfully treated can have complete recovery.
DISCLOSURE: Brent Riscili, No Financial Disclosure Information; No Product/Research Disclosure Information