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Critical Care |

MRSA Ascending Aorta Mycotic Pseudoaneurysm in a Post-Lung Transplant Recipient Presenting as Superior Vena Cava Syndrome

Laneshia Thomas, MD; Erin Lowery, MD
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Loyola University Medical Center, Maywood, IL


Chest. 2013;144(4_MeetingAbstracts):318A. doi:10.1378/chest.1702833
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Abstract

SESSION TITLE: Cardiovascular Critical Care

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Sunday, October 27, 2013 at 10:45 AM - 11:45 AM

INTRODUCTION: Mycotic aortic pseudoaneurysm is a rare but lethal complication in heart transplant recipients. We describe the first reported case of a MRSA mycotic aortic pseudoaneurysm in a lung transplant recipient.

CASE PRESENTATION: A 24-year-old man with cystic fibrosis who underwent lung transplantation 3 months prior to admission presented with fevers, fatigue, and facial swelling for three days with a 3 gram hemoglobin drop. His post-transplant course was complicated by re-do exploration and evacuation of a left hemothorax during which time he required ECMO, and chronic respiratory failure requiring tracheostomy and mechanical ventilation. He was admitted one month prior to current presentation with fevers and increased tracheal secretions, treated for MRSA pneumonia and bacteremia, and discharged to a ventilator weaning facility. This admission, exam was notable for fever a 101.2°F, tachycardia, facial and neck swelling, dilated but reactive right pupil, bilateral lower extremity edema and scattered petechiae on both feet. Labs revealed leukopenia, acute renal failure and MRSA bacteremia. CXR showed a new,well-defined right hilar mass. Chest CT showed a 10 cm mass near the ascending aorta. CT angiography revealed an ascending aortic mycotic pseudoaneurysm compressing the superior vena cava. The patient was taken for emergent repair of the pseudoaneurysm and debridement of a sternal defect. His aortic tissue and sternal cultures grew MRSA. He was continued on vancomycin for MRSA bacteremia, osteomyelitis and mycotic ascending aortic pseudoaneurysm.

DISCUSSION: Mycotic aortic pseudoaneurysm is a rare diagnosis with high mortality (1). The vessel wall is weakened by an infectious process and intra-arterial pressure causes localized dilation (aneurysm formation), leading to bleeding and contained rupture (pseudoaneurysm formation) (1). This has been described as a potentially fatal complication of heart transplantation with patients with sternal osteomyelitis or mediastinitis at greatest risk (2). There has been one report of a mycotic aneurysm in a lung transplant recipient caused by Scedosporium prolificans (3). However, this is the first report of a MRSA mycotic aortic pseudoaneurysm in a lung transplant recipient.

CONCLUSIONS: Early detection of mycotic aortic pseudoaneurysm and appropriate treatment (surgery and antibiotics) are essential for survival.

Reference #1: Malouf JF, Chandrasekaran K, Orszulak TA. Mycotic aneurysms of the thoracic aorta: a diagnostic challenge. Am J Med 2003;115(6):489-96.

Reference #2: Knosalla, C. et al. "Mycotic Aortic Aneurysms after Orthotopic Heart Transplantation: A Three-case Report and Review of the Literature." Journal of Heart and Lung Transplant 15.8 (n.d.): 827-39.

Reference #3: Sayah, D. M. et al. "Scedosporium Prolificans Pericarditis and Mycotic Aortic Aneurysm in a Lung Transplant Recipient Receiving Voriconazole Prophylaxis." Transplant Infectious Disease 00.00 (2013): 000 epub ahead of print.

DISCLOSURE: The following authors have nothing to disclose: Laneshia Thomas, Erin Lowery

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