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A Mycotic Aneurysm and a Pulmonary Nodule in Immunocompromised Patient: Where Is Occam's Razor When You Need It? FREE TO VIEW

Tatsiana Beiko, MD; John Huggins, MD
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MUSC, Charleston, SC

Chest. 2013;144(4_MeetingAbstracts):171A. doi:10.1378/chest.1704259
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SESSION TITLE: Infectious Disease Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Aortic aneurysm is an abnormal dilatation of the aorta (>50% than normal size) and is most often caused by atherosclerosis and chronic hypertension. A mycotic aneurysm refers to an infected aneurysm which weakens the layers of the aortic wall, predisposing one to rupture and dissection. These aneurysms occur with increased incidence in immunocompromised patients and those with autoimmune diseases. We describe a case of fungal mycotic aneurysm and solitary pulmonary nodule positive for Nocardia in immunocompromised patient.

CASE PRESENTATION: A 67 year-old woman with a history of myelodysplastic syndrome status post allogeneic bone marrow transplant with subsequent graft vs. host disease and Cytomegalovirus (CMV) viremia was hospitalized for work-up of aortic arch aneurysm measuring 5.4 cm and 1.7 cm irregular non-calcified right upper lobe pulmonary nodule found on chest computed tomography (CT). Patient had a CT-guided biopsy of the lung lesion. Immunohistochemical staining was positive for CMV and culture was positive for Nocardia. Cytology and fungal stains and were negative. (1,3)-Beta-D-glucan was positive; however, Aspergillus Galactomannan Antigen assay was negative. Patient was started on Bactrim, meropenem, voriconazole and micafungin. She was not a candidate for surgical repair due to complexity of her underlying conditions. On the ninth day of her hospitalization she had cardiopulmonary arrest and expired. Postmortem examination revealed ruptured aortic arch mycotic aneurysm with resultant bilateral hemothoraces. The lung nodule stains were consistent with Nocardia sp and staining of aortic aneurysm wall was suggestive of Aspergillus.

DISCUSSION: Most common pathogens causing mycotic aneurysms are gram-positive cocci, usually S.aureus; fungal mycotic aneurysms are rare but may occur in patients with immune suppression. Thoracic aortic aneurysms often present with rupture, as the majority are asymptomatic and lead to late diagnosis. Possible symptoms vary depending on the size and location of the aneurysm and may include hoarseness, dyspnea, wheezing, cough, dysphagia, hemoptysis, hematemesis, chest or back pain, heart failure and aortic insufficiency. The chance of survival is poor once an aortic aneurysm has ruptured. Most recent case reports describe repair of mycotic descending thoracic aortic aneurysms by endoluminal stent graft.

CONCLUSIONS: To date, there are no randomized trials to guide the management of mycotic aneurysm. Standard treatment includes antibiotic therapy combined with surgical repair.

Reference #1: Fares S; Thoracic emergencies in immunocompromised patients. Emerg Med Clin North Am: 2012 May; 30(2): 565-89, x

Reference #2: Mycotic Aneurysms Marx: Rosen's Emergency Medicine, 7th ed.; Chapter 85

Reference #3: Marjanovic I, et al; Endovascular Repair of Mycotic Aneurysm of the Descending Thoracic Aorta: Diagnostic and Therapeutic Dilemmas-Two Case Reports with 1-Year Follow-Up. Thorac Cardiovasc Surg: 2012 Dec 6

DISCLOSURE: The following authors have nothing to disclose: Tatsiana Beiko, John Huggins

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