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An Arteriosclerotic Aneurysm of the Abdominal Aorta Secondarily Infected with Group C, Beta-hemolytic Streptococci Report of a Case D E N V E R E. P E R K I N S , J R . , M.D., AND R. P A R K E R M C R A E , B.A. Department of Pathology, Vanderbilt University School of Medicine, Nashville, Tennessee 3 7232 ABSTRACT Perkins, Denver E., Jr., and McRae, R. Parker: An arteriosclerotic aneurysm of the abdominal aorta secondarily infected with group C, beta-hemolytic streptococci. Report of a case. Am. J. Clin. Pathol. 62: 646-648, 1974. A 59-year-old man was admitted to the Nashville Veterans Administration Hospital for evaluation of fever, weight loss, and nausea and vomiting of one month's duration. Subsequently he was found to have an aneurysm of the abdominal aorta 8 cm. in diameter, secondarily infected with group C beta-hemolytic streptococci. T h e aneurysm was not resected, and in spite of theoretically adequate antibiotic therapy, the aneurysm ruptured and exsanguination occurred. No case similar to ours was found in a review of the literature concerning mycotic aneurysms of the abdominal aorta. Aneurysms of the abdominal aorta which became infected with bacteria are difficult therapeutic problems. Surgical resection of such lesions carries, at most institutions, a mortality rate greater than 95%. There are only six reported long-term survivors of this procedure. (Key words: Aneurysm, myotic; Aorta; Beta-hemolytic streptococci.) IN 1967, Bennett and Cherry reviewed the world literature on secondarily infected arteriosclerotic abdominal aneurysms and discovered only 34 reported cases. 2 T h e most common causative organism was found to be Salmonella, followed by Staphylococcus. Species of streptococci have rarely been implicated, and a careful review of the literature reveals that a case of an arteriosclerotic abdominal aneurysm secondarily infected Received April 22, 1974, accepted for publication May 8, 1974. Address reprint requests to Dr. Perkins, 3808 Amhurst, Dallas, Texas 75225. 646 with group C beta-hemolytic streptococci has not been previously reported. Group C beta-hemolytic streptococci a r e infrequently associated with human disease; only two cases in which death was attributed to documented infection with this organism have been reported. 3 Report or a Case A 59-year-old farmer was admitted to the Nashville Veterans' Administration Hospital for evaluation of fever, weight \oss nausea and vomiting, and intermit. . ,. , , . Singultus, of one month s duration. Past history was not contributory. t e n t November 1974 GROUP C STREPTOCOCCAL MYCOTIC ANEURYSM *% • ':. • 647 J u FIG. 1 (upper). This section through the aorta at a point adjacent to the site of rupture demonstrates the marked loss of smooth muscle and elastic fiber. Verhoff-Van Gieson tain, x 12.8. FlG. 2 {lower). Colonies of Gram-positive cocci are present in this section of the media of the aorta. Brown and Brenn stain. x320. Physical examination revealed only one pertinent symptom—a diffusely tender abdomen. T e m p e r a t u r e was 100.5 F., leukocyte count 13,600, and hematocrit 32%. Cultures of blood drawn on the first, fourth, eighth, and tenth hospital days were positive for group C beta-hemolytic streptococci. (Identification was estab- 648 PERKINS AND McRAE A.J.C.P.—Vol.62 lished by acid-heat precipitation.) Sub- ness of the aorta. At the point of rupture, sequent to the first report of a positive the elastic and smooth muscle fiber of the blood culture (tenth hospital day), the media abruptly disappeared, and the aorpatient received 20 million units of aque- tic wall became, essentially, a thin band of ous penicillin per day, intravenously, via a fibrous tissue apposed to adventitia (Fig. continuous-drip system for 36 days. For 1). Colonies of Gram-positive cocci were seven days thereafter, he received 20 present both in the media and in an million units of aqueous penicillin per organized t h r o m b u s beneath an arday, intravenously, divided into four teriosclerotic plaque adjacent to the point equal doses. A Schlichter test, performed of rupture (Fig. 2). with serum drawn during the thirteenth Conclusion day of antibiotic treatment, demonstrated that the patient's serum was cidal to the Infection greatly increases the likeliinfecting organism at dilutions of 1:1,024. hood of rupture of an arteriosclerotic An a o r t o g r a m p e r f o r m e d o n t h e aneurysm, an event with an almost invarithirty-fourth hospital day revealed a sacably fatal outcome. 4 cular aneurysm in the infrarenal aspect of This case demonstrates well that anthe abdominal aorta. An exploratory tibiotics are ineffective in treating bactelaboratomy was performed, a n d the rial infections sequestered beneath araneurysm was found to be inflamed and teriosclerotic plaques. surrounded by an intense fibrotic reacThe logical alternative to the use of tion. It was judged to be infected and antibiotics alone, the use of antibiotics unresectable. Two weeks postoperatively, before and after surgical resection of the the aneurysm ruptured and the patient aorta, carries a mortality rate greater than died of acute hemorrhage. 95%. 4 There are only six reported cases of long-term survival (more than a year and Autopsy Findings (AVN-101-73) a half) following resection of an abdomiThe peritoneal cavity was filled with nal aneurysm infected by bacteria, and approximately 3 liters of blood. A ret- three of these cases were reported by a ,,5>6 roperitoneal hematoma extended from single group. the inferior surface of the right leaf of the References diaphragm to the floor of the pelvis. A 1. Austin DJ, Thompson JE, Patman DR, et al: saccular aneurysm 9 cm. long and 8 cm. Infected arteriosclerotic aneurysm of the abin diameter, with a 4 cm. longitudinal rent dominal aorta. Am J Surg 118:950-952, 1969 2. Bennet DE, Cherry JK: Bacterial infection of along the right posterolateral aspect, was aortic aneurysms. Am J Surg 113:321-326, present in the infrarenal aspect of the 1967 3. Bullock JD, Cruz MG, Rabin ER, et al: A fatal abdominal aorta. An intense inflammation case of group C streptococcal endocarditis. surrounded the aneurysm, and tracts of Missouri Med 67:595-598, 1970 fibrous tissue extended superiorly as far 4. Hardy J D , Timmis H H : Abdominal aortic aneurysms: Special problems. Ann Surg as the inferior surface of the diaphragm. 173:945-965, 1971 The aorta showed grade VII/VII ar5. Mundt ED, Darling RC, Alvarado RH, et al: Surgical management of mycotic aneurysms teriosclerosis. Microscopic examination of and the complications of infection in vascular sections of the aneurysm revealed, as well reconstructive surgery. Am J Surg 117:460as the usual changes of arteriosclerosis, 470, 1969 6. Reichle RH, Tyson RR, Soloff LA, et al: Salnumerous aggregates of chronic inflammonellosis and aneurysm of the distal abdommatory cells throughout the entire thickinal aorta. Ann Surg 171:219-228, 1970