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Aortic infection 111
Hematemesis, A Rare Sign of Aortic Infection
Wei-Kee Huang1, Fu-Chean Chen2, Tzu-Hsuan Weng3
Ming-Hai Du1, Carlos Lam1
Non-typhoid salmonella infection of a mycotic aortic aneurysm is rare, but it is fatal when diagnosis
is delayed. The clinical presentation is often nonspecific and varies widely, with fever being the most
common initial presentation. Early diagnosis requires a high level of alertness and a detailed history.
We report a 77 year-old man who visited our emergency room with complaints of vomiting with bloody
content for two days, with increasing severity. The chest radiographs showed infiltration of the paraaortic arch left lung fields. A ruptured aneurysm was diagnosed only after contrast-enhanced computed
tomography (CT) was performed. The patient received immediate surgical treatment and adequate
preoperative and postoperative antimicrobial therapy.
Key words: hematemesis, mycotic aortic aneurysm, non-typhoid salmonella infection
Introduction
Aortic infection is relatively rare but highly
fatal, especially when there is formation or
infection of an aneurysm (1,5). The mortality rate
ranges from 20% to 53%, depending on the severity
of infection, the location of the infected aneurysm,
and the development of rupture, as well as whether
the infection is caused by salmonella species or
staphylococcus aureus (1,3,5-8). The most common
pathogen is Salmonella supp. (57%), followed
by Staphylococcus aureus (14%) (3) . Therefore,
prompt and accurate diagnosis followed by surgical
treatment and prolonged antibiotic therapy are
necessary.
Case Report
A 77 year-old man with a history of gouty
arthritis and peptic ulcer disease visited our
emergency department (ED) because of persistent
fever for 2 days. He had been treated by a local
medical doctor under the impression of urinary
tract infection, but his symptoms continued. He
presented with an elevated body temperature of
38.3℃ and a stable hemodynamic status with
pulse rate 92/min., respiratory rate 16/min., and
blood pressure 113/53 mmHg. Routine laboratory
studies showed a decreased hemoglobin level
(9.6 g/dl), but a normal white blood cell count
(6,630/μL). The urinanalysis was negative for
infection. Hydration and antibiotic treatment with
one dose of intramuscular gentamycin 80 mg were
given in the ED and the fever subsided. The patient
was discharged to follow-up in the outpatient
department with sulfamethoxazole/trimethoprim
800 mg twice per day and acetaminophen 500 mg 4
times per day prescribed for 2 days. However, the
Received: April 27, 2009 Accepted for publication: September 11, 2009
From the 1Department of Emergency Medicine, 2Department of Cardiovascular Surgery
Taipei Medical University-Municpal Wanfang Hospital, Taipei
3
Department of Emergency Medicine, Taipei Medical University Hospital
Address reprint requests and correspondence: Dr. Carlos Lam
Department of Emergency Medicine, Taipei Medical University-Municpal Wanfang Hospital, Taipei
111 Section 3, Hsinglong Road, Taipei 116, Taiwan (R.O.C.)
Tel: (02)29307930 ext 1211 Fax: (02)29301255
E-mail: [email protected]
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J Emerg Crit Care Med. Vol. 21, No. 2, 2010
patient returned three days later with complaints
of vomiting blood for two days. The patient was
the adventitia of the aorta. Atheromatous plaques
composed of necrotic debris and cholesterol clefts
37.5℃, pulse rate 100/min. and respiratory rate
17/min. However, the fever recurred ,with the body
species. A blood culture performed in the ED
during his first visit grew no bacteria. However,
ambulatory, and in stable hemodynamic condition,
with blood pressure 128/79 mmHg, temperature
temperature elevated to 37.8℃ two hours later
when acetaminophen was discontinued in the ED.
Laboratory data showed a decreased hemoglobin
level (9.4 g/dl), elevated blood urea nitrogen
(23 mg/dl), creatinine (1.9 mg/dl), and aspartate
aminotranferase (50 U/L) levels, and a normal
white cell count (6,610/μL) and urinanalysis. The
patient was admitted under a tentative diagnosis
of upper gastrointestinal bleeding. Endoscopic
examination performed on the second day showed
the esophagus was not the bleeding source and had
no other significant abnormality. However, a large
amount of blood was noted in the stomach and a
small amount in the duodenum without evidence
of an active bleeding source. Therefore, a review
of the disease course and previous examinations
was done. A review of the chest radiographs (Fig. 1)
showed blurring of the para-aortic knob lung fields,
and contrast-enhanced computed tomography (Fig. 2)
disclosed a wide-based 2.1 × 1.8 cm saccular aneurysm
of the aortic arch just adjacent and distal to the left
subclavian artery, with increased infiltrates at the
left upper lobe near the aortic aneurysm, which
might have been caused by previous hemorrhage
into the lung parenchyma. The patient may have
vomited blood after swallowing blood coughed up
from the lungs. The patient had immediate surgery
under a diagnosis of ruptured mycotic aneurysm
of the aortic arch. The patient received a thorough
debridement and resection of the infected segment
of the aortic arch followed by a 24 mm Hemashield
graft repair. Microscopically, the tissue specimens
disclosed a picture of a ruptured atherosclerotic
aneurysm of the aorta with fresh hemorrhage and
acute and chronic inflammatory cell infiltraiton in
were noted in the intima.
Tissue culture was positive for salmonella
one of the two blood cultures obtained immediately
after admission to the hospital was positive for
Staphylococcus epidermidis (MRSE), but this
might have been caused by contamination because
the rest of the blood cultures during his stay in
hospital were all negative for bacterial growth.
The patient received intravenous ceftriaxone 1 g
q12h and vancomycin 500 mg q8h for 25 days,
before and after operative treatment until skin
rashes and impaired hepatic function were noted.
The antibiotic treatment continued with oral
ampicillin 1000 mg for 8 months. Laboratory
markers for inflammation including the erythrocyte
sedimentation rate (ESR) and C-reactive
protein (CRP) were used for monitoring. The
postoperative condition was stable and the patient
had an uneventful follow-up in the departments of
cardiovascular surgery and infectious disease.
Discussion
Mycotic infection occurs in 12% of all
aneurysms(4,7), and 0.8%-3.3% of patients who have
reconstructive surgery for aortic aneurysm (4,8-10).
Infection occurs in all portions of the aorta, most
frequently in the abdominal aorta, followed by the
thoraco-abdominal aorta and the thoracic aorta.
Nearly all of these infections result in formation
of an aneurysm, or infection of a previously
existing aneurysm(1,4,5,7,9). In most patients, mycotic
aneurysms are solitary lesions, but multiple
aneurysms have been described (4,11). Salmonellainfected aneurysm in the thoracic aorta is rare
and the prognosis is poor because the anatomical
position results in a difficult surgical approach(3).
Aortic infection 113
(a)
(b)
Fig. 1
(a)
Chest radiographs (a) during the 1st and (b) 2nd ED visits. Both show a
prominent aortic knob with blurring of the para-aortic lung fields (arrows)
(b)
Fig. 2
CT angiography (a) with sagittal reconstruction (b) shows a ruptured
aneurysm at the aortic arch just adjacent to the left subclavian artery with
mural thrombus and hemorrhage (arrows)
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J Emerg Crit Care Med. Vol. 21, No. 2, 2010
The majority of salmonella infections occur in
the abdominal aorta(1). The reported incidence of
include fever, unremitting sepsis, and relapsing
bacteraemia. Localized symptoms may be related
Reported risk factors for aortic infection
include diagnostic or therapeutic arterial
rupture (2,15) . Rare presentations include psoas
and pelvic abscesses, vertebral osteomyelitis,
these infections ranges from 9 to 10% in western
countries to 16.2% in a recent Taiwanese series(2).
catheterization, intravenous drug use, and
immunocompromised status due to chronic or
neoplastic diseases such as diabetes mellitus
(DM), liver cirrhosis, cancer ,or acquired
immunodeficiency syndrome(1,6). DM is reported
to be the most common underlying disease in
salmonella aortitis. Oskoui et al. (5) reported that
28% of 98 patients with salmonella aortitis had
DM. Bacterial seeding of the aortic wall can
occur by hematogenous spread to the intima or
vasa vasarum such as in pneumonia or systemic
sepsis, by lymphatic spread such as in tuberculous
aortitis (4,12) , or by direct extension from an
adjacent focus such as in purulent pericarditis
or osteomyelitis (4,12,13) . The thin endothelial
intimal lining of the aorta is generally highly
resistant to infection (4,14), but disruption of this
barrier by atherosclerosis reduces this resistance.
The normal aortic intima can also be subject to
bacterial invasion causing degenerative changes
in the arterial wall which result in aneurysm
formation and rupture(4,12,14). The latter may occur
as early as 1 week after the onset of aortitis,
and may be heralded by pericardial or pleural
effusion (4,12) . Infection of a pre-existing aortic
aneurysm is reported to occur in 3% of patients
with aneurysm (1,6) . Salmonella species have a
predilection for diseased arteries and are associated
with a high incidence of early aneurysm rupture(4,12).
Hence, salmonella sepsis should alert the physician
to the possibility of salmonella aortitis, particularly
i n t h e e l d e r l y, i n w h o m t h e p r e v a l e n c e o f
atherosclerosis is increased.
Manifestations of endovascular infections can
be protean and non-specific. Common presentations
to pressure effects from aneurysms, contagious
extension of infection, or impending aneurysmal
endobronchial masses(2), hemoptysis(2), and gastrointestinal bleeding due to aortobronchial or
aortoduodenal fistula formation(2,15). The presence
of blood in our patient’s stomach and duodenum
were not due to bleeding from the fistula tract
but from swallowing blood after hemoptysis.
Failure to consider these unusual complications of
non-typhoid salmonella bacteraemia can lead to
catastrophic consequences.
Routine chest radiographs can be significant
if they show prominent periaortic lung tissue
infiltration. Computed tomography is usually
the initial radiographic study of choice for
detection of mycotic aneurysms. Transesophageal
echocardiography is the diagnostic method of
choice for ruling out endocarditis(4,14) and a negative
result should prompt the operator to examine the
thoracic aorta for evidence of a mycotic aneurysm.
Aortography may be useful for excluding multiple
mycotic aneurysms, and outlining the relation of
the mycotic aneurysm to the major branches of
the aorta (4,8-11,13). Endoscopic study of the upper
gastrointestinal system may be necessary if there
is any doubt in differentiating hemoptysis from
hematemesis. Therefore, a mycotic aneurysm may
not be suspected initially, as in out patient, but the
diagnosis is made eventually while searching for
the source of persistent fever and hematemesis. A
high degree of awareness remains an indispensable
prerequisite for early diagnosis. Laboratory
investigation may reveal nonspecific findings such
as leukocytosis, or an increased ESR. Negative
blood cultures have been reported in up to 25% of
cases and may be caused by antibiotic pretreatment
and anaerobic organisms. This may also could
Aortic infection 115
account for negative culture results in surgically
removed pathological tissue sections(4,8,9).
or reduced immunity, a detail medical history is,
therefore, necessary. The appearance of periaortic
admission(4,10), and appropriate antibiotic therapy.
Complete excision of the affected aorta is the key
a targeted CT scan should be done urgently.
Immediate surgical treatment must be available
Current management of mycotic aneurysm
c o n s i s t s o f s u rg e r y a s e a r l y a s t h e d a y o f
to curative treatment. It is the definitive treatment
even when the infection appears to be controlled
with antibiotics, because adequate infection control
does not prevent aneurysm rupture(4,18).
There is no consensus on the duration of
antibiotic therapy(4,10). The length of preoperative
antibiotic usage can range from 24 hours to 30
days (4,10,13), whereas postoperative treatment can
range from 6 weeks to 12 months. When the source
of infection is not known, life-long prophylactic
antibiotic therapy is recommended, particularly if
disease is caused by salmonella species, and if there
is active infection (regardless of cause) at the time
of surgery (4,8,9). In postoperative follow-up serial
non-invasive imaging studies should be done to
exclude recurrent infection and laboratory markers
of inflammation should be monitored(4,8). Recurrent
or persistent infection is the leading cause of death
after successful surgery.
Conclusion
We reported a rare case of non-typhoid
salmonella mycotic aneurysm of the aortic arch in
a patient presenting with recurrent fever despite
antipyretic treatment, and an initial presentation of
hematemesis. Non-typhoid salmonella bacteraemia
is frequently associated with fever or sepsis,
unexplained symptoms of chest, abdominal or
back pain, hemoptysis, and rarely, hematemesis.
Whether or not blood is coughed up or vomited,
an alert physician should perform a prompt and
thorough evaluation for possible aortic infection
in the ED, especially in patients over 50 years old,
and in those with risk factors for atherosclerosis
infiltrates on routine chest radiography should
arouse the suspicion of the ED physician and
with adequate preoperative and postoperative
antimicrobial therapy.
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主動脈感染 117
吐血、罕見之主動脈細菌感染徵象的個案報告
范為其1　陳復銓2　翁子軒3　杜明海1　林樹基1
主動脈非典型沙門氏桿菌感染是一種罕見但卻可致命的疾病，尤其因未能早期診斷因而延誤手術治
療。此疾病的臨床病徵經常是非特定性且多變的，一般常見症狀為發燒，直到較特定性病徵如胸痛的出
現，這通常表示動脈瘤擴大或破裂，而急診醫療人員需具備高度警覺性，才能在此發病初期診斷此疾
病。本文報告一位77歲男性患者，因發燒，吐血兩天且日趨嚴重，到本院急診就診。胸部X光檢查顯示
主動脈弓旁之左側肺部浸潤，雖然經由造影加強之電腦斷層檢查後確認診斷。
關鍵詞： 吐血，主動脈瘤，非典型沙門氏桿菌感染
收件：98年4月27日　接受刊載：98年9月11日
台北醫學大學市立萬芳醫院　1急診醫學部　2心臟血管外科部　3台北醫學大學附設醫院急診醫學部
通訊及抽印本索取：林樹基醫師　116台北市文山區興隆路三段111號　台北醫學大學市立萬芳醫院急診醫學部
電話：(02)29307930轉1211　傳真：(02)29301255
E-mail: [email protected]