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A 35-year-old man was admitted to our emergency department after 3 weeks of fever, chills, arthralgia, and general weakness. He had a mild fever and a grade 2/6 systolic murmur over the precordium. Four years earlier, an aortic aneurysm had prompted replacement of his ascending aorta and aortic valve with a composite Bentall graft. His heart rate (92 beats/min), leukocyte count (18,000/mm3), erythrocyte sedimentation rate (72 mm/hr), and C-reactive protein level (68 mg/dL; normal range, 0–5) suggested infective endocarditis. Echocardiography showed a vegetation (0.9 × 0.4 cm) on the aortic valve. He was put on a regimen of intravenous teicoplanin and gentamicin. On the 4th day of treatment, blood cultures yielded gentamicin- and teicoplanin-sensitive, methicillin-resistant Staphylococcus aureus. A homograft reconstruction of the left ventricular outflow tract with a cryopreserved aortic graft was planned. The patient developed ataxia and dysarthria during the 2nd week of antibiotic treatment, but these resolved 12 hours after onset. Cranial computed tomography revealed a hemorrhagic abscess in the left parieto-occipital area, and 2 other intracerebral abscesses (Fig. 1). Two weeks later, a large, painful, pulsatile swelling developed in the patient's right antecubital space. Peripheral arteriography revealed a 6 × 4-cm aneurysm with a preocclusive stenosis of the distal right brachial artery (Fig. 2). After local débridement and resection of the aneurysmal sac and the inflamed segment of the brachial artery, the patient's circulation was restored with an interpositional graft of a reversed saphenous vein from his thigh. The surgery and his recovery were uneventful, with no residual ischemia in the forearm.
Systemic embolization is a frequent sequela of infective endocarditis, but mycotic peripheral artery aneurysms are uncommon. To the best of our knowledge, a mycotic brachial artery aneurysm of this size has not previously been reported. Brachial mycotic aneurysms of embolic origin are usually fatal.1–4 Those of cardioembolic origin are most commonly seen in the abdominal aorta and in the femoral, popliteal, and superior mesenteric arteries. Angiography can be used to confirm the diagnosis.
It is essential to treat the source of the infectious emboli with intravenous antibiotics and (if appropriate) valvular replacement. Septic embolization should be suspected when the patient's extremities are acutely affected. The aneurysmal artery can be excised and ligated if adequate collateral vessels exist; if bypass of the lesion is necessary, the use of autologous material can decrease the risk of infection.5,6
Address for reprints: Yusuf Tavil, MD, Yesitepe bl. 7. blok, daire:45, Emek-Ankara 06510, Turkey. E-mail: moc.liamg@livatfusuy