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1.  What is the optimal timing for surgery in infective endocarditis with cerebrovascular complications? 
Neurologic dysfunction complicates the course of 10–40% of left-side infective endocarditis (IE). In right-sided IE, instead, when systemic emboli occur, paradoxical embolism should be considered. The spectrum of neurologic events includes embolic cerebrovascular complication (CVC), intracranial haemorrhage, ruptured mycotic aneurysm, transient ischaemic attack (TIA), meningitis, encephalopathy and brain abscess. Cardiopulmonary bypass might exacerbate neurological deficits due to: heparinization and secondary cerebral haemorrhage; hypotension and cerebral oedema in areas of the disrupted blood brain barrier. A best evidence topic was written according to a structured protocol. The question addressed was, whether there is an optimal timing for surgery in IE with CVCs. One hundred papers were found using the reported search criteria, and out of these 20 papers, provided the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results were tabulated. We found that evidence is conflicting because of lack of controlled studies. The optimal timing for the valve replacement depends on the type of neurological complication and the urgency of the operation. The new 2009 Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (IE) recommend a multidisciplinary approach and to wait for 1–2 weeks of antibiotics treatment before performing cardiac surgery. However, early surgery is indicated in: heart failure (class 1 B), uncontrolled infection (class 1 B) and prevention of embolic events (class 1B/C). After a stroke, surgery should not be delayed as long as coma is absent and cerebral haemorrhage has been excluded by cranial CT (class IIa level B). After a TIA or a silent cerebral embolism, surgery is recommended without delay (class 1 level B). In intracranial haemorrhage (ICH), surgery must be postponed for at least 1 month (class 1 level C). Surgery for prosthetic valve endocarditis (PVE) follows the general principles outlined for native valve IE. Every patient should have a repeated head CT scan immediately before the operation to rule out a preoperative haemorrhagic transformation of a brain infarction. The presence of a haematoma warrants neurosurgical consultation and consideration of cerebral angiography to rule out a mycotic aneurysm.
doi:10.1093/icvts/ivr010
PMCID: PMC3420303  PMID: 22108925
Infective endocarditis; Cerebrovascular complication; Brain injury; Stroke cardiac surgery; Timing
2.  Ruptured mycotic cerebral aneurysm development from pseudoocclusion due to septic embolism 
Background:
Cerebral mycotic aneurysms are rare sequelae of systemic infections that can cause profound morbidity and mortality with rupture. Direct bacterial extension and vessel integrity compromise from septic emboli have been implicated as mechanisms for formation of these lesions. We report the 5-day development of a ruptured mycotic aneurysm arising from a septic embolism that caused a focal M1 pseudoocclusion.
Case Description:
A 14-year-old girl developed acute left-sided hemiparesis while hospitalized for subacute bacterial endocarditis that was found after she presented with a 2-week history of fever, myalgia, shortness of breath, and lethargy. Mitral valve vegetations were confirmed in the setting of hemophilus bacteremia. Brain magnetic resonance (MR) imaging and angiography confirmed middle cerebral artery infarct with focal pseudoocclusion of the distal M1 segment. Given that further middle cerebral artery territory was at risk, a trial of heparin was attempted for revascularization but required discontinuation owing to hemorrhagic conversion. Decline of the patient's mental status necessitated craniectomy for decompression. Postoperatively, her mental status improved with residual left hemiparesis. On the third postoperative day (5 days after MR angiography), the patient's neurologic condition acutely declined, with development of right-sided mydriasis. Computed tomography (CT) angiography revealed a ruptured 19 × 16 mm pseudoaneurysm arising from the M1 site of the previous occlusion. Emergent coiling of aneurysm and parent vessel followed by hematoma evacuation ensued. At discharge, the patient had residual left hemiparesis but intact speech and cognition.
Conclusion:
Focal occlusions due to septic emboli should be considered high-risk for mycotic aneurysm formation, prompting aggressive monitoring with neuroimaging and treatment when indicated.
doi:10.4103/2152-7806.121109
PMCID: PMC3841922  PMID: 24340226
Cerebral aneurysm; infective endocarditis; mycotic aneurysm; septic emboli
3.  Endovascular Treatment of Intracerebral Mycotic Aneurysm before Surgical Treatment of Infective Endocarditis 
Texas Heart Institute Journal  2004;31(2):165-167.
Mycotic aneurysms are rarely seen in patients who have infective endocarditis, and the management of these patients remains controversial. We present the case of a patient who had infective endocarditis complicated by a mycotic aneurysm of the left middle cerebral artery. There was substantial mitral regurgitation, and Streptococcus viridans was isolated from the blood samples. Dysarthria appeared during the 4th week of the antibiotic therapy, but resolved completely 8 hours after onset. The left middle cerebral artery was embolized with platinum detachable coils. On the 7th day after the radiologic intervention, the native mitral valve was replaced with a 33-mm St. Jude Medical® bileaflet mechanical mitral prosthesis. Most mycotic aneurysms show notable regression of symptoms with effective antibiotic treatment, and a very few may diminish in size. However, it is impossible to predict the response of these aneurysms to therapy. To prevent the perioperative rupture of mycotic aneurysms and intracranial hemorrhage, priority should be given to endovascular interventions to treat cerebrovascular aneurysms in patients such as ours.
PMCID: PMC427378  PMID: 15212129
Aneurysm, infected; embolization, therapeutic; endocarditis, bacterial; intracranial aneurysm/therapy; mitral valve/surgery
4.  Chest pain with ST segment elevation in a patient with prosthetic aortic valve infective endocarditis: a case report 
Introduction
Acute ST-segment elevation myocardial infarction secondary to atherosclerotic plaque rupture is a common medical emergency. This condition is effectively managed with percutaneous coronary intervention or thrombolysis. We report a rare case of acute myocardial infarction secondary to coronary embolisation of valvular vegetation in a patient with infective endocarditis, and we highlight how the management of this phenomenon may not be the same.
Case presentation
A 73-year-old British Caucasian man with previous tissue aortic valve replacement was diagnosed with and treated for infective endocarditis of his native mitral valve. His condition deteriorated in hospital and repeat echocardiography revealed migration of vegetation to his aortic valve. Whilst waiting for surgery, our patient developed severe central crushing chest pain with associated anterior ST segment elevation on his electrocardiogram. Our patient had no history or risk factors for ischaemic heart disease. It was likely that coronary embolisation of part of the vegetation had occurred. Thrombolysis or percutaneous coronary intervention treatments were not performed in this setting and a plan was made for urgent surgical intervention. However, our patient deteriorated rapidly and unfortunately died.
Conclusion
Clinicians need to be aware that atherosclerotic plaque rupture is not the only cause of acute myocardial infarction. In the case of septic vegetation embolisation, case report evidence reveals that adopting the current strategies used in the treatment of myocardial infarction can be dangerous. Thrombolysis risks intra-cerebral hemorrhage from mycotic aneurysm rupture. Percutaneous coronary intervention risks coronary mycotic aneurysm formation, stent infections as well as distal septic embolisation. As yet, there remains no defined treatment modality and we feel all cases should be referred to specialist cardiac centers to consider how best to proceed.
doi:10.1186/1752-1947-5-408
PMCID: PMC3177923  PMID: 21864374
5.  Mycotic Aneurysms of the Ascending Aorta in the Absence of Endocarditis 
Texas Heart Institute Journal  2012;39(5):692-695.
Mycotic aneurysm formation is a rare and potentially fatal sequela of bacteremia. We present the cases of 2 octogenarians who had surgically confirmed mycotic aneurysms that involved the ascending aorta, with contained rupture (pseudoaneurysm). Neither patient had evidence of valvular endocarditis. Patient 1, an 82-year-old man, had streptococcal bacteremia. Imaging confirmed a mycotic aneurysm of the ascending aorta, and resection was successful. Patient 2, an 83-year-old woman, had recurrent staphylococcal bacteremia and progressive widening of the mediastinum, and imaging revealed a mycotic pseudoaneurysm. She underwent surgical repair with use of a bovine pericardial patch, but she died 2 weeks later because of patch dehiscence.
We did not initially suspect mycotic aneurysm in either patient. Despite the availability of accurate, noninvasive imaging techniques, strong clinical suspicion is required for the early diagnosis of mycotic aneurysm.
PMCID: PMC3461658  PMID: 23109770
Aneurysm, infected/diagnosis/etiology/pathology/surgery/ultrasonography; anti-bacterial agents/therapeutic use; aorta/pathology/surgery; aortic aneurysm/diagnosis/surgery; staphylococcus infections/complications/pathology
6.  Cardiobacterium hominis endocarditis: two cases and a review of the literature 
Cardiobacterium hominis, a member of the HACEK group (Haemophilus parainfluenzae, Haemophilus aphrophilus, and Haemophilus paraphrophilus, Actinobacillus actinomycetemcomitans, C. hominis, Eikenella corrodens, and Kingella species), is a rare cause of endocarditis. There are 61 reported cases of C. hominis infective endocarditis in the English-language literature, 15 of which involved prosthetic valve endocarditis. There is one reported case of C. hominis after upper endoscopy and none reported after colonoscopy. Presented here are two cases of C. hominis prosthetic valve endocarditis following colonoscopy and a review of the microbiological and clinical features of C. hominis endocarditis. Patients with C. hominis infection have a long duration of symptoms preceding diagnosis (138±128 days). The most common symptoms were fever (74%), fatigue/malaise (53%), weight loss/anorexia (40%), night sweats (24%), and arthralgia/myalgia (21%). The most common risk factors were pre-existing cardiac disease (61%), the presence of a prosthetic valve (28%), and history of rheumatic fever (20%). Of the 61 cases reviewed here, the aortic valve was infected in 24 (39%) and the mitral valve in 19 (31%) patients. The average duration of blood culture incubation before growth was detected was 6.3 days (range, 2–21 days). Complications were congestive heart failure (40%), central nervous system (CNS) emboli (21%), arrhythmia (16%), and mycotic aneurysm (9%). C. hominis is almost always susceptible to β-lactam antibiotics. Ceftriaxone is recommended by the recently published American Heart Association guidelines. The prognosis of C. hominis native valve and prosthetic valve endocarditis is favorable. The cure rate among 60 patients reviewed was 93% (56/60). For prosthetic valve endocarditis, the cure rate was 16/17 (94%). Valve replacement was required in 27 (45%) cases.
doi:10.1007/s10096-006-0189-9
PMCID: PMC2276845  PMID: 16955250
7.  Spontaneous infective spondylitis and mycotic aneurysm: incidence, risk factors, outcome and management experience 
European Spine Journal  2007;17(3):439-444.
Infective spondylitis occurring concomitantly with mycotic aneurysm is rare. A retrospective record review was conducted in all cases of mycotic aneurysm from January 1995 to December 2004, occurring in a primary care and tertiary referral center. Spontaneous infective spondylitis and mycotic aneurysm were found in six cases (10.3% of 58 mycotic aneurysm patients). Neurological deficit (50% vs. 0; P < 0.001) is the significant clinical manifestation in patients with spontaneous infective spondylitis and mycotic aneurysm. The presence of psoas abscess on computed tomography (83.3% vs. 0; P < 0.001) and endplate destruction on radiography (50% vs. 0; P < 0.001) are predominated in patients with spontaneous infective spondylitis and mycotic aneurysm. Of these six patients, four with Salmonella infection received surgical intervention and all survived. Another two patients (one with Streptococcus pyogenes, another with Staphylococcus aureus) received conservative therapy and subsequently died from rupture of aneurysm or septic shock. Paravertebral soft tissue swelling, presence of psoas abscess and/or unclear soft tissue plane between the aorta and vertebral body in relation to mycotic aneurysm may indicate a concomitant infection in the spine. In contrast, if prevertebral mass is found in the survey of spine infection, coexisting mycotic aneurysm should be considered.
doi:10.1007/s00586-007-0551-3
PMCID: PMC2270374  PMID: 18046585
Infective spondylitis; Mycotic aneurysm; Psoas abscess
8.  Infective Endocarditis in the Pediatric Patient: A 60-Year Single-Institution Review 
Mayo Clinic Proceedings  2012;87(7):629-635.
Objective
To determine the epidemiology of infective endocarditis (IE) presenting in pediatric patients during a 60-year period at our institution.
Patients and Methods
In this retrospective medical record review, we extracted demographic characteristics, diagnostic variables, and outcomes for patients less than 20 years of age diagnosed with IE from January 1, 1980, to June 30, 2011. We compared this cohort with a previously reported cohort of pediatric patients with IE from our institution diagnosed from 1950 to 1979.
Results
We identified 47 patients (24 males; mean ± SD age at diagnosis, 12.3±5.5 years [range, 1 day to 18.9 years]) who had 53 episodes of IE. The most common isolated organisms were viridans streptococci (17 of 53 episodes [32%]) and Staphylococcus aureus (12 of 53 episodes [23%]). Of the 47 patients, 36 (77%) had congenital heart disease, 24 of whom had cardiac surgery before their first episode of IE (mean ± SD time to IE diagnosis after surgery, 4.2±3.2 years [range, 64 days to 11.3 years]). Fourteen patients (30%) required valve replacement because of valvular IE, and 16 (34%) had complications, including mycotic aneurysm, myocardial abscess, or emboli. Vegetations were identified using echocardiography in 37 of the 53 unique episodes of IE (70%). Endocarditis-related mortality occurred in 1 patient. Compared with the historical (1950-1979) cohort, there were no differences in patient demographic characteristics, history of congenital heart disease, or infecting organisms. One-year mortality was significantly lower in the modern cohort (4%) compared with the historical cohort (38%) (P<.001).
Conclusion
Most pediatric episodes of IE occur in patients with congenital heart disease. Mortality due to endocarditis has decreased in the modern era.
doi:10.1016/j.mayocp.2012.02.023
PMCID: PMC3497940  PMID: 22766082
CHD, congenital heart disease; IE, infective endocarditis; VSD, ventricular septal defect
9.  Cardiac Surgery in Patients Infected with Human Immunodeficiency Virus 
Texas Heart Institute Journal  2000;27(4):356-360.
From January 1991 through December 1999, 5 consecutive patients who were infected with human immunodeficiency virus presented in need of cardiac surgery. All were men; the median age was 44 years. Two of them presented with mitral and aortic infectious valve endocarditis, 1 with tricuspid endocarditis, 1 with prosthetic valve endocarditis, and 1 with pericarditis and pericardial tamponade.
Under cardiopulmonary bypass, the 4 patients with endocarditis underwent these procedures: mitral and aortic valve replacement (2), tricuspid valve replacement (1), and aortic valve replacement (reoperation) and concomitant repair of a mycotic ascending aortic aneurysm (1). In the patient who had pericardial effusion, subxifoid pericardiostomy and drainage were performed, and a pericardial window was created.
There was no intraoperative mortality. The patient with pericardial effusion died 8 days after surgery; he was in septic shock and had multiple organ failure. Two deaths occurred at 2 and 63 months, due to hemoptysis and sudden death, respectively. The 2 patients who underwent double valve replacement are alive and in good condition after a median follow-up of 71 months.
Cardiac surgery is indicated in selected patients infected by the human immunodeficiency virus. These patients are frequently drug abusers or homosexual. Valvular endocarditis is the most common finding. Hospital morbidity and mortality rates are higher than usual in this group of patients.
PMCID: PMC101104  PMID: 11198308
Endocarditis, bacterial/surgery; heart valve diseases/surgery; heart valve prosthesis; HIV infections; substance abuse, intravenous/complications
10.  Management of neurological complications of infective endocarditis in ICU patients 
Patients with infective endocarditis (IE) are generally referred to the intensive care unit (ICU) for one or more organ dysfunctions caused by complications of IE. Neurologic events are frequent causes of ICU admission in patients with IE. They can arise through various mechanisms consisting of stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are a hallmark of left-sided abnormalities of native or prosthetic valves. Occlusion of cerebral arteries, with stroke or transient ischemic attack, accounts for 40% to 50% of the central nervous system complications of IE. CT scan is the most easily feasible neuroimaging in critically unstable patients. However, magnetic resonance imaging is more sensitive and when performed should follow a standardized protocol. In patients with ischemic stroke who are already receiving oral anticoagulant therapy, this treatment should be replaced by unfractionated heparin for at least 2 weeks with a close monitoring of coagulation tests. Mounting evidence shows that, for both complicated left-sided native valve endocarditis and Staphylococcus aureus prosthetic valve endocarditis, valve replacement combined with medical therapy is associated with a better outcome than medical treatment alone. In a recent series, approximately 50% of patients underwent valve replacement during the acute phase of IE before completion of antibiotic treatment. After a neurological event, most patients have at least one indication for cardiac surgery. Recent data from literature suggest that after a stroke, surgery indicated for heart failure, uncontrolled infection, abscess, or persisting high emboli risk should not be delayed, provided that the patient is not comatose or has no severe deficit. Neurologic complications of IE contribute to a severe prognosis in ICU patients. However, patients with only silent or transient stroke had a better prognosis than patients with symptomatic events. In addition, more than neurologic event per se, a better predictor of mortality is neurologic dysfunction, which is associated with location and extension of brain damage. Patients with severe neurological impairment and those with brain hemorrhage have the worse outcome.
doi:10.1186/2110-5820-1-10
PMCID: PMC3224466  PMID: 21906336
11.  In Situ Reconstruction with Cryopreserved Arterial Allografts for Management of Mycotic Aneurysms or Aortic Prosthetic Graft Infections 
Texas Heart Institute Journal  2006;33(1):14-18.
We designed this study to evaluate a multi-institutional experience regarding the efficacy of cryopreserved aortic allografts in the treatment of infected aortic prosthetic grafts or mycotic aneurysms. We reviewed clinical data of all patients from 4 institutions who underwent in situ aortic reconstruction with cryopreserved allografts for either infected aortic prosthetic graft or mycotic aneurysms from during a 6-year period. Relevant clinical variables and treatment outcomes were analyzed.
A total of 42 patients (37 men; overall mean age 63 ± 13 years, range 41–74 years) were identified during this study period. Treatment indications included 34 primary aortic graft infections (81%), 6 mycotic aneurysms (22%), and 2 aortoenteric erosions (5%). Transabdominal and thoracoabdominal approaches were used in 38 (90%) and 4 patients (10%), respectively. Staphylococcus aureus was the most commonly identified organism (n=27, 64%). Although there was no intraoperative death, the 30-day operative mortality was 17% (n=7). There were 21 (50%) nonfatal complications, including local wound infection (n=8), lower-extremity deep venous thrombosis (n=5), amputation (n=6), and renal failure requiring hemodialysis (n=2). The average length of hospital stay was 16.4 ± 7 days. During a mean follow-up period of 12.5 months, reoperation for allograft revision was necessary in 1 patient due to graft thrombosis (6%). The overall treatment mortality rate was 21% (n=9).
In situ aortic reconstruction with cryopreserved allografts is an acceptable treatment method in patients with infected aortic prosthetic graft or mycotic aneurysms. Our study showed that mid-term graft-related complications such as reinfection or aneurysmal degeneration were uncommon.
PMCID: PMC1413601  PMID: 16572862
Aneurysm, infected/surgery; bacterial infections/complications/surgery; arteries/transplantation; blood vessel prosthesis/adverse effects; cryopreservation; prosthesis-related infections/ surgery; staphylococcal infections/surgery; surgical wound infection/surgery; reoperation; transplantation, homologous
12.  Massive haemoptysis in an intravenous drug user with infective tricuspid valve endocarditis 
BMJ Case Reports  2010;2010:bcr1020092404.
Major causes of morbidity in intravenous drug users are infections. In infective endocarditis, the tricuspid valve is mainly involved. Masses can cause septic embolisms and, in rare cases, they are associated with mycotic aneurysms of pulmonary arteries that lead to severe haemorrhage.
We report the case of a young woman with a history of intravenous drug abuse and prolonged infective tricuspid valve endocarditis. Initially, echocardiography showed large masses on the anterior leaflet of the tricuspid valve and severe tricuspid regurgitation; blood cultures revealed staphylococcus and streptococcus species. Eight months after initial diagnosis, she presented with severe haemoptysis and fever. CT revealed a ruptured mycotic aneurysm of the right pulmonary artery. Lobectomy was performed immediately.
Postoperatively, the patient fully recovered. After continued antibiotic treatment, follow-up examinations showed negative echocardiographic findings and blood cultures results.
doi:10.1136/bcr.10.2009.2404
PMCID: PMC3027946  PMID: 22767369
13.  Ruptured Intracranial Mycotic Aneurysm in Infective Endocarditis: A Natural History 
Case Reports in Medicine  2010;2010:168408.
Mycotic aneurysms are a rare cause of intracranial aneurysms that develop in the presence of infections such as infective endocarditis. They account for a small percentage of all intracranial aneurysms and carry a high-mortality rate when ruptured. The authors report a case of a 54-year-old man who presented with infective endocarditis of the mitral valve and acute stroke. He subsequently developed subarachnoid hemorrhage during antibiotic treatment, and a large intracranial aneurysm was discovered on CT Angiography. His lesion quickly progressed into an intraparenchymal hemorrhage, requiring emergent craniotomy and aneurysm clipping. Current recommendations on the management of intracranial Mycotic Aneurysms are based on few retrospective case studies. The natural history of the patient's ruptured aneurysm is presented, as well as a literature review on the management and available treatment modalities.
doi:10.1155/2010/168408
PMCID: PMC2946581  PMID: 20885918
14.  The forgotten disease: Bilateral lemierre’s disease with mycotic aneurysm of the vertebral artery 
Patient: Male, 25
Final Diagnosis: Lemierre’s disease
Symptoms: Back pain • fever • headache • tachycardia • tachypnoe
Medication: —
Clinical Procedure: —
Specialty: Infectious Diseases
Objective:
Rare disease
Background:
Lemierre’s disease, also known as the forgotten disease, postanginal sepsis, or necrobacillosis, was first reported in 1890 by Courmont and Cade, but it was Dr. Andre Lemierre, a professor of microbiology, who described this disease in 1936. The typical causative agent is Fusobacterium necrophorum, although other organisms may be involved. The pathogenesis of Lemierre’s disease is not well understood. It is characterized by a primary oropharyngeal infection associated with septicemia, internal jugular vein thrombosis, and metastatic septic emboli.
Case Report:
We report a case of Lemierre’s disease with bilateral internal jugular vein (IJV) thrombosis and metastatic septic emboli to the lungs and brain, associated with epidural abscess and mycotic aneurysm of the vertebral artery, which is quite rare in Lemierre’s disease. This is the first report of a case of Lemierre’s disease associated with mycotic aneurysm of the vertebral artery.
Conclusions:
Lemierre’s disease is a rare and perplexing medical entity. Clinical suspicion should be high in previously healthy young adults presenting with fever and neck pain following oropharyngeal infection. Dr. Lemierre stated that ‘symptoms and signs of Lemierre’s disease are so characteristic that it permits diagnosis before bacteriological examination’. The prognosis of patients with Lemierre’s disease is generally good, provided prompt recognition and appropriate treatment.
doi:10.12659/AJCR.890449
PMCID: PMC4038640  PMID: 24883173
Aneurysm; Infected – microbiology; Lemierre Syndrome; Thrombosis
15.  Extracardiac Manifestations of Bacterial Endocarditis 
Western Journal of Medicine  1979;131(2):85-91.
Bacterial endocarditis is an elusive disease that challenges clinicians' diagnostic capabilities. Because it can present with various combinations of extravalvular signs and symptoms, the underlying primary disease can go unnoticed.
A review of the various extracardiac manifestations of bacterial endocarditis suggests three main patterns by which the valvular infection can be obscured. (1) A major clinical event may be so dramatic that subtle evidence of endocarditis is overlooked. The rupture of a mycotic aneurysm may simulate a subarachnoid hemorrhage from a congenital aneurysm. (2) The symptoms of bacterial endocarditis may be constitutional complaints easily attributable to a routine, trivial illness. Symptoms of low-grade fever, myalgias, back pain and anorexia may mimic a viral syndrome. (3) Endocarditis poses a difficult diagnostic dilemma when it generates constellations of findings that are classic for other disorders. Complaints of arthritis and arthralgias accompanied by hematuria and antinuclear antibody may suggest systemic lupus erythematosus; a renal biopsy study showing diffuse proliferative glomerulonephritis may support this diagnosis. The combination of fever, petechiae, altered mental status, thrombocytopenia, azotemia and anemia may promote the diagnosis of thrombotic thrombocytopenic purpura.
When the protean guises of bacterial endocarditis create these clinical difficulties, errors in diagnosis occur and appropriate therapy is delayed. Keen awareness of the varied disease presentations will improve success in managing endocarditis by fostering rapid diagnosis and prompt therapy.
PMCID: PMC1271697  PMID: 516715
16.  Endovascular Management of Infective Intracranial Aneurysms with Acrylic Glue 
Interventional Neuroradiology  2009;15(4):443-447.
Summary
Cerebral mycotic aneurysms (MAs) also called infective aneurysms, are uncommon and are usually encountered in patients with infective endocarditis. These aneurysms often present with intracranial hemorrhage. MAs may resolve on treatment with antibiotics alone. However prognosis with medical management alone is unpredictable. Good prognosis with surgery has been reported for single accessible ruptured MAs. However surgery is associated with significant morbidity. Endovascular treatment of MAs along with appropriate antibiotics is emerging as an acceptable option for these patients.
We describe two cases of infective endocarditis complicated by ruptured MA treated successfully by liquid embolic glue material.
PMCID: PMC3299432  PMID: 20465872
mycotic aneurysm, infective endocarditis, endovascular treatment, liquid embolic glue material
17.  Septic embolism in the intensive care unit 
Septic embolism encompasses a wide range of presentations and clinical considerations. From asymptomatic, incidental finding on advanced imaging to devastating cardiovascular or cerebral events, this important clinico-pathologic entity continues to affect critically ill patients. Septic emboli are challenging because they represent two insults—the early embolic/ischemic insult due to vascular occlusion and the infectious insult from a deep-seated nidus of infection frequently not amenable to adequate source control. Mycotic aneurysms and intravascular or end-organ abscesses can occur. The diagnosis of septic embolism should be considered in any patient with certain risk factors including bacterial endocarditis or infected intravascular devices. Treatment consists of long-term antibiotics and source control when possible. This manuscript provides a much-needed synopsis of the different forms and clinical presentations of septic embolism, basic diagnostic considerations, general clinical approaches, and an overview of potential complications.
doi:10.4103/2229-5151.109423
PMCID: PMC3665121  PMID: 23724387
Complications; diagnosis and management; septic embolism; system-based approach
18.  Surgical Considerations in Aortitis * 
Texas Heart Institute Journal  1983;10(4):329-335.
Mycotic aneurysms were first described as the result of nonsyphilitic bacterial infection of the arterial wall. They were often caused by septic emboli from bacterial endocarditis and were much more common prior to the era of antibiotics.
Although the aorta is most often affected, such aneurysms may arise in any artery. Classified according to their etiology as primary, secondary, and cryptic mycotic aneurysms, it is imperative that immediate treatment be instituted once the diagnosis is confirmed by angiography. The patient should be placed on high doses of antibiotics appropriate for the offending pathogens.
The goal of surgical treatment is the complete removal of the infected aneurysm and preservation of the distal circulation. Alternate methods of treating these lesions include the use of bypass grafts and interposition grafts. The virulence of the offending pathogen and the sensitivity to antibiotic therapy play a significant role in the success of these procedures.
PMCID: PMC344360  PMID: 15226965
19.  Aorto-enteric fistula development secondary to mycotic abdominal aortic aneurysm following intravesical bacillus Calmette–Guerin (BCG) treatment for transitional cell carcinoma of the bladder 
INTRODUCTION
Intravesical BCG-instillation for bladder cancer is considered safe but is not without risk. While most side-effects are localised and self-limiting, the development of secondary vascular pathology is a rare but significant complication.
PRESENTATION OF CASE
A 77-year-old male presented with a mycotic abdominal aortic aneurysm and associated aorto-enteric fistula 18 months after receiving intravesical BCG-instillations for early stage transitional cell carcinoma.
DISCUSSION
Response rates to intravesical BCG for early stage transitional cell carcinoma are high. The procedure produces a localised inflammatory response in the bladder but the exact mechanism of action is unclear. The treatment is generally well tolerated but BCG-sepsis and secondary vascular complications have been documented.
Mycotic abdominal aortic aneurysm with associated aorto-enteric fistula secondary to BCG is very rare. Few examples have been documented internationally and the extent of corresponding research and associated management proposals is limited.
Surgical options include in situ repair with prosthetic graft, debridement with extra-anatomical bypass and, occasionally, endovascular stent grafting. Recommended medical therapy for systemic BCG infection is Isoniazid, Rifampicin and Ethambutol.
CONCLUSION
Current screening methods must be updated with clarification regarding duration of anti-tuberculous therapy and impact of concomitant anti-tuberculous medication on the therapeutic action of intravesical BCG. Long-term outcomes for patients post graft repair for mycotic aneurysm are unknown and more research is required regarding the susceptibility of vascular grafts to mycobacterial infection.
Recognition of the risks associated with BCG-instillations, even in immunocompetent subjects, is paramount and must be considered even several months or years after receiving the therapy.
doi:10.1016/j.ijscr.2012.09.009
PMCID: PMC3537938  PMID: 23127864
BCG; Aortic aneurysm; Aorto-enteric fistula; Bladder carcinoma
20.  Multiple fusiform cerebral aneurysms – case report 
Polish Journal of Radiology  2012;77(1):50-53.
Summary
Background:
A true aneurysym is a dilation of arterial lumen as a consequence of congenital or acquired abnormalities leading to a reduction of mechanical resistance of vascular wall, most commonly caused by its defected structure in the form of absence or weakening of the muscular and/or elastic layer. From the pathophysiological point of view, cerebral aneurysms can be classified as ‘saccular’ – most commonly occurring, and ‘other types’, including fusiform/dolichoectatic, dissecting, serpentine, posttraumatic, mycotic and giant aneurysms with or without intra-aneurysmal thrombosis.
Case Report:
We present a rare case of a patient with multiple fusiform dilations of cerebral vessels and giant fusiform aneurysm in supraclinoid segment of the internal carotid artery. The patient presented to hospital because of sudden, severe vertigo with nausea, impaired balance and disturbed vision. Vascular anomalies were detected on CT scanning without contrast. The diagnostic work-up was complemented by CT angiography, MRI and cerebral angiography.
Conclusions:
Aneurysm located within the intracranial arteries is one of the most common vascular defects of the brain. The number, size and location of aneurysms are highly variable. Aneurysms can have either supra- or infratentorial location, affecting a single or multiple arteries within one or both brain hemispheres. There is often a correlation between the location of the aneurysm and its etiology, as in case of so-called mirror-image aneurysms. Symmetrically located aneurysms may indicate a defect in vascular structure. Asymmetric location, as in the patient described above, is more likely due to acquired causes, mainly atherosclerosis, but also septic emboli or blood disorders.
PMCID: PMC3389952  PMID: 22802866
fusiform aneurysm; dolichoectasia; cerebral giant aneurysm; angio-CT; angiography; endovascular treatment
21.  Large Intracranial Aneurysm after Transsphenoidal Surgery for Pituitary Macroadenoma 
Uncontrolled cerebrospinal fluid (CSF) leakage after transsphenoidal surgery (TSS) for pituitary adenoma can lead to meningitis. Intracranial mycotic pseudoaneurysm is a rare complication in central nervous system infection. Large single pseudoaneurysm is more uncommon. Most mycotic aneurysms occur due to endocarditis. The present patient had no heart problem and was infected by CSF leakage after transsphenoidal surgery. We present a case of large ruptured mycotic pseudoaneurysm as a complication of cerebral infection after TSS for pituitary macroadenoma.
doi:10.3340/jkns.2014.55.3.160
PMCID: PMC4024817  PMID: 24851153
Intracranial aneurysm; Transsphenoidal surgery; Pituitary macroadenoma
22.  Infective endocarditis with cerebrovascular complications: timing of surgical intervention 
Management of infective endocarditis (IE) with cerebrovascular complications is difficult due to absence of concrete evidence. These patients usually have multiple neurological deficits and the optimal timing for cardiac operation remains controversial. The aims of this study were to present cases and discuss the treatment options for IE with cerebrovascular complications. From 1998 to 2010, 51 patients underwent operations for IE at our institution. From a review of medical records, 10 patients (19.6%) with preoperative neurological complications were identified. Data on these 10 patients were analysed. Cerebrovascular complications included cerebral infarction (n = 4, 40.0%), mycotic aneurysm (n = 1, 10.0%), mycotic aneurysm plus cerebral infarction (n = 3, 30.0%), meningitis (n = 1, 10.0%) and mycotic aneurysm with cerebral haemorrhage plus meningitis (n = 1, 10.0%). Of 5 patients having mycotic aneurysms, 3 underwent clipping before cardiac operations. The mean interval from craniotomy to cardiac operations was 26.7 ± 21.8 days. A cardiac operation was performed initially on seven patients. The mean interval from the onset of neurological deficit to cardiac operation was 7.4 ± 9.8 days. The mortality rate was 10.0%. Postoperative deterioration was not observed. Management of IE with cerebrovascular complications should be based on case-by-case multidisciplinary assessment of potential risks and benefits of intracranial and cardiac operations.
doi:10.1093/icvts/ivr038
PMCID: PMC3420269  PMID: 22108940
Infective endocarditis; Cerebrovascular complications; Surgical intervention
23.  Infective endocarditis with multiple mycotic aneurysms mimicking vasculitis: A case report 
The manifestation of infective endocarditis often resembles vasculitis. Approximately one in five infective endocarditis cases are referred initially to a nephrologist because of abnormal renal function or abnormal urinalysis; therefore, infection should be ruled out before diagnosing vasculitis.
A case involving a patient with infective endocarditis who presented with migrating skin lesions, renal infarction and multiple pseudoaneurysms is reported. Echocardiography revealed mitral valve vegetation and viridans streptococci were identified in peripheral blood cultures. Although mitral valve annuloplasty and an aneurysm ligation operation were performed with proper antibiotic treatment, the remaining mycotic aneurysm progressed and caused neurological complications. The patient was cured completely after reoperation.
PMCID: PMC3476565  PMID: 23997788
Aneurysm; Endocarditis; Infected; Vasculitis
24.  Mycotic aneurysms of the abdominal aorta due to Listeria monocytogenes 
INTRODUCTION
Infected abdominal aortic aneurysms (AAAs) can present insidiously with non-specific symptoms or they may present as ruptured AAA in the classical manner.
PRESENTATION OF CASE
We report two cases of mycotic AAA with Listeria monocytogenes. One patient presented with a ruptured aneurysm, while the other patient had a symptomatic non-ruptured presentation with computer tomography (CT) angiogram demonstrating peri-aortic inflammatory change of a rapidly expanding aneurysm. Both patients were treated with excision of the infected tissue and inlay prosthetic surgical repair as well as long term antibiotics.
DISCUSSION
Arterial aneurysms caused by L. monocytogenes are rare. Risk factors include immunosuppression, infective endocarditis, intravenous drug use and septicaemia. Listeria infections should be discussed with the Health Protection Agency and local microbiologists due to their ubiquity.
CONCLUSION
Abdominal aortic aneurysm due to L. monocytogenes is best managed via surgical resection in combination with long term antimicrobial therapy. The role of endovascular exclusion is unclear.
doi:10.1016/j.ijscr.2013.02.024
PMCID: PMC3679443  PMID: 23711639
Mycotic; Aneurysm; Listeria; Monocytogenes; Aortic
25.  Bacteroides fragilis aortic arch pseudoaneurysm: case report with review 
We present a case of 58-year-old woman with underlying diabetes mellitus, hepatitis C virus-related liver cirrhosis, and total hysterectomy for uterine myoma 11 moths ago, who was diagnosed ruptured aortic arch mycotic pseudoaneurysm after a certain period of survey for her unknown fever cause. After emergent surgery with prosthetic graft interposition, all her blood cultures and tissue cultures revealed pathogen with Bacteroides fragilis. Although mycotic aneurysms have been well described in literatures, an aneurysm infected solely with Bacteroides fragilis is unusual, with only eight similar cases in the literature. Here we reported the only female case with her specific clinical and management course and summarized all reported cases of mycotic aneurysm caused by Bacteroides fragilis to clarify their conditions and treatments, alert the difficulty in diagnosis, and importance of highly suspicious.
doi:10.1186/1749-8090-3-29
PMCID: PMC2430200  PMID: 18492250

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