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Case report
Ruptured mycotic aneurysm of the common femoral artery complicating a mitral valve infective endocarditis
Endocarditis infecciosa de la válvula mitral complicada por la rotura de un aneurisma micótico de la arteria femoral común
Assia Elouardia,b,
Corresponding author
Dr.elouardi.assia@gmail.com

Corresponding author.
, Samir Elyoubib,c, Emannuel Kibassima,b, Anas Elhafidia,b, Salah Eddine Boulmakoula,b, Amine Majdouba,b, Mohammed Messouaka,b
a Cardiovascular Surgery Department, Hassan II University Hospital, Fez, Morocco
b Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez, Morocco
c Vascular Surgery Department, Hassan II University Hospital, Fez, Morocco
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with known rheumatic disease&#44; previously diagnosed to have mitral valve prolapse&#44; was admitted to the emergency department with a two-months history of fever&#44; night sweats&#44; increasing breathlessness&#44; and weight loss over three months&#46; The patient also reported a pulsatile&#44; painful swelling in the right thigh&#46; On examination her temperature was 39<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; heart rate 110<span class="elsevierStyleHsp" style=""></span>beats&#47;min and blood pressure 102&#47;60<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Auscultation of her chest revealed bibasilar crepitations and a 4&#47;6 pan-systolic murmur was heard best at the apex radiating to the axilla&#46; There was also a large pulsating mass in the anteromedial right thigh&#46; Blood tests showed anemia &#40;hemoglobin 10<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#44; mild neutrophil leukocytosis &#40;white cell count 12&#46;5<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; and raised C-reactive protein &#40;178<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41; with normal electrolytes&#44; blood cultures were found positive for Staphylococcus Hominis&#46; Transthoracic echocardiography revealed a bright echogenic mobile mass on the mitral valve measuring 21<span class="elsevierStyleHsp" style=""></span>mm on the atrial side of the anterior mitral valve&#44; several other small vegetations were evident on the posterior mitral valve with severe mitral regurgitation and elevated pulmonary artery systolic pressure&#46; Color doppler ultrasound was performed and showed a thrombosed aneurysm of the common femoral artery&#46; Appropriate intravenous antibiotic therapy was initiated and given the severity of endocarditis and cardiac failure&#44; the patient underwent first an emergency prosthetic mitral valve replacement with a 31-mm SJM valve under standard cardiopulmonary bypass&#46; The postoperative course was uneventful&#44; the fevers remitted&#44; but the white blood cell&#47;C-reactive protein &#40;WBC&#47;CRP&#41; count elevated&#44; with a continuous complaint of right thigh pain and numbness&#46; On the 4th day after MVR&#44; the patient experienced acute pain and a marked increase in the thigh swelling &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; contrast-enhanced CT scan showed acute expansion of the common femoral aneurysm with evidence for contained rupture &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Under general anesthesia&#44; the patient underwent an emergency exploratory surgery of the right lower limb&#46; There was a large-volume hematoma related to the ruptured aneurysm of the common femoral artery &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The aneurysm was resected and the vascular segment reconstructed by reversed interposition of a segment of the ipsilateral saphenous vein &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The post-operative course was uneventful and other laboratory data immediately normalized&#46; Microbiology tests on the aneurysm sac were negative with no germ growth on culture&#46; On histopathology&#44; the artery wall was disrupted and replaced by fibrin and thrombus&#46; The patient progressed well and was discharged on the fifth postoperative day&#46; There was no recurrence of infection&#44; and the graft remains patent&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Despite improvement in treatment of infective endocarditis &#40;IE&#41;&#44; the complications are frequently seen&#46; The complications of IE consist of neurological vascular complications &#40;45&#46;5&#37;&#41; and peripheral vascular complications &#40;myocardial infarction&#44; pulmonary embolism&#44; splenic infarction&#44; acute limb ischemia&#44; gangrene&#41; that are mainly the consequence of emboli from valve vegetations&#44; which are life threatening and debilitating&#46; However&#44; 20&#37; of embolisms are asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Mycotic aneurysms &#40;MA&#41; are rarely seen and defined as localized&#44; irreversible vascular dilatations caused by weakening and destruction of the vessel wall by an invasive organism establishing an infective arteritis&#46; In 1885&#44; Sir William Osler described the first infected aneurysm of the aorta complicating bacterial endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The term &#8216;mycotic&#8217; derives from the mushroom-like appearance of the aneurysms originally described&#44; and not their underlying microbiological etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Endarterial infection may arise through hematogenous seeding from distant septic foci either direct to the arterial intima or to deeper mural layers via the vasa vasorum&#46; Currently&#44; the incidence of these aneurysms following an episode of endocarditis is quite rare&#44; and their location is dependent upon the peripheral lodgment site of mycotic emboli&#46; Peripheral embolic events usually involve the lower extremities with most emboli lodging at the common femoral artery bifurcation followed by the abdominal and thoracic aorta&#46; MA of intracranial vessels are uncommon and visceral arteries are extremely rare&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Fever&#44; painful pulsatile mass with palpable thrill and local inflammatory changes are the most clinical findings of physical examination&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> The most frequently involved bacteria are Staphylococcus&#44; Streptococcus&#44; Pneumococcus and Pseudomonas aeruginosa however negative hemocultures are seen relatively high &#40;25&#37;&#41;&#46; Transthoracic and transesophageal echocardiography are used for the prediction of embolisms&#46; The size and mobility of vegetations are predictive factors of embolisms&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In the literature&#44; the most often reported MA diagnostic tool is angiography&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Computed tomographic angiography is an accurate and effective diagnostic method for tracking size&#44; configuration&#44; and extravasation of blood into the soft tissue of the thigh&#46; Ultrasound is considered a better test to precisely determine aneurysm diameter&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> MRI can be of diagnostic utility or of discriminatory value when other tests are inconclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The natural history of untreated mycotic aneurysms is of fatality from either massive hemorrhage or fulminant sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Manifestations of aneurysm expansion correlate with anatomical location&#46; Although occurring as late as complications in terms of the natural history&#44; up to 45&#37; rupture&#44; with fistula formation in 18&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Management of MA is less clear because of paucity of cases reported in the literature&#44; in general&#44; the standard therapy includes early antibiotic use&#44; which should be based on appropriate guidelines&#44; valve surgery and&#47;or complete excision of infective tissues&#46; Surgical treatment of MA is directed to control hemorrhage&#46; Debridement of all infected tissue and restoration of circulation is the subsequent aim&#46; Hemorrhage can be controlled by clamping the vessel proximally and distally&#46; Debridement should include evacuation of infected hematoma and excision of all necrotic tissues&#44; which usually includes the arterial wall itself&#46; Restoration of circulation in such cases is typically achieved with bypass grafting using autogenous vein&#46; Endovascular options such as coil embolization&#47;thrombin glue injection&#44; stenting appear attractive alternatives to surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> We did not consider them in our case&#44; as the patient had signs of compartmental compression due to the large thigh hematoma&#46; Additionally&#44; the evidence of such interventions in mycotic aneurysms is limited&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Mycotic aneurysms are a serious clinical condition that are associated with significant morbidity and mortality&#46; They may be prevented with an early and appropriate management of IE but once diagnosed they should be treated surgically&#46; Even if Antibiotics may control sepsis&#44; they do not reduce risk of rupture of the weakened vessel wall&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Informed consent</span><p id="par0025" class="elsevierStylePara elsevierViewall">Verbal and written informed consent were obtained from the patient for the publication of this case report&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest regarding the publication of this paper&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ruptured mycotic aneurysm following infective endocarditis is rare&#44; but remains a life-threatening condition&#46; We report a case of surgical management of a ruptured mycotic aneurysm of the common femoral artery&#44; complicating mitral valve endocarditis with heart failure in a twenty-nine-year-old female who underwent a prosthetic mitral valve replacement and an in situ successful reconstruction using reversed saphenous vein graft&#46; The patient recovered uneventfully and was found in good condition as a three-year follow-up&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El aneurisma mic&#243;tico roto despu&#233;s de una endocarditis infecciosa es raro&#44; pero sigue siendo una afecci&#243;n potencialmente mortal&#46; Presentamos el caso de manejo quir&#250;rgico de un aneurisma mic&#243;tico roto de la arteria femoral com&#250;n&#44; que complica la endocarditis de la v&#225;lvula mitral con insuficiencia card&#237;aca en una mujer de 29 a&#241;os&#44; a la que se le realiz&#243; un reemplazo valvular mitral y una reconstrucci&#243;n exitosa <span class="elsevierStyleItalic">in situ</span>&#44; utilizando injerto de vena safena&#46; El paciente se recuper&#243; sin incidentes y se encontr&#243; en buenas condiciones a los tres a&#241;os de seguimiento&#46;</p></span>"
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ISSN: 11340096
Original language: English
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es en pt

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