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Intracranial mycotic aneurysm in a 5 month-old infant with pneumococcal meningitis
Aneurisma micótico intracraneal en lactante con meningitis neumocócica
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Llorente, Olga Ordóñez, Ana Martínez de Aragón" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Alba" "apellidos" => "Palacios" "email" => array:2 [ 0 => "alba_palacios@hotmail.com" 1 => "alba.palacios@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ana M." "apellidos" => "Llorente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Olga" "apellidos" => "Ordóñez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Ana" "apellidos" => "Martínez de Aragón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Neurorradiología Pediátrica, Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aneurisma micótico intracraneal en lactante con meningitis neumocócica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 612 "Ancho" => 1771 "Tamanyo" => 94667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Image of coronal magnetic resonance angiogram: stenosis and dilations (string of bead) in the middle cerebral artery and basilar artery. (B) CT scan: subarachnoid and subdural haemorrhage. (C) Magnetic resonance angiogram with contrast: aneurysm of the basilar artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A previously healthy 5-month-old boy vaccinated according to the official vaccination schedule (including the 23-valent pneumococcal vaccine) was admitted to the paediatric intensive care unit with symptoms of sepsis and generalised seizures. A lumbar puncture was performed, which showed fluid compatible with bacterial meningitis (1200 leukocytes, 80% neutrophils, glucose 2<span class="elsevierStyleHsp" style=""></span>mg/dl and proteins 2<span class="elsevierStyleHsp" style=""></span>g/dl), and Gram-positive diplococci was observed on the Gram stain. Antibiotic treatment was started with cefotaxime (300<span class="elsevierStyleHsp" style=""></span>mg/kg/day) and vancomycin (60<span class="elsevierStyleHsp" style=""></span>mg/kg/day). Penicillin-sensitive <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> (MIC 0.008<span class="elsevierStyleHsp" style=""></span>μg/ml) and cefotaxime (MIC 0.012<span class="elsevierStyleHsp" style=""></span>μg/ml) were isolated in the blood and cerebrospinal fluid and were later identified as serotype 15C, which is not included in the vaccine.</p><p id="par0010" class="elsevierStylePara elsevierViewall">24<span class="elsevierStyleHsp" style=""></span>h after initiating treatment, the infant was afebrile, with improved general condition and level of consciousness. Vancomycin was suspended. On the third day, the patient deteriorated and seizures reappeared. A cranial CT scan was performed that revealed ventricular enlargement and frontal effusions. An external ventricular drain was placed, which was replaced 3 days later due to obstruction. The infant improved slowly but on the twelfth day of admission he presented sudden deterioration with decreased level of consciousness, abnormal movements, pupillary changes, abnormal heart rate and increased blood flow due to the ventricular drain.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A new cranial CT scan was performed, which revealed ventricular and subarachnoid haemorrhage. With a suspected ruptured aneurysm, an angiography and magnetic resonance angiogram were performed. These tests confirmed the diagnosis of haemorrhage due to ruptured mycotic aneurysm of the basilar artery and multiple stenosis of most of the cerebral arteries studied (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient was not eligible for surgery and it was not possible to embolise the aneurysm due to a lack of collateral circulation. As such, life support was withdrawn and the patient died.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The term “mycotic” aneurysm was coined by Osler in 1885 to describe a mushroom-shaped aneurysm in subacute endocarditis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Although some authors use the term “mycotic” to describe infected aneurysms of any aetiology, most limit use of this term to aneurysms that form when material from a distant site causes infection of the vascular wall and subsequent dilation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The pathogenic mechanism includes septic emboli that occlude the <span class="elsevierStyleItalic">vasa vasorum</span>, contiguous spread of infection from other foci of infection, haematogenous infection of the tunica intima or damage to the arterial wall caused by surgery or vascular devices.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Subarachnoid haemorrhage secondary to a ruptured aneurysm is the most common cause of spontaneous subarachnoid haemorrhage in children. However, a recent review by Garg et al. found that out of 62 children with intracranial aneurysms, only 2 were mycotic.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Published cases of mycotic aneurysms in infants under the age of 1 year are extremely rare. In children, most mycotic aneurysms occur in the context of endocarditis, underlying vascular malformations, connective tissue disease or iatrogenesis, such as neonates with umbilical catheters.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Before the advent of antibiotics, <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> was a common cause of aneurysm infection. Although this fell dramatically with the arrival of penicillin, it may once again be an emerging pathogen in infected aneurysm.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> In a review of the literature, we found 23 published cases of aneurysms (mycotic and infected) caused by <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>, all of which were located in the aorta and in adults. We only found one case of a 65-year-old woman who was admitted for pneumococcal meningitis and died one week later due to a ruptured mycotic aneurysm.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There is one published case of mycotic aneurysm and subarachnoid haemorrhage following tuberculous meningitis in an infant with congenital cytomegalovirus infection, in whom the vessels at the base of the cranium surrounded by inflammatory exudate developed infiltrative lesions. The granulomatous process in the subarachnoid space weakens and destroys the middle cerebral artery, causing aneurysmatic dilatation of the artery.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">This is the first case of pneumococcal intracranial mycotic aneurysm reported in the literature in infants.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The most important factor to consider in terms of treatment is aneurysm rupture.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Unruptured aneurysms can only be treated with antibiotics, whereas ruptured aneurysms must be treated with antibiotics and surgery. Endovascular techniques may be useful in patients with ruptured infected aneurysms to contain the rupture until surgical treatment is viable.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Palacios A, Llorente AM, Ordóñez O, Martínez de Aragón A. Aneurisma micótico intracraneal en lactante con meningitis neumocócica. Enferm Infecc Microbiol Clin. 2017;35:267–269.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 612 "Ancho" => 1771 "Tamanyo" => 94667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Image of coronal magnetic resonance angiogram: stenosis and dilations (string of bead) in the middle cerebral artery and basilar artery. (B) CT scan: subarachnoid and subdural haemorrhage. (C) Magnetic resonance angiogram with contrast: aneurysm of the basilar artery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endocarditis and intravascular infections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V. Fowler" 1 => "W. Scheld" 2 => "A. Bayer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "Mandell, Douglas, and Benett's principles and practice of infectious diseases" "paginaInicial" => "1099" "paginaFinal" => "1103" "edicion" => "7th ed." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 32 | 11 | 43 |
| 2024 September | 18 | 4 | 22 |
| 2024 August | 27 | 9 | 36 |
| 2024 July | 48 | 10 | 58 |
| 2024 June | 14 | 6 | 20 |
| 2024 May | 22 | 7 | 29 |
| 2024 April | 21 | 3 | 24 |
| 2024 March | 25 | 4 | 29 |
| 2024 February | 14 | 4 | 18 |
| 2024 January | 19 | 9 | 28 |
| 2023 December | 33 | 9 | 42 |
| 2023 November | 27 | 7 | 34 |
| 2023 October | 35 | 7 | 42 |
| 2023 September | 30 | 1 | 31 |
| 2023 August | 24 | 1 | 25 |
| 2023 July | 15 | 5 | 20 |
| 2023 June | 35 | 4 | 39 |
| 2023 May | 45 | 3 | 48 |
| 2023 April | 45 | 1 | 46 |
| 2023 March | 80 | 8 | 88 |
| 2023 February | 9 | 3 | 12 |
| 2023 January | 79 | 4 | 83 |
| 2022 December | 58 | 9 | 67 |
| 2022 November | 41 | 16 | 57 |
| 2022 October | 34 | 9 | 43 |
| 2022 September | 18 | 10 | 28 |
| 2022 August | 29 | 10 | 39 |
| 2022 July | 30 | 6 | 36 |
| 2022 June | 17 | 6 | 23 |
| 2022 May | 35 | 11 | 46 |
| 2022 April | 42 | 8 | 50 |
| 2022 March | 61 | 11 | 72 |
| 2022 February | 92 | 8 | 100 |
| 2022 January | 74 | 12 | 86 |
| 2021 December | 49 | 14 | 63 |
| 2021 November | 47 | 8 | 55 |
| 2021 October | 26 | 25 | 51 |
| 2021 September | 14 | 8 | 22 |
| 2021 August | 20 | 14 | 34 |
| 2021 July | 36 | 11 | 47 |
| 2021 June | 21 | 6 | 27 |
| 2021 May | 26 | 6 | 32 |
| 2021 April | 74 | 15 | 89 |
| 2021 March | 53 | 8 | 61 |
| 2021 February | 44 | 11 | 55 |
| 2021 January | 37 | 11 | 48 |
| 2020 December | 31 | 7 | 38 |
| 2020 November | 27 | 7 | 34 |
| 2020 October | 23 | 8 | 31 |
| 2020 September | 18 | 15 | 33 |
| 2020 August | 22 | 10 | 32 |
| 2020 July | 12 | 10 | 22 |
| 2020 June | 23 | 13 | 36 |
| 2020 May | 38 | 9 | 47 |
| 2020 April | 16 | 5 | 21 |
| 2020 March | 30 | 6 | 36 |
| 2020 February | 20 | 3 | 23 |
| 2020 January | 25 | 14 | 39 |
| 2019 December | 28 | 13 | 41 |
| 2019 November | 31 | 6 | 37 |
| 2019 October | 21 | 7 | 28 |
| 2019 September | 12 | 4 | 16 |
| 2019 August | 15 | 5 | 20 |
| 2019 July | 13 | 16 | 29 |
| 2019 June | 11 | 39 | 50 |
| 2019 May | 68 | 64 | 132 |
| 2019 April | 35 | 17 | 52 |
| 2019 March | 8 | 3 | 11 |
| 2019 February | 4 | 0 | 4 |
| 2019 January | 5 | 12 | 17 |
| 2018 December | 4 | 4 | 8 |
| 2018 November | 5 | 3 | 8 |
| 2018 October | 10 | 1 | 11 |
| 2018 September | 20 | 2 | 22 |
| 2018 August | 4 | 3 | 7 |
| 2018 July | 9 | 0 | 9 |
| 2018 June | 5 | 3 | 8 |
| 2018 May | 7 | 0 | 7 |
| 2018 April | 4 | 0 | 4 |
| 2018 March | 10 | 5 | 15 |
| 2018 January | 4 | 0 | 4 |
| 2017 December | 5 | 0 | 5 |
| 2017 November | 1 | 0 | 1 |
| 2017 October | 16 | 1 | 17 |
| 2017 September | 2 | 0 | 2 |
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