Rapidly Expanding Mycotic Abdominal Aortic Aneurysm caused by Haemophilus Influenzae in a HIV Patient
Elias Fakhoury, DO, Christopher P. Buchholz, DO, MPH, Timothy Wu, MD, Joe T. Huang, MD, Michael A. Curi, MD, Ajay K. Dhadwal, MD.
Rutgers, NJMS, Newark, NJ, USA.
Objective
We present only the fourth documented case of an abdominal mycotic aneurysm caused by haemophilus influenzae type f since it first appeared in the literature in 1885 and the first in a patient with HIV.
Methods
PubMed search of key words: mycotic aneurysm and haemophilus influenzae.
Results
51-year-old Haitian female with a past medical history of HIV, hypertension, and breast cancer presented with a four-day history of worsening back pain. Her medications included antiretroviral therapy. She denied any constitutional symptoms. She had presented 6 months prior for abdominal pain and a CT scan had demonstrated a normal appearing aorta without evidence of other intra-abdominal pathology. The abdominal exam was limited due to her obese habitus; however, it revealed no pulsatile masses. Laboratory analysis showed WBC of 12,000, CRP level of 137 mg/L and an ESR level of greater than 145. Her CD4/CD8 ratio was 0.27 (normal range 1.0-3.6). Repeat CT scan demonstrated a 5.3 x 5.2 cm infrarenal aortic aneurysm. Blood cultures were positive for H. influenzae serotype f.
The patient underwent an excision of the aneurysm and in situ reconstruction with a tube graft repair using CryoGraft (Cryolife) via a transperitoneal approach. The right side of the aneurysm had a noticeably weak area with a focal segment indicating impending rupture. Portions of the aorta were thickened with associated rind. Pathology of the aortic wall revealed severely inflamed aneurysmal tissue consistent with mycotic aneurysm and small amounts of atheromatous material. The patient has been maintained on long-term Augmentin and 2 year follow-up CT scan is normal with her return to baseline activities and no evidence of aneurysmal expansion or infection.
Conclusion
Mycotic aneurysms remain a rare entity, but are becoming more common because of the increasing incidence of invasive procedures, vascular prostheses, intravenous drug use, and immunosuppression. Although rare, clinicians must have a high index of suspicion for mycotic aneurysm formation in the immunocompromised patient who presents with abdominal or back pain. This is especially true of the HIV population who increasingly have a longer life expectancy with the success of antiretroviral therapy and are likely to have seemingly innocuous organisms causing mycotic aneurysms.
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