50 Year Old Male With HIV And Type V Thoracoabdominal Aortic Aneurysm
Armin Tabiei, Medical Student, Sebastian Cifuentes, MD., Manju Kalra, M.B.B.S..
Mayo Clinic, Rochester, MN, USA.
DEMOGRAPHICS: A 50-year-old HIV-positive male with moderate COPD, ongoing nicotine dependence and pulmonary coccidioidomycosis adequately treated 4 years previously presented with an enlarging thoracoabdominal aortic aneurysm (TAAA) after being denied repair elsewhere.
HISTORY: He presented to an outside institution with back pain and fever 4 months previously, was diagnosed with blood culture negative infective aortitis and treated with IV Vancomycin and Ertapenem along with oral fluconazole. Imaging revealed a 3.4 cm type V TAAA which was hypermetabolic on PET-CT. Serial monthly imaging was performed and at presentation the TAAA measured 6.0 cm, involved visceral / renal arteries with occlusion of the right renal artery and atrophy of the kidney. He now had chronic kidney disease Stage 3a. A remote arterial embolic episode and femoropopliteal bypass had left him with right lower extremity weakness. TEE demonstrated no intracardiac thrombus or PFO. Syphilis, Bartonella, Brucella, Q fever, Histoplasma and Blastomycosis serologies were negative. HIV 1 PCR was <48 and CD4 count 237.
PLAN: Following pre-operative multidisciplinary evaluation he underwent antegrade debranching of the celiac, superior mesenteric artery, and left renal arteries from the mid-descending thoracic aorta with aortoiliac cryopreserved arterial allograft (CAA) followed by repair of the TAAA with resection and replacement with 12.5 cm long descending thoracic aortic CAA. Histopathological analysis of the resected aneurysm wall confirmed active coccidioides spp infection with demonstration of fungal hyphae on GMS stain. Postoperative treatment was with Ertapenem and Daptomycin IV followed by oral Amphotericin B and he was discharged home after an uneventful stay of 2 weeks. At 1 year follow-up CT-angiogram revealed good incorporation and patency of aortic and visceral grafts and negative PET-CT. Yearly follow-up was scheduled, and lifelong antibiotic prophylaxis with fluconazole for coccidioides spp was prescribed.
DISCUSSION: To our knowledge this is the first report of a mycotic TAAA secondary to coccidioidomycosis. In the absence of knowledge of the causative organism at the time of repair CAA conduit was selected in view of his potentially immunosuppressed state from HIV. Antegrade debranching was performed to reconstruct the visceral and renal arteries away from the infected field and limit ischemia time.
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