|Year : 2021 | Volume
| Issue : 2 | Page : 167-168
Air in the aortic wall: A rare case of Clostridium septicum aortitis
Aniket Pradhan, Giordano Perin
Department of Vascular Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, England, United Kingdom
|Date of Submission||23-May-2020|
|Date of Acceptance||31-May-2020|
|Date of Web Publication||13-Apr-2021|
Department of Vascular Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster
Source of Support: None, Conflict of Interest: None
An 81-year-old male presented to the emergency department with a 48-h history of central chest pain radiating to the back. Observations revealed hypoxia, tachycardia, and hypotension. Biochemistry revealed raised inflammatory markers (white cell count: 18.5 × 109/L and C-reactive protein: 62.5 mg/L) and reduced renal function (creatinine: 157 μmol/L and urea 10.2 mmol/L). Computed tomographic (CT) scan (CT aortogram) revealed the presence of air in a diseased thoracic and abdominal aorta wall with no evidence of aneurysm (A, B, and C). Wall thickening at the cecal pole was noted as well (D). A diagnosis of acute aortitis was made, and the patient was started on intravenous antibiotics. Blood cultures isolated Clostridium septicum. Follow-up CT aortogram performed at 2 weeks revealed a resolution of the pockets of air. Colonoscopy revealed the presence of a fungating cecal mass (adenocarcinoma) as a source of bacteremia leading to aortitis; further, staging identified the disease as nonresectable.
Keywords: Aortitis, Clostridium septicum, colorectal cancer
|How to cite this article:|
Pradhan A, Perin G. Air in the aortic wall: A rare case of Clostridium septicum aortitis. Indian J Vasc Endovasc Surg 2021;8:167-8
| Introduction|| |
Clostridium septicum aortitis is a rare condition with only a few case reports published in the literature (41 cases identified in total). The case we are presenting highlights the relevance of previously reported aspects of the management of the above condition – particularly concerning surgical and medical management – as well as other points unique to this case.
| Case Report|| |
An 81-year-old male attended the emergency department complaining of a 48-h history of lower central chest pain radiating to the back and feeling generally unwell. His medical history included gout and hypertension. Observations at assessment revealed hypoxia, tachycardia, and hypotension, with normal respiratory rate, temperature, and level of consciousness. Biochemical investigations revealed raised inflammatory markers (white cell count: 18.5 × 109/L and C-reactive protein: 62.5 mg/L) and reduced renal function (creatinine 157 μmol/L and urea 10.2 mmol/L). Computed tomographic (CT) scan of the chest, abdomen, and pelvis (CT aortogram) was performed and revealed the presence of air in the thoracic and abdominal aorta wall [Figure 1]a, [Figure 1]b, [Figure 1]c. There was no evidence of aneurysm; however, the aorta was diffusely diseased. The initial CT scan [Figure 1]d highlighted the presence of nonspecific abnormalities at the cecal pole.
|Figure 1: Initial computed tomographic aortogram findings: air in the thoracic (a) and abdominal (b and c) aorta as well as cecal pole changes (d)|
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A diagnosis was made of acute aortitis, and the patient was started on intravenous (IV) antibiotics (co-amoxiclav and metronidazole) and admitted to the intensive care unit for cardiovascular support and management of renal failure. Blood cultures taken at the time of admission isolated C. septicum sensitive to co-amoxiclav. Once stabilized, 72 h after admission, the patient was stepped down to ward care and continued IV antibiotic treatment and fluid management. Two weeks after initial presentation, a follow-up CT scan was performed to assess for disease progression. The up-to-date CT scan [Figure 2]a, [Figure 2]b, [Figure 2]c revealed a diffusely thick-walled and diseased aorta and a resolution of the pocket of air previously identified. It also highlighted again the changes previously detected at the level of the cecal pole [Figure 2]d. During inpatient stay, a new diagnosis of heart failure was made with a transthoracic echocardiogram revealing the presence of mild impairment of left ventricular systolic function, right ventricular dilatation with impaired systolic function, and moderate pulmonary hypertension.
|Figure 2: Two-week interval computed tomographic aortogram findings: resolution of pocket of air in the thoracic (a) and abdominal (b and c) aorta. Persistence of cecal pole changes (d)|
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The case was referred for discussion at the colorectal multidisciplinary team (MDT), and a decision was made to perform a colonoscopy to obtain direct visualization and histological assessment of the cecal pole abnormalities. The colonoscopy itself revealed the presence of a fungating cecal lesion. Biopsies were taken and histology revealed invasive well to moderately differentiated adenocarcinoma of the cecum.
As part of staging investigations for the newly diagnosed colorectal cancer, the patient underwent a further CT scan of the chest abdomen and pelvis. A further CT scan revealed the presence of peritoneal metastatic deposits. MDT consensus was to offer the patient palliative care.
| Discussion|| |
C. septicum is a microorganism often associated with colorectal malignancy. This case report highlights again the importance of suspecting the presence of a colorectal condition – often malignancy – in the context of C. septicum septicemia and the relevance of prompt multidisciplinary involvement. Aortic infection, as previously reported, will be more likely to happen in a diseased aorta, especially in the presence of an aneurysm.
This is one of the very few cases of C. septicum aortitis affecting the entirety of the aorta (thoracic and abdominal) and not associated with aneurysmal disease. To the best of our knowledge, only two cases of C. septicum aortitis affecting the entirety of the aorta have been reported so far:, both cases resulted in dissection and ultimately death. Only one of the two previously reported cases presented in a nonaneurysmal aorta. Another very important point specific to this case is that this is one of the very few cases of successfully medically managed C. septicum aortitis. This condition has previously been associated with a very high mortality (80%) if treated with medical management alone.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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[Figure 1], [Figure 2]