Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 283-285

A case of brachial artery infected aneurysm secondary to infective endocarditis from intramuscular steroid use


Department of Vascular Surgery, Alfred Hospital, Melbourne, VIC, Australia

Date of Submission25-Aug-2020
Date of Acceptance14-Sep-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Thomas Lovelock
Department of Vascular Surgery, Alfred Hospital, Melbourne, VIC
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_123_20

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  Abstract 


Infected aneurysms are a subset of aneurysms associated with infection. Approximately 10% of infected aneurysms involve the upper extremity. Infected aneurysms present a management challenge as patients are often unwell with concomitant infective endocarditis or septicemia. We present a case of a brachial artery infected aneurysm secondary to mitral valve infective endocarditis likely due to intramuscular anabolic steroid use. A 52-year-old male presented with a 24-h history of lethargy, blurred vision, and ataxia. He had a background history of intramuscular anabolic steroid use for the past 5 years. Swelling of his left arm localized to his cubital fossa was noted. Blood cultures were positive for Cardiobacterium hominis. Transthoracic echocardiography demonstrated a large vegetation on the mitral valve. Magnetic resonance imaging angiography demonstrated a right middle cerebral artery aneurysm. Computed tomography angiography of the left arm demonstrated an abrupt filling defect of the distal 2 cm of the brachial artery, with surrounding fat stranding and aneurysmal degeneration of the artery. Following successful aneurysm coiling, the patient underwent excision and debridement of the infected aneurysm. Histopathology was consistent with infected thromboembolism with aneurysmal degeneration of the artery. The patient underwent mitral valve replacement 10 days later. The brachial artery is the most common site of upper extremity infected aneurysms. Open surgical resection of the infected tissue is accepted as the gold standard. The rich collateral supply of the upper extremity permits ligation and debridement without needing simultaneous revascularization. We present this case to draw attention to an interesting manifestation of a rare pathology.

Keywords: Cardiobacterium hominis, infected aneurysm, infective endocarditis


How to cite this article:
Lovelock T, Dean A, Saran A, Vasudevan T. A case of brachial artery infected aneurysm secondary to infective endocarditis from intramuscular steroid use. Indian J Vasc Endovasc Surg 2021;8:283-5

How to cite this URL:
Lovelock T, Dean A, Saran A, Vasudevan T. A case of brachial artery infected aneurysm secondary to infective endocarditis from intramuscular steroid use. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:283-5. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/283/320618




  Introduction Top


Infected aneurysms are a subset of aneurysms associated with infection.[1] Approximately 10% of infected aneurysms involve the upper extremity.[1] Infected aneurysms are rare, but are a source of significant morbidity, particularly in the case of rupture.[2] Surgical management is challenging, as patients are often unwell with concomitant infective endocarditis or septicemia. We present a case of a brachial artery-infected aneurysm secondary to mitral valve infective endocarditis likely due to intramuscular anabolic steroid use.


  Case Report Top


A 52-year-old male presented with a 24-h history of lethargy, blurred vision, and ataxia. This was on a background of undiagnosed fevers and headaches with neck pain for 4 weeks. He had also developed left arm swelling and pain 2 days prior.

He was a nonsmoker, rarely drank alcohol, and denied intravenous drug use. He had a background history of intramuscular anabolic steroid use for the past 5 years. He had a number of tattoos however none inked recently. He denied any other risk factors for blood borne infection.

On examination, he was hemodynamically stable. He was febrile with a temperature of 38.8°C. He had a new systolic heart murmur. Swelling of his left arm localized to his cubital fossa was noted. Despite absent left radial and ulnar pulses, his hand was warm and pink, with brisk capillary return and neurologically intact.

Blood cultures were positive for Cardiobacterium hominis. Transthoracic echocardiography and subsequent transesophageal echocardiography demonstrated a large vegetation on the mitral valve, causing moderate-to-severe mitral regurgitation. Computed tomography (CT) brain revealed the right occipital intracranial hemorrhage. Magnetic resonance imaging with gadolinium-enhanced angiography of the brain showed a right M2 middle cerebral artery (MCA) aneurysm. CT angiography of the left arm demonstrated an abrupt filling defect of the distal 2 cm of the brachial artery, which extended to the origin of the radial, interosseous, and ulnar arteries. There was aneurysmal degeneration of the artery, with surrounding fat stranding [Figure 1].
Figure 1: Axial (a) and Coronal (b) slices of computed tomography arm angiogram. A computed tomography arm angiogram was undertaken which demonstrated an abrupt filling defect of the distal 2 cm of the brachial artery, extending to the origin of the radial and ulnar arteries. There was aneurysmal degeneration of the artery, with surrounding fat stranding

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A diagnosis of infective endocarditis of the mitral valve was made, secondary to C. hominis, likely due to intramuscular anabolic steroid use. This was complicated by septic emboli to the brain, with a right M2 MCA-infected aneurysm, and a left arm brachial trifurcation-infected aneurysm. The perioperative necessity for increasing sterility and anticoagulation dictated the order in which these septic complications were treated.

Following successful cerebral-infected aneurysm coiling, the left brachial artery-infected aneurysm was treated. Parts of the arterial trifurcation involved in the aneurysmal process were excised and debrided [Figure 2]. The stumps of the brachial, ulnar, interosseous, and radial arteries were oversewn with 5'0 Prolene. Histopathology revealed an infected thromboembolism with aneurysmal degeneration of the artery. The left hand was warm and well perfused at the end of the case. The patient underwent a successful mitral valve replacement 10 days later.
Figure 2: Intraoperative view of mycotic brachial aneurysm excision. The brachial artery was dissected proximal to the aneurysm (blue vessel loop). Distally, the vessel was noted to have disintegrated. The proximal radial and ulnar arteries were dissected out (yellow vessel loops). The necrotic and aneurysmal tissue was debrided

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  Discussion Top


C. hominis is a rare cause of infective endocarditis, accounting for somewhere between 3% and 6% of cases.[3] This pathogen typically presents with features of subacute endocarditis, and patients may have felt unwell for weeks to months.[3] Embolic complications are common, being present in 44% of patients in a historical case series.[3],[4] C. hominis is a HACEK organism, typically found in the upper respiratory tract, and is not associated with intravenous drug use or infection elsewhere in the body,[3] despite our patient's presumed etiology through intramuscular anabolic steroid administration.

The brachial artery is the most frequently reported site of upper extremity-infected aneurysms.[1] Aneurysms at this site are commonly associated with infectious endocarditis, intravenous drug use, or invasive catheterization procedures.[1] The management of this pathology significantly varies in the literature, however, it is accepted that open surgical resection with wide debridement of infected tissue is the gold standard.[1] Case reports have described the use of endovascular interventions as an adjunct to surgical repair.[5] The upper extremity carries an extensive network of collateral circulation, which permits initial ligation and debridement without revascularization.[6] This is attractive as it avoids the need for either revascularization through an infected field or extra-anatomical bypass at the time of initial surgery. We present this case to draw attention to an interesting manifestation of a rare pathology.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Leon LR, Psalms SB, Labropoulos N, Mills JL. Infected upper extremity aneurysms: A review. Eur J Vasc Endovasc Surg 2008;35:320-31.  Back to cited text no. 1
    
2.
Lim D, Parizh D, Meytes V, Kopatsis A. Surgical emergency: Rupture of infected brachial artery pseudoaneurysm. BMJ Case Rep 2017:2017-220034.  Back to cited text no. 2
    
3.
Walkty A. Cardiobacterium hominis endocarditis: A case report and review of the literature. Can J Infect Dis Med Microbiol 2005;16:293-7.  Back to cited text no. 3
    
4.
Wormser GP, Bottone EJ. Cardiobacterium hominis: Review of microbiologic and clinical features. Rev Infect Dis 1983;5:680-91.  Back to cited text no. 4
    
5.
Strosberg DS, Oriowo BA, Davies MG, El Sayed HF. The role of endovascular in situ revascularization in the treatment of arterial and graft infections. Ann Vasc Surg 2017;42:299.e15-22.  Back to cited text no. 5
    
6.
Salzler GG, Long B, Avgerinos ED, Chaer RA, Leers S, Hager E, et al. Contemporary results of surgical management of peripheral mycotic aneurysms. Ann Vasc Surg 2018;53:86-91.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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