History
This 58-year-old man is a patient of
alcoholic liver disease, hypertension, gouty arthritis with
tophi formation and duodenal ulcer status post subtotal
gastrectomy with BII anastomosis 30 years ago. He suffered
from left subcostal pain and intermittent fever for 3 weeks.
He denied diarrhea, and other symptoms. The pain did not
radiate to back, unrelated to food intake, and did not relieve
by drugs from LMD. He was sent to emergency department on
November 23, 2000. Acute ill-looking appearance, fever (39°C),
left upper abdominal tenderness, and leukocytosis (WBC
11,620/uL) were noted. However, chest X-ray and abdominal echo
did not reveal significant anomalies. Cefoxitin was given
empirically, but septic shock developed on the following day.
Then, antibiotic was shifted to ceftriaxone. Abdominal CT on
November 23 revealed an aneurysm at proximal abdominal aorta
and mycotic aneurysm was considered(Figure)
. After discussion with
cardiovascular surgery, medical treatment followed by surgical
intervention was suggested. Therefore, he was admitted to
medical ward on Nov 24.
Physical
findings: Appearance: acute
ill-looking Consciousness:
clear Vital sign: temperature 38.5°C,
pulse rate 100/min, respiratory rate 20/min, blood pressure
108/64 mmHg (premix dopamine
10ml/hr) Chest: breath sound: clear;
Heart: regular heart beat; no murmur, no thrills, no
heaves Abdomen: soft; distended; op scar
(+); bowel sound: normoactive; no abdominal bruit;
liver/spleen: not palpable; tenderness at left upper
quadrant Extremities: freely movable; no
pitting edema, no palmar erythema, no
petechiae
Course and
treament Salmonella was isolated from
blood culture on November 29. Despite of ceftriaxone therapy,
high fever and severe pain responded very slowly. Higher fever
and relative leukopenia were noted on December 2. Drug fever
was suspected and antibiotic was shifted to ciprofloxacin on
December 4. Fever subsided subsequently and follow-up blood
cultures were negative. Panendoscopy was done on December 13
for persistent left subcostal pain and very poor appetite, but
no significant lesion noted. General condition improved
gradually. Follow-up abdominal CT on December 28 revealed
progression of saccular aneurysmal dilatation of aorta at
thoraco-abdomen junctional area and increased soft tissue
density. Surgical intervention was performed on January 12. A
fusiform thoracic aortic aneurysm about 5x5 cm in size and
mural thrombus adhered to pulmonary tissue were noted.
Necrotic tissue was excised and grafting with 24mm Hemashield
of thoracic-abdominal aorta was performed. The debrided tissue
was sterile. This patient was extubated smoothly on Jan 14 and
was discharged on Jan 18.
一般檢查紀錄(General
Inspection): [ CBC+PLT
]
項目 |
WBC |
RBC |
HB |
HCT |
MCV |
MCH |
MCHC |
PLT |
日期 |
K/μL |
M/μL |
g/dL |
% |
fL |
pg |
g/dL |
K/μL |
891122 |
11.62 |
3.94 |
11.6 |
34.4 |
87.3 |
29.4 |
33.7 |
516.0 |
891128 |
8.45 |
3.81 |
11.5 |
33.1 |
86.9 |
30.2 |
34.7 |
458.0 |
項目 |
Seg |
Eos |
Baso |
Mono |
Lym |
日期 |
% |
% |
% |
% |
% |
891122 |
84.5 |
1.5 |
0.2 |
5.8 |
8.0 | [
Biochemistry ]
項目 |
GLU |
UN |
CRE |
Na |
K |
Cl |
T-BiL |
D-Bil |
AMY |
Ca |
AST |
ALT |
日期 |
mg/dl |
mg/dl |
mg/dl |
mmole/l |
mmole/l |
mmole |
mg/dl |
mg/dl |
U/l |
mmole/l |
U/l |
U/l |
891122 |
146.0 |
34.0 |
1.8 |
138.0 |
4.4 |
|
0.6 |
|
|
2.35 |
77.0 |
50.0 |
891124 |
|
23.0 |
1.4 |
136.0 |
4.6 |
100.0 |
1.4 |
1.0 |
87.0 |
|
|
| 檢
體 : Urine
項目 |
Sp.Gr.(c) |
pH(c) |
Protein(c) |
Glu.(c) |
Ketones(c) |
O.B.(c) |
Urobil.(c) |
Bil.(c) |
WBC.(c) |
日期 |
* |
* |
mg/dL |
g/dL |
* |
* |
EU/dL |
* |
* |
891122 |
5 |
+/- |
- |
+/- |
- |
1.0 |
1+ |
|
|
項目 |
RBC(S) . |
WBC(S) |
EpithCell(S) |
Cast(S) |
Crystal(S) |
Other(S) |
VireCond |
日期 |
/HPF |
/HPF |
/HPF |
* |
* |
* |
|
891122 |
0-1 |
0-1 |
0-1 |
|
|
Y;C |
|
STOOL (891214): Appearance: yellowish,
O.B. (-) C-Reactive Protein (891128) 18.3 (normal, < 0.8
(mg/dl))
Blood
Culture & Sensitivity: Salmonella O9
(group D1), susceptible to chloramphenicol, ampicillin,
cefotaxime, ciprofloxacin, co-trimoxazole
Radiology
Report 89/11/22
Standing chest PA view shows: Rotative position;
low volume film; increased infiltration at R't lower lung
field; bil. sharp CP angles. normal heart size; tortuous aorta
with artherosclerotic change. 89/11/24, CT.
With/Without co-ABDOMEN: Bil. pleural effusion and
atelectasis of the bil. lower lobe is noted. abnormal soft
tissue density is noted around the aortic esophageal recess.
The inflammatory process at the A recess is highly suspected.
A bulging lesion with well enhancement is noted at the post.
aspect of the aorta. Aneurysmal change cannot be excluded. The
aortic wall showed atherosclerotic changes. Abnormal
thickening and effusion are noted at bil. lower pleura.
minimal atelectatic change at the left lower lung. Dot
calcifications at the spleen 89/11/28,
GA-67 Whole body scintigraphy in the anterior and
posterior projections were performed at 24 & 48 hours
after tracer injection. Findings: 1) The scans demonstrated
normal distribution of the tracer activity to the liver,
spleen and skeletal system. 2) One focal faint abnormal
concentration of tracer activity was noted at left posterior
mediastinal (or paraspinal) region which is consistent with an
active inflammatory process such as abscess, pneumonia, or
mycotic aneurysm of aorta 89/12/28, CT.
With/Without co-ABDOMEN: Saccular
aneurysmal dilatation of aorta at thoraco-abdomen junctional
area, with largest diameter about 5 cm, hypodense mass between
aorta and left lateral margin of T9 and T10, hypodense rim
around the enhanced lumen and partial atelectasis of adjacent
lung is also found, mild left pleural effusion, mycotic
aneurysm should be considered first. suspicious curvilinear
lucent line in the aneurysmal dilatation, r/o aortic
dissection. atherosclerosis with mural thrombus and
calcification of abdomen aorta. suspicious a small enhanced
nodule at segment 7 of liver, r/o hemangioma. tiny
calcification in spleen. bil. renal cysts. no definite lesion
in GB, pancreas, and bil adrenal glands. suspicious small
nodules at RML.
Impression:
Saccular aneurysmal dilatation of aorta at thoraco-abdomen
junctional area, mycotic aneurysm should be considered first,
r/o dissection aneurysm. r/o small hemangioma at segment 7 of
liver. suspicious small nodules at RML.
Discharge Clinical Diagnosis
Thoracic aortic aneurysm
due to Salmonella
O9 (group D1) status post grafting
|