Case Discussion
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<Brief
Presentation>
A 77-year-old lady was admitted because of fever and chest
pain for one month.
A month prior to this hospitalization, she developed fever,
chills and concomitant chest pain, located at the left
anterolateral chest with a stabbing character initially, and
developed into severe, intolerable sharp pain with radiation
to the back thereafter. The pain was aggravated by deep
inspiration, cough, and swallowing, and was not alleviated by
changing position. She has been admitted for this problem
while antibiotics were prescribed for several days and the
fever subsided. After discharge, she suffered from recurrent
fever, chills and aggravating chest pain, accompanied by
diaphoresis. She was hospitalized again, and due to the
characteristic chest pain and fever, CT scan was performed and
revealed saccular aneurysm of the proximal descending aorta
with size up to 3 cm. Because previous blood culture yielded
Salmonella species, group D (O9), mycotic aneurysm was
diagnosed through microbiological and imaging study.
Intravenous ceftriaxone 2 g twice per day were started with no
delay. Fever, leucocytosis, and CRP improved under antibiotic
treatment. Despite 2-week antibiotic management and aggressive
blood pressure control, the chest pain was not improved. She
was thus referred to our hospital. She denied body weight
loss, cough, sputum production, hemoptysis, dyspnea,
odynophagia, dysphagia, hoarseness, acid regurgitation or
burning sensation, focal limb weakness or pain, syncope, near
fainting, arthralgia, skin rash, photosensitivity, or
abdominal discomfort. She did not recall any preceding upper
respiratory tract infection episode, trauma, dental or
urological procedure.
Reviewing the past history, she has diabetes and
hypertension under regular medical control. She had received
left lung lobectomy for solitary pulmonary nodule. No
malignancy or tuberculosis was told ever. She had good
functional capacity and no further abnormality was noted. She
did not smoke or drink. There was no chronic consumption of
particular drugs or herbs except the medications for diabetes
and hypertension, which included long-acting nifedipine,
isosorbide mononitrate, and glipizide.
At admission, she appeared acute ill-looking but
the consciousness was clear and oriented. The body temperature
was 38.3℃, the pulse rate 88 beats/min, and the respiratory
rate 20 breaths/min. Pulse oxygenation was 96% under room air.
The blood pressure measured at the right arm was 130/80
mmHg, 136/80 mmHg at the right leg, 130/72 mmHg at the left arm
and 138/82 mmHg at the left leg. The conjunctivae were pink and
the sclerae were anicteric. She had no nuchal rigidity, no
goiter, no neck mass and no lymphadenopathy. The jugular vein
was not engorged. The chest wall symmetrically expanded.
Pulmonary ausculation revealed rales and friction rub over the
left lower chest. The point of maximal impulse was localized
at the fifth intercostal space and left middle clavicular
line. No thrill or heave was noted by palpation. The cardiac
auscultation disclosed a grade II/VI pansystolic murmur over
apex area without radiation. No S3 or S4 gallop was noted. No
frictoin rub was noted. She had soft and flat abdomen with
neither tenderness nor rebounding pain. The liver and spleen
span were not enlarged. The bowel sound was normoactive. The
extremities were freely movable without pitting edema or
cyanosis. Except the operation scar over the left lateral
chest, she had intact skin, nails and hair. The other physical
examinations were unremarkable.
The laboratory tests revealed leucocytosis with left shift,
and normocytic anemia. The serum CRP level was high. The
biochemistry showed normal kidney and liver functional test.
No proteinuria, hematuria, pyuria, or active sediment was
noted in urinalysis. The coagulation profile was normal.
Blood, urine and stool were collected for further
microbiological study. The detailed laboratory data were
available in tables below.
CT scan was performed again and revealed progression of the
disease. There was aortic aneurysmal dilation, 5 cm in size
with risk of impending rupture and image character of
aortitis. Aortic dissection with partial mural thrombosis,
involving aortic arch, left subclivian artery and the
descending thoracic aorta was also noted. Echocardiography of
the chest and heart revealed only minimal pericardial and
pleural effusion. Intravenous ceftriaxone 2 g twice per day
was given continuously. Labetalol infusion was applied for BP
control. Cardiovascular surgeon was then consulted.
She underwent operation 3 weeks after parenteral effective
antibiotic treatment. Wide debridement of the infected tissue,
and in-situ repair with aorta graft were done. Parenteral
ceftriaxone was kept for 4 weeks and followed by oral
ciprofloxacin. No recurrent fever episode was ever noted. She
was smoothly discharged with oral ciprofloxacin, which was
scheduled to be kept for 4 months after operation.
<Laboratory
data>
1. Hemogram
Date |
WBC |
RBC |
HB |
HCT |
MCV |
MCH |
MCHC |
PLT |
|
K/μL |
M/μL |
g/dL |
% |
fL |
Pg |
g/dL |
K/μL |
940119 |
14100 |
3.68 |
10.7 |
32.8 |
89.1 |
29.1 |
32.6 |
344 |
|
Band % |
Seg % |
Eos % |
Baso % |
Mono % |
Lym % |
Aty. Lym % |
Normob % |
|
0 |
89 |
1.5 |
0.2 |
5.8 |
20.5 |
0 |
0 | 2.
Biochemistry and electrolyte
Date |
Alb |
Glo |
T/D-bil |
AST |
ALT |
ALP |
LDH |
BUN |
Cre |
|
g/dL |
g/dL |
mg/dL |
U/L |
U/L |
U/L |
U/L |
mg/dL |
mg/dL |
940119 |
3.0 |
3.7 |
0.31/0.37 |
30 |
17 |
116 |
593 |
13.5 |
0.8 |
Date |
UA |
Na |
K |
Cl |
Ca |
TG |
T-cho |
CRP |
AC glu |
|
mg/dL |
mmol/L |
mmol/L |
mmol/L |
mmol/L |
mg/dL |
mg/dL |
mg/dL |
mg/dL |
940119 |
6.5 |
133 |
4.1 |
103 |
1.96 |
109 |
75 |
15.5 |
165 |
Date |
Iron |
TIBC |
Ferritin |
Folic acid |
Vit B 12 |
|
μg/dl (66-155) |
μg/dl (275-332) |
ng/ml |
ng/ml (3.1-12.4) |
Pg/ml (239-931) |
940121 |
23 |
134 |
401 |
4.27 |
442 | 3. Coagulation
|
PT |
PTT |
Date |
Sec |
Sec |
940119 |
14.3/12.2 |
32.6/28.9 | 4. Urine
|
Outlook |
PH |
Sp Gr |
Pro |
Bil |
Glu |
OB |
Uro |
K. B |
WBC |
RBC |
Epi |
Date |
|
|
|
Mg/dL |
|
G/dL |
|
EU/dL |
|
/HPF |
/HPF |
/HPF |
940119 |
Y;C |
7.0 |
1.014 |
- |
- |
- |
- |
0.1 |
- |
0-1 |
- |
0-1 | 5. Microbiology
lab 931209: Blood culture and sensitivity Salmonella
group D (O9) for two sets Sensitive to ampicailline,
ceftriaxone, cefotaxime, ciprofloxacin, floxacin,
levofloxacin, SXT, ZOX,
6. Stool
Date |
Appearance |
OB |
940124 |
YB;F |
- | <
CXR> 94.01.19
Cardiomegaly. Calcification of the aortic knob.
The contour of the lower thoracic aorta is blurred. Blunted
left CP angle. <ECG>94.01.19 Sinus rhythm,
rate 83 beats/min; first degree AV block;
RBBB.
<Echocardiography & color
duplex>94.01.19 AO 29 mm
IVS 10
mm LVEF M-mode 65% AV 16 mm
LVPW 11 mm LA 29 mm LVEDD 52
mm LV mass 244
gm
LVESD 33 mm Good LV contractility Probable LV
diastolic dysfunction MR , mild TR, mild, PG 26
mmHg Minimal pericardial effusion, with no RA/RV diastolic
collapse sign <CT
scan>saccular aneurysm <CT
scan>aortic dissection
Chest, abdomen CT without/with
enhancement showed
- Aortic dissection with intimal flap
from aortic arch to descending thoracic aorta is noted.
Partial mural thrombus in the false lumen with extension
upward into proximal left subclavian artery is also found.
Calcification at the orifice of left common carotid artery is
noted.
- Aneurysmal dilatation of descending thoracic
aorta, diameter up to 5cm, with enhancement of descending
thoracic aorta and small hypodensity at periaortic
region.
- There is mild bilateral left pleural effusion
with partial atelectasis at left basal lung.
- No definite mediastinal LAP; no
definite nodular lesion or consolidation in both lungs; no
definite lesion in liver, GB, spleen, pancreas, both kidneys
and adrenal
glands.
<Discussion>
Salmonella are widely distributed in nature in a range of
animal hosts and are strongly associated with agricultural
products. More than 95% of cases of Salmonella infection are
food born. Virtually any anatomical site maybe seeded
hematogenously by non-typhoidal Salmonella, but only a
minority of bacteremic patients will develop focal metastatic
infections of the bones, meninges, brain, lung, abdominal
viscera, and cardiovascular system. Risk factors of
salmonellosis include extreme of age, diabetes, malignancy,
rheumatologic disorder, AIDS, SLE, gastric hypoacidity,
alteration of endogenous bowel flora resulted from
antimicrobial therapy or surgery.
In contrast to most Gram-negative bacteria, Salmonella has
the propensity to adhere to damaged endothelium of the heart
and arterial walls. Cardiovascular infections due to
Salmonella had the spectrum of mycotic aneurysm, pericarditis,
endocarditis, AV fistula infection, and device related
infections.
Mycotic aneurysm is the most common endovascular infections
caused by non-typhoidal Salmonella. Salmonella can infect
preexisting aneurysms or atherosclerotic plaques and produce
necrosis of the arterial wall, resulting in rapid formation of
a mycotic pseudoaneurysm. Old age, diabetes mellitus,
hypertension, and preexisting atherosclerotic disease are the
predominant risk factors among these patients. The most
frequent site involved is the abdominal aorta, especially
infrarenal segment, followed by thoracic aorta. The clinical
presentation is usually a subacute course of fever, chills,
chest pain, back pain, or abdominal pain, with or without
preceding diarrhea and abdominal cramping pain. According to
the infected site, there may be pulsatile tender abdominal
mass, psoas muscle or pelvic abscess, vertebral osteomyelitis,
purulent pericarditis, empyema, hemoptysis or GI bleeding due
to aortobronchial or aortoenteric fistula. Persistent or
relapsing bacteremia after discontinuing antibiotics were
important clues for the diagnosis of Salmonella aortitis.
Diagnosis needs a high index of suspicion. In the
elderly, fever and abdominal pain or chest pain with a history
of diarrhea suggested the diagnosis. CT scan with contrast
enhancement is the diagnostic tool of choice. Other
modalities, such as MRI, angiography, Ga-67 scan, Tc-99m
labeled leucocyte scan and TEE, were also useful diagnostic
tools. Diagnostic features on CT scan include (1) a periaortic
soft tissue density with rim enhancement, consistent with
periaortic inflammation; (2) hematoma suggesting
pseudoaneurysm formation; (3) an eccentric, saccular,
thickened aorta wall without calcium; and (4) gas in the
aneurysmal sac. Differentiation from atherosclerotic aneurysms
depends on the nonfusiform appearance, atypical location and
rapid progression.
In the past, mycotic aneurysm had high mortality. Prognosis
has significantly improved in the last 2 decades, from 69%
mortality rate and common relapse before 1987 to 40% mortality
rate currently. Early diagnosis, surgical intervention plus
prolonged antibiotics therapy are essential for survival.
Medical treatment only carries poor prognosis compared to
surgical treatment plus prolonged antibiotics. In Hsu's series
in our center, the 30-day, 90-day, and 1-year mortality rates
were 3%, 12%, and 25%, respectively, in patients undertaking
operation, and 45%, 59%, and 59%, respectively, in patients
with no operation.
In this case, medical treatment composes of prolonged
effective antibiotics and standard treatment of aortic
aneurysm and dissection. In our center, due to high prevalence
of Salmonella resistance to ampicillin, the antibiotics
regimen usually start with cefotaxime or ceftriaxone, which
were proved to have higher in-vitro beta-lactamase stability.
Aortic dissection involving the ascending aorta (Stanford type
A; DeBakey type I or II) needs immediate surgical treatment.
Surgical treatment of type A aortic dissection reduces the
risk of poor outcomes (acute aortic insufficiency, tamponade,
and neurologic sequelae) from progression of the dissection.
Management of distal aortic dissection (Stanford type B;
DeBakey type III) generally needs aggressive blood pressure
control to target systolic pressure of 110 mmHg and pain
control. The goal of medical treatment is to reduce shearing
force (dP/dt) to the aortic wall. The recommended
antihypertensives include intravenous s-blockers (metoprolol,
propranolol, or labetalol) or in combination with vasodilating
drugs such as sodium nitroprusside or angiotensin-converting
enzyme inhibitors. Intravenous verapamil or diltiazem may also
be used, especially if s-blockers are contraindicated. Among
patients with type B dissection with medically uncontrolled
pain and/or hypertension, or evidence of rupture or end organ
involvement, surgical intervention should be emergently
applied.
In patients with a good response to antibiotic treatment,
surgical intervention is considered after a complete course of
antibiotic treatment for 4-6 weeks in the hospital. If
symptoms such as fever, pain, shock and other possible
complications related to aneurysm recur or newly develop,
image study was followed. Emergent surgical intervention is
considered for uncontrolled infection, evidence of impending
rupture (severe pain, shock, large pseudoaneurysm for more
than 5 cm). The surgical treatment includes wide debridement
of necrotic tissue, copious saline irrigation, and in-situ
graft reconstruction or extra-anatomic bypass. With combined
treatment, in our center, the 30-day was 0%. The 90-day
mortality rates were 0% for elective operation and 36% for
non-elective operation. Advanced age, urgent surgery and
medical treatment are associated with higher overall
mortality. Post-operative antibioitc therapy is administered
for at least 4 to 9 weeks in foreign series. In our center,
the postoperative antibiotics is administered for 4 months and
discontinued only when careful examination reveals no further
signs of infection.
<References>
- Guerrero F, Manuel L. The spectrum of cardiovascular
infections due to Salmonella enterica: a review of clinical
features and factors determining outcome. Medicine 2004;83:
123-138.
- Nienaber CA, Eagle KA. Aortic dissection: new
frontiers in diagnosis and management: Part I. Circulation
2003;108: 628–635.
- Nienaber CA, Eagle KA. Aortic
dissection: new frontiers in fiagnosis and management: Part
II. Circulation 2003;108: 772–778.
- Meerkin D, Yinnon
AM, Munter RG, Shemesh O, Hiller N, Abraham AS. Salmonella
mycotic aneurysm of the aortic arch: Case report and review.
Clin Infect Dis 1995;21:523-528.
- Soravia-Dunand VA, Loo
VG, Salit IE. Aortitis due to Salmonella: Report of 10 cases
and comprehensive review of the literature. Clin Infect Dis
1999;29:862-868.
- Howe HS, Wong JSL, Ding ZP, Sivathasan
C, Ang B, Koh WH, Feng PH. Mycotic aneurysm of a coronary
artery in SLE-a rare complication of Salmonella infection.
Lupus 1997;6:404-407.
- Nader R, Mohr G, Sheiner NM,
Tampieri D, Mendelson J, Albrecht S. Mycotic aneurysm of the
carotid bifurcation in the neck: Case report and review of the
literature. Neurosurgery 2001;48:1152-1156.
- Carreras M,
Larena JA, Tabernero G, Langara E, Pena JM. Evolution of
salmonella aortitis towards the formation of abdominal
aneurysm. Eur Radiol 1977;7:54-56.
- Hsu RB, Chen RJ.
Infected aortic aneurysms: clinical outcome and risk factor
analysis. J vas surg 2004;40:30-5.
- Wang JH, Liu YC, Yen MY, Wang JH,
Chen YS, Wann SR, Cheng DL. Mycotic aneurysm due to
non-typhi Salmonella: Report of 16 cases. Clin Infect Dis
1996;23:743-747.
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繼續教育考題
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1.
(B) |
All of the following
statements regarding chest pain are true except |
A | Rapid evaluation of chest pain
to identify life-threatening illness is important. Early
identification of aortic dissection, AMI, pneumothorax and pulmonary
embolism determines the prognosis. |
B | Assessment involves a careful
history, physical examination, and 12-lead ECG, chest roentgenogram.
Biochemical tests, including cardiac enzyme, are essential for
diagnosis and further triage decisions can’t be made without
them. |
C | Chest pain with constricting,
squeezing or heaviness character, locating over substernum,
radiating to left arm, shoulder, neck, jaw, with associated nausea,
vomiting and diaphoresis suggests cardiac ischemic origin of chest
pain. |
D | Severe chest pain, with
tearing, ripping or stabbing character and radiation to the back
suggests aortic dissection. |
2.
(C) |
All of the following
statements regarding aortic dissection are true except |
A | Two classification schemes,
Debakey and Stanford, based on anatomy are used currently, |
B | In addition to chest
pain, congestive heart failure, AMI, syncope, CVA, paraplegia, and
cardiac arrest could be the initial presentations of aortic
dissection. |
C | Pulse deficits, may be seen in
up to 50% of cases and do not carry outcome impact. |
D | All mechanisms weakening the
aortic media layers can induce aortic dilatation and aneurysm
formation, and eventually lead to intramural hemorrhage, aortic
dissection, or rupture. Conditions such as long standing
hypertension, Marfan syndrome, and Ehlers-Danlos syndrome are the
examples. |
3.
(A) |
All of the following
statements regarding the diagnosis of aortic dissection are true
except |
A | Virtually all cases of aortic
dissection have abnormal chest roentgenogram. |
B | CT scan, MRI, TEE/TTE and
angiography can be the first diagnostic aid in establishing the
diagnosis. |
C | Modalities chosen should be
based on local expertise and clinical availability rather than the
published data, since each method has advantages and
disadvantages. |
D | CT scan and TEE offer the most
rapid answer in most emergent situations. |
4.
(D) |
All of the following
statements regarding the treatment of aortic dissection are true
except |
A | Therapy of aortic dissection
started from the differentiation of proximal ( type A) and
non-proximal type of aortic dissection. |
B | Patients with suspected acute
aortic dissection should be admitted to an intensive care or
monitoring unit and undergo diagnostic evaluation immediately. |
C | Proximal aortic
dissections mandate immediate surgical treatment. Patients with
uncontrolled pain, hypertension, major branch vessel and end-organ
involvement should also receive surgical intervention. |
D | Management of distal aortic
dissection is generally started with medical treatment, including
aggressive pain and blood pressure control with beta-blockers,
calcium channel blockers, and hydralazine. |
5.
(D) |
Which of the
statements below is true? |
A | Salmonella is a Gram-positive
organism. |
B | Salmonella causes only
gastrointestinal symptoms. |
C | Only immunocompromised patients
pose the risk of salmonella bactermia. |
D | Emergence of drug-resistant
Salmonella has become the major clinical problem. Resistance to
extended spectrum cepholosporins and fluoroquinolone has been
reported. |
6.
(C) |
Which of the statements
below is not true? |
A | Salmonella species,
Staphylococcus aureus, Pseudomonas and mycobacterium tuberculosis
can be the pathogens of infected aneurysm. |
B | Old age, DM, hypertension and
preexisting atherosclerotic disease are the feature of these
patients of mycotic aneurysm caused by Salmonella |
C | Due to the uncommon incidence,
we should not consider mycotic aneurysm as a possible cause in an
elderly patient with prolonged chest pain, abdominal pain and
fever |
D | Since AIDS is a risk factor of
salmonellosis, AIDS patients rarely develop aortitis because they
are younger and have no atherosclertic risk factors |
7.
(D) |
Considering mycotic
aneurysm cause by Salmonella, which one is true? |
A | The most involved site is
thoracic aorta followed by abdominal aorta. |
B | Except for aorta, no
other arteries can be involved. |
C | You should never suspect
mycotic aneurysm in a patient with fever, abdominal pain who denied
preceding or concurrent diarrhea. |
D | Most patients with mycotic
aneurysm caused by Salmonella presented with a subacute clinical
picture with duration of symptoms ranging from 2 to 7 weeks; though
fulminant cases do exist. |
8.
(B) |
For the diagnosis of
mycotic aneurysm, which statement is not true? |
A | CT scan with contrast is the
modality of choice. |
B | CT scan can absolutely detect
the early change of aortitis, thus salmonella bacteremia with
negative CT scan rule out the possibility of mycotic aneurysm. |
C | Angiography, Gallium scan,
Tc-99m scan, TEE can be alternative diagnostic tool. |
D | Saccular aneurysm with
periaortic inflammation signs is the diagnostic clue on CT
scan |
9.
(B) |
For the treatment of
mycotic aneurysm, which one is not true? |
A | Delayed diagnosis carried even
more high mortality. |
B | Medical treatment is sufficient
to control the infection and the weakened aortic wall will resolve
after adequate infection control. |
C | For endovascular infection
caused by Salmonella, third generation of cepholosporin is the
better choice of initial regimen because of the proved better
in-vitro beta-lactamase stability. |
D | Prolonged antibiotics after
definitive treatment is mandatory. |
10.
(D) |
A 83-year-old male
patient with DM, hypertension was diagnosed to have Salmonella
related infective aneurysm over the proximal thoracic aorta, 3.0 cm
in size with the presentations of fever, and abdominal pain. Initial
CT study revealed no pseudoaneurysm, periaortic abcess or major
branch involvement. He was treated with intravenous ceftriaxone 2g
q12h. The fever subsided along with the leucocytosis and CRP level.
One week later, he complained of aggravating chest pain. There was
no new fever, focal neurologic deficit, new cardiac murmur, friction
rub or unstable hemodynamics. The leucocytosis improved compared to
previous study and no hemoglobin drop was noted. Chest roentgenogram
revealed no mediastinal widening or accumulation of pleural
effusion. The blood pressure under labetalol infusion was 128/70
mmHg. If you were his doctor, you should: |
A | Give adequate pain control
only. |
B | Give pain control and lower the
BP more aggressively. |
C | Since CT scan was just
performed 7 days ago and obtain the diagnosis of uncomplicated aorta
mycotic aneurysm of descending thoracic aorta in small size, there
is no need to repeat the image study. |
D | Give pain control, lower the BP
more aggressively and follow CT study since rapid progression of
mycotic aneurysm can occur in one week or
less. |
- (B)
Biochemical test can supply additional data, but the data
are not available immediately, and triage decisions are made
without them. Take acute myocardial infarction as an
example, the elevation of cardiac enzyme usually take 4-6
hours to rise after onset. The time delay is an obstacle of
appropriate diagnosis and timely treatment.
- (C) Pulse deficits carry
an ominous sign heralding complications and bad outcome.
- (A) Chest roentgenogram
is abnormal in 60% to 90% of cases of aortic dissection.
Acute dissection, especially type A lesion, can present with
a normal chest film.
- (D) Patients with
suspected acute aortic dissection should be admitted to an
intensive care or monitoring unit and undergo diagnostic
evaluation immediately. Pain and blood pressure control to a
target systolic pressure of 110 mm Hg can be achieved using
morphine sulfate and intravenous s-blockers (metoprolol,
propranolol, or labetalol) or in combination with
vasodilating drugs such as sodium nitroprusside or
angiotensin-converting enzyme inhibitors. Intravenous
verapamil or diltiazem may also be used, especially if
s-blockers are contraindicated. The aim of medical treatment
is to reduce shearing force within the aorta; thus direct
vasodilator
with propensity of reflex tachycardia is not
suitable for blood pressure control in cases of aortic
dissection
- (D) Salmonella is
Gram-negative, being a member of the family
enterobacteriaciae. Salmonella causes gastrointestinal,
cardiovascular, neuropsychiatric, respiratory and
hematologic symptoms. Blood stream infection of Salmonella
is more likely to occur in immunocompromised patients, but
is also found in immunocompetent patients.
- (C) The number of
reports of mycotic aneurysm was 150 till 1999. However, with
the aging population, prevalence of risk factors of
atherosclerosis and the well-established Salmonella in
nature, potential of salmonella spreading with modern
practices of food production, the possibility of salmonella
related infective aneurysm should be always kept in mind in
an elderly
patient with prolonged chest
pain, abdominal pain and fever.
- (D) The most frequent
site involved is the abdominal aorta, more precisely its
infrarenal segment, followed by the thoracic aorta. Other
arteries, such as the iliac, popliteal, carotid, and
coronary arteries, can on occasion be involved.
- (B) It must be taken
into account that when Salmonella infects atherosclerotic
plaques, CT scan and even aortography do not detect the
early changes produced in the arterial wall or in the
periaortic tissue. Evolution of Salmonella aortitis to the
formation of a mycotic aneurysm is, however, a rapid process
that takes 1 week or less, so subsequent CT scans may
exhibit the definitive signs of arterial infection.
- (B) In series of Hsu,
30-day, 90-day, and 1-year mortality rates were 3%, 12%, and
25%, respectively, in patients receiving operation, and 45%,
59%, and 59%, respectively in patients not operated.
Treatment with antibiotics alone, aortitis due to Salmonella
was uniformly fatal.
- (D) Combined medical and
surgical treatment is recommended. Among patients with a
good response to antibiotic treatment (no fever, declining
white blood cell count), surgical intervention is considered
after a complete course of antibiotic treatment for 4 to 6
weeks in the hospital and the infection is controlled.
Imaging studies should be repeated if new symptoms
(recurrent fever, pain, shock) develop or after complete
antibiotic treatment. Early surgical intervention, which is
defined as operation before 4 to 6 weeks of antibiotic
treatment, should be performed in patients with uncontrolled
infection (persistent fever, septic shock) or evidence of
impending aortic rupture (severe pain, shock, large
pseudoaneurysm formation on imaging studies).
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