International Journal of Cardiology 187 (2015) 530–531
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Intracoronary blood sampling with a microcatheter for the diagnosis of giant infective coronary aneurysm: Melioidosis of coronary artery mycotic aneurysm Kuan Leong Yew a,⁎, Chun Ngok Choy b, Ji Yen Kam b, Zarrin Kang a a b
Cardiology Department, Sarawak General Hospital Heart Center, 94300 Kota Samarahan, Sarawak, Malaysia Cardiology Department, Sultanah Aminah Hospital, 80100 Johor Bahru, Johor, Malaysia
a r t i c l e
i n f o
Article history: Received 31 March 2015 Accepted 1 April 2015 Available online 3 April 2015 Keywords: Mycotic aneurysm Coronary aneurysm Microcatheter Intracoronary Melioidosis Burkholderia pseudomallei
Coronary artery aneurysm and infection in relation to post-coronary artery stent implantations are rare but well documented in the literature [1–5]. These can manifest as pyrexia of unknown origin (PUO) and present clinical and diagnostic conundrums. It is often compounded with a negative blood culture result. We would like to highlight the first reported case of bacterial melioidotic mycotic coronary aneurysm in a man with PUO and the novel use of coronary microcatheter for intracoronary blood sampling to clinch the microbiological evidence of Burkholderia pseudomallei. A 72-year-old man with 1 month history of fever and angina pectoris was admitted for pneumonia at another hospital. After he had convalesced from the pneumonia, he underwent coronary angiography which demonstrated a tight discrete stenosis at proximal left anterior descending artery (LAD) and a pre-stenotic saccular coronary aneurysm. A bare metal stent was deployed at the stenotic area. He developed acute chest pain one week later with anterior ST segment elevation myocardial infarction. There was subacute stent thrombosis which was remedied by balloon angioplasty and abciximab infusion. He continued to have intermittent low grade fever, chills and rigors for the next 3 months. Then his clinical condition worsened and he presented to our medical institution with septic shock. He was stabilized ⁎ Corresponding author. E-mail address: [email protected] (K.L. Yew).
http://dx.doi.org/10.1016/j.ijcard.2015.04.013 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
and supported with inotropic agents. Empirical intravenous broad spectrum meropenem was initiated after appropriate blood samples were taken. Peripheral blood culture tests were negative. He had intermittent chest pain with no electrocardiography and cardiac enzyme changes. However, white cell counts, erythrocyte sedimentation rate and Creactive protein were all raised. Bedside echocardiogram showed moderately reduced left ventricular systolic function, no valvular vegetation and inexplicable echolucency was detected below the aortic valve level at the short-axis view. Bedside ultrasound of the abdomen did not reveal any obvious organomegaly or focus of infection. After being stabilized for a few days, he went for cardiac catheterization study which revealed multiple large aneurysms in the LAD with no blood flow beyond the stent (Fig. 1A–C). Otherwise the left circumflex artery and right coronary artery were relatively normal. A coronary wire was advanced into the proximal stented segment to guide the placement of a coronary microcatheter (Fig. 1D). There was no flow of contrast beyond the diseased aneurysmal and mycotic segments after injection of contrast through the microcatheter. Then a set of aerobic and anaerobic blood cultures was obtained through the aspiration of the microcatheter. Both blood cultures yielded B. pseudomallei. The case was discussed with the cardiothoracic team. In view of the ongoing sepsis, he was deemed a high surgical risk patient with high morbidity and mortality rates. The surgeons planned to reassess his clinical response to antibiotic in a fortnight's time. Despite intensive medical care, the patient's condition deteriorated and he succumbed 2 weeks later. There was incomplete clinical and angiographic information about the patient's initial hospitalization. In view of the preceding pneumonia and documented LAD coronary aneurysm prior to the stenting, it was unlikely that infective coronary mycotic aneurysm happened as a result of the stent implantation. B. pseudomallei or Pseudomonas pseudomallei as it was previously known, is a gram negative aerobic bacillus that causes melioidosis infection. It is endemic in southeast Asia and northern Australia [6,7]. Melioidosis infection is a great disease mimicker and can infect any organ. It can cause pneumonia, pericardial effusion, cardiac tamponade, prostatic abscess, liver abscess, and splenic abscess [6–8]. Melioidosis pneumonia was the most probable initial clinical presentation. It was partially and inadequately treated. Thus, the bacteremia persisted and spread by the hematogenous route to infect the
K.L. Yew et al. / International Journal of Cardiology 187 (2015) 530–531
531
Fig. 1. Giant left anterior descending artery mycotic aneurysm and contrast stasis in the saccular aneursyms (white arrows) (A. B). LAO cranial view showing the absence of contrast flow beyond the stented segment with mycotic aneurysms (C). A coronary microcatheter (white arrow) was placed in the stented segment for intracoronary blood sampling for blood culture (D).
coronary vasculature. The metallic bare metal stent as a foreign body could have helped to propagate the infection and attenuated the local response to infection. The mycotic coronary aneurysm grew in number and size until it interfered with the coronary blood flow and caused stent thrombosis as evidenced by the persistence of contrast during the coronary angiography (Fig. 1B). Coronary angiography study was warranted as the patient had angina episodes. The spectacular finding of giant mycotic coronary aneurysm reinforced the suspicion that it was the culprit for infection. A coronary microcatheter was initially used to help to delineate the LAD beyond the mycotic segment. As there was no contrast flow beyond the microcatheter and mycotic segments, it was dangerous to advance the coronary wire and microcatheter beyond the stented segment. The wall of mycotic coronary aneurysm would be thin, friable and prone for iatrogenic perforation. These saccular aneurysms contained pus and intracoronary blood sampling with a microcatheter at the site of infection would greatly increase the microbiological yield probability of blood microorganism. Thus, we managed to obtain positive intracoronary blood culture despite negative peripheral blood culture. We do not know about the microbiological yield probability of blood sampling if obtain direct from the guiding catheter. The definitive treatment of the infective mycotic coronary aneurysm is surgical excision, ligation and coronary artery bypass grafting [4]. However, the patient was too ill for surgical intervention. Melioidosis is known to have high mortality rate [6,7]. This is the first reported case of melioidotic involvement of the coronary vasculature with fatal outcome. Coronary microcatheter is commonly used concomitantly with a high performance coronary wire for challenging complex
coronary anatomy such as chronic total occlusion. As illustrated by this case, it can also be used successfully for intracoronary blood sampling from the culprit infective mycotic coronary aneurysmal site when microbiological diagnosis is of paramount importance.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
References [1] R.S. Dieter, Coronary artery stent infection, Clin. Cardiol. 23 (2000) 808–810. [2] C.P. Lim, K.L. Ho, T.T. Tan, A.S. Wong, J.W. Tan, Y.L. Chua, et al., Infected coronary artery pseudoaneurysm after repeated percutaneous coronary intervention, Ann. Thorac. Surg. 91 (2011) e17–e19. [3] W.M. Bosman, B.L. Borger van der Burg, H.M. Schuttevaer, S. Thoma, P.P. Hedeman Joosten, Infections of intravascular bare metal stents: a case report and review of literature, Eur. J. Vasc. Endovasc. Surg. 47 (2014) 87–99. [4] V. Janaswamy, M.S. Gargipati, K. Sudhaker, S.S. Parupati, R.K. Alluri, A.G. Gokhale, Successful surgical outcome of infected aneurysmal drug-coated stent endocarditis, Asian Cardiovasc. Thorac. Ann. 22 (2014) 484–486. [5] M. Fisk, L.F. Peck, K. Miyagi, M.J. Steward, S.F. Lee, M.B. Macrae, et al., Mycotic aneurysms: a case report, clinical review and novel imaging strategy, QJM 105 (2012) 181–188. [6] Allen C. Cheng, Bart J. Currie, Melioidosis: epidemiology, pathophysiology, and management, Clin. Microbiol. Rev. 18 (2005) 383–416. [7] S.D. Puthucheary, Melioidosis in Malaysia, Med. J. Malays. 64 (2009) 266–274. [8] K.L. Yew, T.H. Ng, S.H. How, Y.C. Kuan, The bug and the big heart — melioidotic pericardial effusion, Med. J. Malays. 66 (2011) 71–72.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Intracoronary blood sampling with a microcatheter for the diagnosis of giant infective coronary aneurysm: Melioidosis of coronary artery mycotic aneurysm Kuan Leong Yew a,⁎, Chun Ngok Choy b, Ji Yen Kam b, Zarrin Kang a a b
Cardiology Department, Sarawak General Hospital Heart Center, 94300 Kota Samarahan, Sarawak, Malaysia Cardiology Department, Sultanah Aminah Hospital, 80100 Johor Bahru, Johor, Malaysia
a r t i c l e
i n f o
Article history: Received 31 March 2015 Accepted 1 April 2015 Available online 3 April 2015 Keywords: Mycotic aneurysm Coronary aneurysm Microcatheter Intracoronary Melioidosis Burkholderia pseudomallei
Coronary artery aneurysm and infection in relation to post-coronary artery stent implantations are rare but well documented in the literature [1–5]. These can manifest as pyrexia of unknown origin (PUO) and present clinical and diagnostic conundrums. It is often compounded with a negative blood culture result. We would like to highlight the first reported case of bacterial melioidotic mycotic coronary aneurysm in a man with PUO and the novel use of coronary microcatheter for intracoronary blood sampling to clinch the microbiological evidence of Burkholderia pseudomallei. A 72-year-old man with 1 month history of fever and angina pectoris was admitted for pneumonia at another hospital. After he had convalesced from the pneumonia, he underwent coronary angiography which demonstrated a tight discrete stenosis at proximal left anterior descending artery (LAD) and a pre-stenotic saccular coronary aneurysm. A bare metal stent was deployed at the stenotic area. He developed acute chest pain one week later with anterior ST segment elevation myocardial infarction. There was subacute stent thrombosis which was remedied by balloon angioplasty and abciximab infusion. He continued to have intermittent low grade fever, chills and rigors for the next 3 months. Then his clinical condition worsened and he presented to our medical institution with septic shock. He was stabilized ⁎ Corresponding author. E-mail address: [email protected] (K.L. Yew).
http://dx.doi.org/10.1016/j.ijcard.2015.04.013 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
and supported with inotropic agents. Empirical intravenous broad spectrum meropenem was initiated after appropriate blood samples were taken. Peripheral blood culture tests were negative. He had intermittent chest pain with no electrocardiography and cardiac enzyme changes. However, white cell counts, erythrocyte sedimentation rate and Creactive protein were all raised. Bedside echocardiogram showed moderately reduced left ventricular systolic function, no valvular vegetation and inexplicable echolucency was detected below the aortic valve level at the short-axis view. Bedside ultrasound of the abdomen did not reveal any obvious organomegaly or focus of infection. After being stabilized for a few days, he went for cardiac catheterization study which revealed multiple large aneurysms in the LAD with no blood flow beyond the stent (Fig. 1A–C). Otherwise the left circumflex artery and right coronary artery were relatively normal. A coronary wire was advanced into the proximal stented segment to guide the placement of a coronary microcatheter (Fig. 1D). There was no flow of contrast beyond the diseased aneurysmal and mycotic segments after injection of contrast through the microcatheter. Then a set of aerobic and anaerobic blood cultures was obtained through the aspiration of the microcatheter. Both blood cultures yielded B. pseudomallei. The case was discussed with the cardiothoracic team. In view of the ongoing sepsis, he was deemed a high surgical risk patient with high morbidity and mortality rates. The surgeons planned to reassess his clinical response to antibiotic in a fortnight's time. Despite intensive medical care, the patient's condition deteriorated and he succumbed 2 weeks later. There was incomplete clinical and angiographic information about the patient's initial hospitalization. In view of the preceding pneumonia and documented LAD coronary aneurysm prior to the stenting, it was unlikely that infective coronary mycotic aneurysm happened as a result of the stent implantation. B. pseudomallei or Pseudomonas pseudomallei as it was previously known, is a gram negative aerobic bacillus that causes melioidosis infection. It is endemic in southeast Asia and northern Australia [6,7]. Melioidosis infection is a great disease mimicker and can infect any organ. It can cause pneumonia, pericardial effusion, cardiac tamponade, prostatic abscess, liver abscess, and splenic abscess [6–8]. Melioidosis pneumonia was the most probable initial clinical presentation. It was partially and inadequately treated. Thus, the bacteremia persisted and spread by the hematogenous route to infect the
K.L. Yew et al. / International Journal of Cardiology 187 (2015) 530–531
531
Fig. 1. Giant left anterior descending artery mycotic aneurysm and contrast stasis in the saccular aneursyms (white arrows) (A. B). LAO cranial view showing the absence of contrast flow beyond the stented segment with mycotic aneurysms (C). A coronary microcatheter (white arrow) was placed in the stented segment for intracoronary blood sampling for blood culture (D).
coronary vasculature. The metallic bare metal stent as a foreign body could have helped to propagate the infection and attenuated the local response to infection. The mycotic coronary aneurysm grew in number and size until it interfered with the coronary blood flow and caused stent thrombosis as evidenced by the persistence of contrast during the coronary angiography (Fig. 1B). Coronary angiography study was warranted as the patient had angina episodes. The spectacular finding of giant mycotic coronary aneurysm reinforced the suspicion that it was the culprit for infection. A coronary microcatheter was initially used to help to delineate the LAD beyond the mycotic segment. As there was no contrast flow beyond the microcatheter and mycotic segments, it was dangerous to advance the coronary wire and microcatheter beyond the stented segment. The wall of mycotic coronary aneurysm would be thin, friable and prone for iatrogenic perforation. These saccular aneurysms contained pus and intracoronary blood sampling with a microcatheter at the site of infection would greatly increase the microbiological yield probability of blood microorganism. Thus, we managed to obtain positive intracoronary blood culture despite negative peripheral blood culture. We do not know about the microbiological yield probability of blood sampling if obtain direct from the guiding catheter. The definitive treatment of the infective mycotic coronary aneurysm is surgical excision, ligation and coronary artery bypass grafting [4]. However, the patient was too ill for surgical intervention. Melioidosis is known to have high mortality rate [6,7]. This is the first reported case of melioidotic involvement of the coronary vasculature with fatal outcome. Coronary microcatheter is commonly used concomitantly with a high performance coronary wire for challenging complex
coronary anatomy such as chronic total occlusion. As illustrated by this case, it can also be used successfully for intracoronary blood sampling from the culprit infective mycotic coronary aneurysmal site when microbiological diagnosis is of paramount importance.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
References [1] R.S. Dieter, Coronary artery stent infection, Clin. Cardiol. 23 (2000) 808–810. [2] C.P. Lim, K.L. Ho, T.T. Tan, A.S. Wong, J.W. Tan, Y.L. Chua, et al., Infected coronary artery pseudoaneurysm after repeated percutaneous coronary intervention, Ann. Thorac. Surg. 91 (2011) e17–e19. [3] W.M. Bosman, B.L. Borger van der Burg, H.M. Schuttevaer, S. Thoma, P.P. Hedeman Joosten, Infections of intravascular bare metal stents: a case report and review of literature, Eur. J. Vasc. Endovasc. Surg. 47 (2014) 87–99. [4] V. Janaswamy, M.S. Gargipati, K. Sudhaker, S.S. Parupati, R.K. Alluri, A.G. Gokhale, Successful surgical outcome of infected aneurysmal drug-coated stent endocarditis, Asian Cardiovasc. Thorac. Ann. 22 (2014) 484–486. [5] M. Fisk, L.F. Peck, K. Miyagi, M.J. Steward, S.F. Lee, M.B. Macrae, et al., Mycotic aneurysms: a case report, clinical review and novel imaging strategy, QJM 105 (2012) 181–188. [6] Allen C. Cheng, Bart J. Currie, Melioidosis: epidemiology, pathophysiology, and management, Clin. Microbiol. Rev. 18 (2005) 383–416. [7] S.D. Puthucheary, Melioidosis in Malaysia, Med. J. Malays. 64 (2009) 266–274. [8] K.L. Yew, T.H. Ng, S.H. How, Y.C. Kuan, The bug and the big heart — melioidotic pericardial effusion, Med. J. Malays. 66 (2011) 71–72.
