Eur J VascSurg 6, 665-667 (1992)

CASE REPORT

Ruptured Mycotic Aneurysm of the Abdominal Aorta in Childhood J. Hollingworth, 1 K. S. Patmer 2 and M. H. S i m m s 1

1Department of Surgery and 2Department of Paediatrics, Selly Oak Hospital, Birmingham B29 6JD, U.K. Aortic aneurysms are exceedingly rare in childhood and, when mycotic, the risk of rupture is high. We report a case of ruptured mycotic abdominal aortic aneurysm presenting in a 9 year old girl, that was successfully repaired after initial misdiagnosis. Key Words: Mycotic aneurysm; Abdominal; Children.

Introduction

Mycotic aneurysms represent 2.6% of aneurysms in all age groups 4 and in children the thoracic aorta is most commonly involved. Mycotic aneurysm of the abdominal aorta usually presents with the features of sepsis. Progressive fever, back pain, leukocytosis and a pulsatile, possibly expanding abdominal mass, suggest the diagnosis but are not invariably present. In the case presented below, the diagnosis was made when a pulsatile upper abdominal mass was palpated during appendicectomy. Ultrasound examination subsequently confirmed an infra-renal aortic aneurysm.

Case Report

A 9-year-old girl was admitted to her local hospital with a 4 day history of abdominal pain, vomiting and constipation. She had a history of recurrent otitis media and, in her last attack 6 months previously, Staphylococcus aureus was cultured. A simultaneous episode of impetigo settled with antibiotic therapy. On this admission her ears and skin appeared healthy. She had a temperature of 37.6 °C and a diffusely tender and tense abdomen with no palpable masses. A diagnosis of appendicitis was made and appendicectomy performed via a gridiron incision. Please address all correspondenceto: J. Hollingworth,Department of Surgery, SellyOak Hospital, RaddlebarnRoad, BirminghamB29 6JD, U.K. 0950-821X/92/060665+03 $08.00/0© 1992Grune &StrattonLtd.

The appendix was normal but intra-abdominal palpation revealed a pulsatile mass in the left upper quadrant. An ultrasound scan performed postoperatively (Fig. 1) showed a 4.5cm saccular aneurysm arising from the anterior surface of the infra-renal aorta. The patient was transferred here and operation scheduled the same day. Midline laparotomy confirmed retroperitoneal haematoma and a friable infra-renal aortic aneurysm which ruptured immediately prior to clamping. The sac was excised and continuity restored with a straight interposition graft of 8 m m polytetrafluoroethylene (PTFE) anastomosed between the infra-renal aorta and the aortic bifurcation with interrupted PTFE sutures. Microscopy of the aneurysm wall showed Grampositive cocci. Staphylococcus aureus was grown from the aortic wall and blood. Subsequently, she made an uneventful recovery with normal lower limb pulses. She was discharged on the ninth postoperative day to complete a 14 day course of antibiotics and currently remains well at 6 months.

Discussion

Sir William Osler 1 introduced the term "mycotic" when describing a case of multiple aneurysms in association with bacterial endocarditis. In children with undiseased aortas, mycotic aneurysms are uncommon and are mostly reported in the thoracic portion of the vessel. They occur in bacterial endocarditis when infected emboli from the heart valves lodge in the vasa vasorum of the aortic wall. Mitchell2 de-

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Fig. 1. (a) Ultrasound examination showing a transverse section through the upper abdomen. The aneurysm is shown arising from the left anterolateral aspect of the infra-renal aorta. (b) Transverse section at a lower level clearly demonstrating the saccular nature of the aneurysm (measured in 2 dimensions between the crosses). scribed a case i n v o l v i n g the a b d o m i n a l aorta a n d r e v i e w e d five o t h e r s f r o m the literature, all of w h i c h w e r e fatal. M o r e recently, t h e y h a v e b e e n r e c o g n i s e d as a c o m p l i c a t i o n of infected umbilical a r t e r y catheters 3 w h e n local t r a u m a at the c a t h e t e r tip a n d h y p o x i a are c o n t r i b u t o r y factors. A m y c o t i c a n e u r Eur J Vasc Surg Vol 6, November 1992

y s m d u e to g e n e r a l i s e d sepsis is rare b u t has b e e n r e p o r t e d in association w i t h p n e u m o n i a . 4 The diagnosis is s u g g e s t e d b y a b d o m i n a l pain, pyrexia, an expansile m a s s a n d leukocytosis. T h e principles of t r e a t m e n t are to p r e - e m p t or arrest h a e m o r r h a g e , m a i n t a i n the distal circulation a n d eradicate infection.

Ruptured Mycotic Aneurysm

In adults, re-infection of the graft may be avoided by extra-anatomical bypass. In children, continuing growth makes this impractical and interposition grafting with intensive antibiotic therapy is the preferred treatment. Excision of the aneurysm and ligation of the aortic stump has been successful, suggesting that an adequate collateral circulation may exist in children. 5 In this case, the development of a collateral circulation should compensate for any relative narrowing at the anastomosis and, in the absence of further sepsis, there should be no need for further revision of the graft. The combination of impetigo and otitis media suggest that the bacteraemia may have occurred from a primary infection in the middle ear. There is one previous description of a successfully treated ruptured abdominal aortic aneurysm, which occurred in a 7 year old girl thought to have Marfan's syndrome. 6 In this case, the diagnosis was made preoperatively and the aneurysm was repaired at emergency laparotomy using a bifurcated graft. Leaking aortic aneurysm is an extremely rare cause of abdominal pain in childhood and a pulsatile mass may be difficult to detect in a tense abdomen. Abdominal ultrasonography is unlikely to be requested

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in the absence of specific indications. In the emergency setting, pre-incision examination under anaesthesia of the whole abdomen provides a final opportunity for palpating any unsuspected mass and avoiding inappropriate operative intervention. To our knowledge, this is the first case of a ruptured mycotic abdominal aortic aneurysm that has been successfully treated in a child using an in situ graft.

References 10SLER W. The Gulstonian lectures on malignant endocarditis. B M J 1885; 1~ 467-470. 2 MITCHELL RG, CLAIREAUXAE. Mycotic aneurysm of the abdominal aorta. Arch Dis Child 1952; 27: 147-152. 3 BERGSLAND A, KAWAGUCHI A, ROLAND JM, PIERONI DR, SImRAMANIAN S. Mycotic aortic aneurysms in children. Ann Thorac Surg 1984; 37(4): 314-318. 4 DEFRAmNE JO, PAQUOT JP, CREAMERS E, LIMET R. Aneurysm of the abdominal aorta in an eighteen month old child. Ann Vasc Surg 1988; 2(2): 193-195. 5 PARK I, PINSKY WW, FRANK L, BAKER CJ. Ruptured mycotic aneurysm of the abdominal aorta: successful treatment in a child. Am J Dis Child 1981; 135: 570-571. 6 TAKAYANAGIK, AL-BADERM. Ruptured abdominal aneurysm in a 7-year-old girl. J Pediatr Surg 1983; 18: 193-195.

Accepted 10 May 1991

Eur J Vasc Surg Vol 6, November 1992

Ruptured mycotic aneurysm of the abdominal aorta in childhood.

Aortic aneurysms are exceedingly rare in childhood and, when mycotic, the risk of rupture is high. We report a case of ruptured mycotic abdominal aort...
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