RUPTURED MYCOTIC AORTIC ANEURYSM EDWARD
R. KATZ, M.D.
CHARLES
M. LYNNE,
VICTOR A. POLITANO,
M.D. M.D.
From the Department of Urology, University of Miami School of Medicine, and Jackson Memorial Hospital, Miami, Florida
ABSTRACT -A right flank mass, in a patient with fever of unknown origin, pain, and superiorly displaced right kidney on excretory urogram, was explored through a subcostal incision. Finding of a retroperitoneal abscess was anticipated; instead a ruptured mycotic aortic aneurysm was encountered. An awareness that entities such as this may exist is imperative in the differential diagnosis of flank masses. Treatment through a fink incision presents an elusive if not impossible feat. Because of the gravity of the underlying disease, misdiagnosis almost always results in death.
Ruptured mycotic aortic aneurysm is a rare occurrence. It is well known that it may present primarily as a problem of sepsis. Regardless of the cause, abdominal aortic aneurysm frequently mimics urologic disease. The presentation and potential complications of this entity is therefore of particular interest to the urologist. Case Report A forty-five-year-old white man had a twomonth history of back pain and fever. He had been hospitalized twice two months prior to his present admission. Extensive workups for “fever of undetermined etiology” revealed only multiple blood cultures positive for Escherichia coli. Findings on urine culture were negative. Intravenous pyelogram revealed an S-shaped left kidney but was otherwise normal (Fig. 1A). Other studies including skin tests for tuberculosis and fungus, and myelogram, oral and intravenous cholecystography, upper gastrointestinal series, barium enema, and liver scan were normal. The patient was treated with intravenous ampicillin; however, symptoms persisted. One month prior to admission exploratory laparotomy revealed a normal appendix. No retroperitoneal masses or indurations were felt. The patient continued to have fever and back pain. Also progressive pain, weakness, and paresthesias of his right leg began
620
to develop. Two months after onset of symptoms he was transferred to the University of Miami Hospitals. On admission, the patient was mildly anemic. Blood and urine cultures were negative. A poorly defined, tender right flank mass was palpable. Intravenous pyelogram now revealed upward and lateral displacement of the right kidney, lateral displacement of the right ureter in its upper half, and mild hydronephrosis (Fig. 1B). The right psoas shadow was obscured. The patient was explored through a flank incision for a suspected retroperitoneal abscess. A large, firm, yellow-brown, nonpulsatile mass was found occupying the entire right retroperitoneum. Several attempts at needle aspiration failed to yield frank pus or blood. The lateral surface of the mass was unroofed. A wall of fibrous and inflammatory tissue 0.75 to 1 cm. thick was found. Within the wall appeared to be an old, foul-smelling blood clot. It was believed this represented a partially organized, infected hematoma. After removal of a few of the infected clots, profuse arterial bleeding ensued which could be controlled only by packing the base of the mass and compressing it vigorously against the vertebral bodies. The aid of a vascular surgery team was obtained. The patient was repositioned on the table and the incision extended across the midline. With much difficulty control of the mass
UROLOGY
/ JUNE 1976 / VOLUME
VII,
NUMBER 6
FIGURE 1. Intravenous pyelogram (A) six weeks prior to final exploration reveals S-shaped left kidney but is otherwise unremarkable; and (B) immediately prior to exploration reveals right kidney and ureter displaced by retroperitoneal mass.
was obtained. It appeared that the hematoma originated from a ruptured aortic aneurysm which involved the aortic bifurcation and right common iliac artery. The bleeding had dissected posteriorly below the right common iliac vein, then upward, filling the right retroperitoneum. The inferior vena cava was pushed medially and compressed between the aorta and the medial wall of the hematoma. The aorta above and iliac arteries below the aneurysm were oversewn as a lifesaving measure. Total blood replacement was 18 units of whole blood. Pathologic examination of pieces of the necrotic aortic wall was consistent with an infected aneurysm. The next day an axillary-bifemoral bypass was performed. Numerous complications including renal failure requiring dialysis, disseminated intravascular coagulopathy, sepsis, and pneumonia finally led to the patient’s death three weeks postoperatively. Comment This is the second reported case of ruptured mycotic aneurysm in which the presenting symptoms were flank mass, back pain, and fever.
UROLOGY
/ JUNE1976
/ VOLUMEVII,
NUMBER6
An earlier case reported by Hyde’ presented with these symptoms; however, the flank mass was on the left, perhaps a more reasonable side on which to expect a ruptured aortic aneurysm. Presenting signs and symptoms may be vague and misleading. A sealed rupture of a small aneurysm may present as a retroperitoneal abscess.2 Szilagyi, Elliott, and Smith3 reviewed 7 cases of ruptured abdominal aortic aneurysms presenting as sepsis and anemia; none presented with a mass. Flank pain was the most common symptom in this series. Another review of mycotic aneurysms by Anderson, Butcher, and Ballinger4 found that only 2 of 6 patients with mycotic aneurym of the aorta or iliac vessels had the diagnosis made preoperatively. Other presenting symptoms may be testicular or suprapubic pain5 or gross hematuria.6 Burke,’ in a review of 158 patients with aortic aneurysms, found that 20 per cent were discovered during routine urologic examinations for unrelated conditions and 14 per cent had primary urologic symptoms. The most significant findings on pyelography were calcification of the aneurysmal wall, erosion of the vertebrae, and displacement of the kidneys and ureters.
621
It is well-known that ruptured aortic aneurysms, whether primarily infected or not may initially appear as a problem of sepsis. Clinically the infected aneurysm differs little from the ordinary ruptured aneurysm except for the increased friability of its wall.* The primary source of the infection is unknown in a large number of cases. Sources which have been reported to be the origins of infection are subacute bacterial endocarditis, osteomyelitis, gastroenteritis, urinary tract infections, and increasingly drug addiction. Since the diagnosis of a ruptured aortic aneurysm of any kind may be extremely difficult to make, the urologist should be aware that evolving clinical events of flank pain, fever, sepsis, anemia, and lastly, a mass, may be heralding such an entity. Accurate preoperative diagnosis can preclude the exploration of such retroperitoneal masses through the flank. Angiography may be helpful. Even so, the prognosis for the ruptured mycotic aortic aneurysm is grave.
622
P.O. Box 520875, Biscayne Annex Miami, Florida 33152 (DR. LYNNE) References 1. HYDE, G. L.: Ruptured mycotic aneurysms of the abdominal aorta, J. Ky. Med. Assoc. 71: 728 (1973). 2. MORGAN,W. L.: Important diagnostic signs of leaking abdominal aortic aneurysms, Arch. Int. Med. 99: 134 (1957). 3. SZILAGYI, D. E., ELLIOTT, J. P., JR., and SMITH, R. . Ruptured abdominal aneurysm-simulating sepsis, z&h. Surg. 91: 263 (1965). 4. ANDERSON,C. B., BUTCHER, H. R., ~~~BALLINGER, W. F.: Mycotic aneurysms, ibid. 109:712 (1974). 5. CULP, 0. S., and BERNATZ, P. E.: Urologic aspects of lesions in the abdominal aorta, J. Ural. 86: 189 (1961). 6. GRAHAMS,J. W., and DOWNS,A. R.: Ruptured abdominal aortic aneurysm presenting with gross hematuria, ibid. 106:628 (1971). 7. BURKE, E. F.: Early discovery of aortic aneurysms termed lifesaving, Clin. Trends Ural. 2: 2 (1974). 8. SOMMERVILLE,R. L., and ALLEN, E. V.: Bland and infected arteriosclerotic abdominal aortic aneurysms: a clinico-pathologic study, Medicine 38: 207 (1959).
UROLOGY /
JUNE 1976 /
VOLUME VII, NUMBER 6
R. KATZ, M.D.
CHARLES
M. LYNNE,
VICTOR A. POLITANO,
M.D. M.D.
From the Department of Urology, University of Miami School of Medicine, and Jackson Memorial Hospital, Miami, Florida
ABSTRACT -A right flank mass, in a patient with fever of unknown origin, pain, and superiorly displaced right kidney on excretory urogram, was explored through a subcostal incision. Finding of a retroperitoneal abscess was anticipated; instead a ruptured mycotic aortic aneurysm was encountered. An awareness that entities such as this may exist is imperative in the differential diagnosis of flank masses. Treatment through a fink incision presents an elusive if not impossible feat. Because of the gravity of the underlying disease, misdiagnosis almost always results in death.
Ruptured mycotic aortic aneurysm is a rare occurrence. It is well known that it may present primarily as a problem of sepsis. Regardless of the cause, abdominal aortic aneurysm frequently mimics urologic disease. The presentation and potential complications of this entity is therefore of particular interest to the urologist. Case Report A forty-five-year-old white man had a twomonth history of back pain and fever. He had been hospitalized twice two months prior to his present admission. Extensive workups for “fever of undetermined etiology” revealed only multiple blood cultures positive for Escherichia coli. Findings on urine culture were negative. Intravenous pyelogram revealed an S-shaped left kidney but was otherwise normal (Fig. 1A). Other studies including skin tests for tuberculosis and fungus, and myelogram, oral and intravenous cholecystography, upper gastrointestinal series, barium enema, and liver scan were normal. The patient was treated with intravenous ampicillin; however, symptoms persisted. One month prior to admission exploratory laparotomy revealed a normal appendix. No retroperitoneal masses or indurations were felt. The patient continued to have fever and back pain. Also progressive pain, weakness, and paresthesias of his right leg began
620
to develop. Two months after onset of symptoms he was transferred to the University of Miami Hospitals. On admission, the patient was mildly anemic. Blood and urine cultures were negative. A poorly defined, tender right flank mass was palpable. Intravenous pyelogram now revealed upward and lateral displacement of the right kidney, lateral displacement of the right ureter in its upper half, and mild hydronephrosis (Fig. 1B). The right psoas shadow was obscured. The patient was explored through a flank incision for a suspected retroperitoneal abscess. A large, firm, yellow-brown, nonpulsatile mass was found occupying the entire right retroperitoneum. Several attempts at needle aspiration failed to yield frank pus or blood. The lateral surface of the mass was unroofed. A wall of fibrous and inflammatory tissue 0.75 to 1 cm. thick was found. Within the wall appeared to be an old, foul-smelling blood clot. It was believed this represented a partially organized, infected hematoma. After removal of a few of the infected clots, profuse arterial bleeding ensued which could be controlled only by packing the base of the mass and compressing it vigorously against the vertebral bodies. The aid of a vascular surgery team was obtained. The patient was repositioned on the table and the incision extended across the midline. With much difficulty control of the mass
UROLOGY
/ JUNE 1976 / VOLUME
VII,
NUMBER 6
FIGURE 1. Intravenous pyelogram (A) six weeks prior to final exploration reveals S-shaped left kidney but is otherwise unremarkable; and (B) immediately prior to exploration reveals right kidney and ureter displaced by retroperitoneal mass.
was obtained. It appeared that the hematoma originated from a ruptured aortic aneurysm which involved the aortic bifurcation and right common iliac artery. The bleeding had dissected posteriorly below the right common iliac vein, then upward, filling the right retroperitoneum. The inferior vena cava was pushed medially and compressed between the aorta and the medial wall of the hematoma. The aorta above and iliac arteries below the aneurysm were oversewn as a lifesaving measure. Total blood replacement was 18 units of whole blood. Pathologic examination of pieces of the necrotic aortic wall was consistent with an infected aneurysm. The next day an axillary-bifemoral bypass was performed. Numerous complications including renal failure requiring dialysis, disseminated intravascular coagulopathy, sepsis, and pneumonia finally led to the patient’s death three weeks postoperatively. Comment This is the second reported case of ruptured mycotic aneurysm in which the presenting symptoms were flank mass, back pain, and fever.
UROLOGY
/ JUNE1976
/ VOLUMEVII,
NUMBER6
An earlier case reported by Hyde’ presented with these symptoms; however, the flank mass was on the left, perhaps a more reasonable side on which to expect a ruptured aortic aneurysm. Presenting signs and symptoms may be vague and misleading. A sealed rupture of a small aneurysm may present as a retroperitoneal abscess.2 Szilagyi, Elliott, and Smith3 reviewed 7 cases of ruptured abdominal aortic aneurysms presenting as sepsis and anemia; none presented with a mass. Flank pain was the most common symptom in this series. Another review of mycotic aneurysms by Anderson, Butcher, and Ballinger4 found that only 2 of 6 patients with mycotic aneurym of the aorta or iliac vessels had the diagnosis made preoperatively. Other presenting symptoms may be testicular or suprapubic pain5 or gross hematuria.6 Burke,’ in a review of 158 patients with aortic aneurysms, found that 20 per cent were discovered during routine urologic examinations for unrelated conditions and 14 per cent had primary urologic symptoms. The most significant findings on pyelography were calcification of the aneurysmal wall, erosion of the vertebrae, and displacement of the kidneys and ureters.
621
It is well-known that ruptured aortic aneurysms, whether primarily infected or not may initially appear as a problem of sepsis. Clinically the infected aneurysm differs little from the ordinary ruptured aneurysm except for the increased friability of its wall.* The primary source of the infection is unknown in a large number of cases. Sources which have been reported to be the origins of infection are subacute bacterial endocarditis, osteomyelitis, gastroenteritis, urinary tract infections, and increasingly drug addiction. Since the diagnosis of a ruptured aortic aneurysm of any kind may be extremely difficult to make, the urologist should be aware that evolving clinical events of flank pain, fever, sepsis, anemia, and lastly, a mass, may be heralding such an entity. Accurate preoperative diagnosis can preclude the exploration of such retroperitoneal masses through the flank. Angiography may be helpful. Even so, the prognosis for the ruptured mycotic aortic aneurysm is grave.
622
P.O. Box 520875, Biscayne Annex Miami, Florida 33152 (DR. LYNNE) References 1. HYDE, G. L.: Ruptured mycotic aneurysms of the abdominal aorta, J. Ky. Med. Assoc. 71: 728 (1973). 2. MORGAN,W. L.: Important diagnostic signs of leaking abdominal aortic aneurysms, Arch. Int. Med. 99: 134 (1957). 3. SZILAGYI, D. E., ELLIOTT, J. P., JR., and SMITH, R. . Ruptured abdominal aneurysm-simulating sepsis, z&h. Surg. 91: 263 (1965). 4. ANDERSON,C. B., BUTCHER, H. R., ~~~BALLINGER, W. F.: Mycotic aneurysms, ibid. 109:712 (1974). 5. CULP, 0. S., and BERNATZ, P. E.: Urologic aspects of lesions in the abdominal aorta, J. Ural. 86: 189 (1961). 6. GRAHAMS,J. W., and DOWNS,A. R.: Ruptured abdominal aortic aneurysm presenting with gross hematuria, ibid. 106:628 (1971). 7. BURKE, E. F.: Early discovery of aortic aneurysms termed lifesaving, Clin. Trends Ural. 2: 2 (1974). 8. SOMMERVILLE,R. L., and ALLEN, E. V.: Bland and infected arteriosclerotic abdominal aortic aneurysms: a clinico-pathologic study, Medicine 38: 207 (1959).
UROLOGY /
JUNE 1976 /
VOLUME VII, NUMBER 6
