Multiple Mycotic Aneurysms Due
to Penicillin Nonsusceptible Streptococcus
pneumoniae Solved With Endovascular Repair
Alvaro Rojas,1Renato Mertens,2Douglas Arbulo,1Patricia Garcia,3
and Jaime Labarca,1Santiago, Chile
Mycotic aneurysm is a life-threatening condition. We report the case of an 83-year-old white
female who had pneumonia, and 3 months later she was admitted with multiple sacular mycotic
aneurysms due to penicillin nonsusceptible Streptococcus pneumoniae. Successful combination
therapy with antibiotics and endovascular repair was done.
Mycotic aneurysm is a life-threatening condition. In
lecture on endocarditis presented at the Royal
College of Physicians in London.1Mycotic aneu-
rysms represent between 1 and 3% of all aortic
aneurysms,2and the reported in-hospital mortality
of patients with this condition ranges from 16 to
44%. The majority of these are single lesions, but
cases of multiple aneurysms have been described
When not associated with endocarditis, the most
frequent organisms responsible for mycotic aneu-
rysms are gram-negative bacteria like Salmonella sp
and gram-positive bacteria like Staphylococcus aureus
and Streptococcus species. Despite its high prevalence,
Streptococcus pneumoniae is a rare cause of mycotic
We report a case of multiple mycotic aneurysms
due to penicillin nonsuceptible S pneumoniae and
the first description of endovascular treatment for
A 83-year-old white female presented with history
of untreated chronic arterial hypertension. On
July 2005, 3 months before admission, she had
fever, cough, and purulent sputum. Her laboratory
tests showed a leukocyte count of 23.9 ? 103/
mm3(normal range, 4.5-110 ? 103/mm3), C-reac-
tive protein level of 101.8 mg/dL (normal range,
< 20.0 mg/dL), and a condensation pattern of
the left inferior lobe on chest radiography. There-
fore, a community-acquired American Thoracic
Society Pneumonia Classification (ATS II) was
diagnosed. She received an ambulatory 10-day
course of levofloxacin 500 mg/qd with a good
Three weeks before admission, in September
2005, she referred an intense, vague periumbilical
abdominal pain that was partially relieved by
nonsteroidal anti-inflammatory drugs. An abdom-
inal computed tomography (CT) scan showed an
infrarenal sacular aortic aneurysm and inflamma-
tory changes in the periaortic fat. In the outpatient
clinic, the physical examination evidenced a left
popliteal pulsatile mass. Because of these findings
the presence of mycotic aneurisms was suspected.
Because of malaise, fever (38?C), and increasing
severity of abdominal pain, she was admitted to
the hospital. In the emergency room, cardiovascular
hemodynamics remained stable. Her laboratory
1Department of Medicine, Pontificia Universidad Cat? olica de Chile,
2Department of Vascular and Endovascular Surgery, Pontificia Uni-
versidad Cat? olica de Chile, Santiago, Chile.
3Department of Clinical Laboratories, Pontificia Universidad
Cat? olica de Chile, Santiago, Chile.
Correspondence to: Jaime Labarca, Department of Medicine, Pontif-
icia Universidad Cat? olica de Chile, Lira 63, Santiago, Chile, E-mail:
Ann Vasc Surg 2010; 24: 827.e5-827.e8
? Annals of Vascular Surgery Inc.
Published online: May 13, 2010
tests showed a leukocyte count of 10.7 ? 103/mm3
(normal range, 4.5-11.0 ? 103/mm3), erythrocyte
29.4 mg/dL (normal range, < 1.0 mg/dL). By means
tified: distal descending thoracic aorta (Fig. 1A),
infrarenal abdominal aorta (Fig. 1C), and left popli-
teal artery. The previously diagnosed infrarenal
aortic aneurysm had expanded 15 mm in diameter
in 1 week.
Empirical antibiotic therapy was initiated intra-
every 6 hours), ciprofloxacin (500 mg every 12
hours), and cloxacillin (2 g every 6 hours). Two
series of blood cultures, three BacT/Alert?bottles
on day 1, and two BacT/Alert?bottles on day 2
were positive for S pneumoniae, with intermediate
susceptibility to Penicillin (minimum inhibitory
concentration [MIC] ¼ 0.5 mg/dL) and susceptible
to Cefotaxime (MIC < 1 mg/dL). Antibiotic therapy
was changed to vancomycin (1 g every 12 hours
iv) and ceftriaxone (2 g/d iv). The study was
completed with a transesophageal ecocardiography
that was negative for endocarditis.
After 48 hours of hospitalization, an endovascu-
lar procedureunder general
performed, deploying a Talent?thoracic endopro-
thesis (26 ? 115 mm, Medtronic, Santa Rosa, CA)
in the distal descending thoracic aortic aneurysm
and two overlapping Zenith?
(Cook Medical, Bloomington, IN) (18 ? 55 mm
and 20 ? 55 mm respectively) to treat the infrarenal
aortic aneurysm (Fig. 1B, D); a left renal stent was
necessary to treat a critical ostial stenosis that wors-
ened after endograft deployment (Genesis?, Cordis
Corporation, Bridgewater, NJ). One week later, the
left popliteal aneurysm was excludedanda femoral-
popliteal bypass with ringed polytetrafluoroethy-
lene 6 mm was done, as neither saphenous nor an
adequate arm vein were available.
The patientpostoperative course wassatisfactory;
she did not present fever or abdominal pain. A 2
weeks course of intravenous antibiotic treatment
was completedbeforebeingdischarged. An ambula-
one (1 g/qd iv) for two more weeks. Later,
amoxicillin (1 g every 12 hours) was given orally
as a suppressive chronic therapy.
Twenty months after the original procedure, the
patient underwent stenting of the right renal artery
for severe hypertension and a critical ostial stenosis
that was present as a moderate lesion at initial treat-
ment. Hypertension control
To date, after 34 months of follow-up, the patient
remains asymptomatic, and her laboratory tests
show a leukocyte count of 4.3 ? 103/mm3(normal
range, 4.5-11.0 ? 103/mm3), erythrocyte sedimen-
tation rate of 19 mm/hr (normal range, 1-29 mm/
hr), and a C-reactive protein level of 0.6 mg/dL
(normal range, < 1.0 mg/dL).
Serial imaging at 4 months, followed by subse-
sion of the aneurysms and complete resolution
without signs of graft infection or endoleak
(Fig. 1B, D).
Mycotic aneurysms are not restricted to fungal infec-
tions, as the name might imply. This term has been
used to describe infection of an aneurysm by any
microorganism. Lately it has been restricted to a type
of aneurysm originating from or secondarily infected
by bacteria arising from a distant site of infection.
complains and some are asymptomatic. The most
frequent symptoms are malaise, fever, and thora-
coabdominal pain with different characterizations.5
A high index of suspicion is needed to achieve the
diagnosis by means of radiological exams, especially
CT scan. Arteriography was formerly used as the
first radiological exam, but has been replaced
because it is invasive, time consuming, and gives
no information regarding the arterial wall and the
S pneumoniae is a leading cause of illness in chil-
dren, theelderly, and inpersons with certain under-
lying medical conditions. However, it is a rare cause
of mycotic aneurysms. During the past 30 years, 33
cases of mycotic aneurysms due to S pneumoniae
have been described.3,4,6-12Some of these cases
were published as a part of series, and exact infor-
mation about the cases involving S pneumoniae is
not available.4Complete information is available
on 26 cases. There were 15 men and 11 women,
with ages ranging from 30 to 87 years. The location
of the aneurysm found in 29 patients was as follows:
thoracic aorta nine cases and abdominal aorta 20
cases. There are two reports of multiple mycotic
aneurysms.3,12Long-term follow-up was described
in 26 cases, and showed that five patients died post-
The patient described had multiple mycotic aneu-
rysms due to penicillin nonsusceptible S pneumoniae,
after 3 months of presenting with pneumonia. There
is one case of aortic mycotic aneurysm originating
from pneumonia, but as direct extension and not
827.e6 Case reports
Annals of Vascular Surgery
from bacteremia.4We hypothesize that pneumonia
was probably associated with bacteremia, and that
the patient had previous atherosclerotic lesions in
her arteries, which facilitated the subsequent
There are two reports of mycotic aneurysms due
to nonsusceptible S. pneumoniae. The first case
involves a patient with pneumonia and meningitis,
who had positive blood and cerebrospinal fluid
cultures. He died on the 13th day of his antibiotic
treatment. Autopsy revealed a ruptured abdominal
aortic aneurysm.13In this case, the isolate was resis-
tant to penicillin (MIC > 4 mg/dL) and ceftriaxone
Fig. 1. A Longitudinal computed tomography (CT)
reconstruction of the sacular thoracic aneurysm. B CT
scan 3D reconstruction of the thoracic aortic endograft.
C Longitudinal CT reconstruction of the sacular abdom-
inal aneurysm. D CT scan 3D reconstruction of the
abdominal aortic endograft.
Vol. 24, No. 6, August 2010
with a vertebral lumbar osteomyelitis and an Download full-text
abdominal aortic aneurysm.14Blood cultures were
positive posthumously for S pneumoniae with resis-
tance, as well as the first case, to penicillin (MIC >
4 mg/dL) and ceftriaxone (MIC > 2 mg/dL). As in
our patient’s case, previous antimicrobial exposure
within the last 6 months has been shown to be
among the most important predictors of infections
by this agent.
An initial antibiotic treatment, based on experts
consultation, with the use of a combination of anti-
microbial agents, such as a third generation cepha-
losporins and vancomycin, was chosen considering
the presence of multiple mycotic aneurysms and
the isolation of penicillin nonsuceptible S pneumo-
niae. The optimal duration of antimicrobial therapy
has not been established; some authors favor a 6-8
week course and some state that a life-long treat-
ment is required.4Considering the few cases
described of multiple mycotic aneurysms due to S.
pneumoniae, a case to case decision with regard to
duration of antimicrobial treatment is required.
Adequate management of mycotic aneurysms
ment. Conventionally, open surgery with debride-
ment of infected tissue and in situ repair has been
the procedure of choice for this condition.15
However, there is a high mortality associated with
open mycotic aneurysm repair specially located at
thethoracic aorta.Considering oldage,thepresence
of multiple mycotic aneurysms, and a high surgical
risk, an endovascular approach was chosen.
Endovascular repair of mycotic aneurysms is
associated with lower mortality, making it an attrac-
tive option in a subset of patients with high surgical
risk.16To date there is some controversy concerning
endovascular repair of mycotic aneurysms because
there is no surgical debridement, and a stent graft
is placed in an infected field. However, it has been
reported that patients have remained well several
years after the procedure using life-long antibiotic
treatment.16-20In our patient, considering multiple
mycotic aneurysms and a high surgical risk, an
endovascular repair of two aortic mycotic aneu-
rysms caused by S pneumoniae was performed with
multiple mycotic aneurysms due to penicillin non-
susceptible S pneumoniae.
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827.e8 Case reports
Annals of Vascular Surgery