BRIEF REPORT • CID 2005:40 (1 January) • 193
B R I E F R E P O R T
Mycotic Aneurysm Due
to Burkholderia pseudomallei Infection:
Case Reports and Literature Review
Jenny Guek Hong Low,1Amy May Lin Quek,2Yoong Kong Sin,3
and Brenda Sze Peng Ang2
1Infectious Disease Unit, Department of Internal Medicine, Singapore
2Department of Infectious Diseases, Tan Tock Seng Hospital,
3Department of Cardiothoracic and Vascular Surgery, National Heart Centre,
Melioidosis caused by Burkholderia pseudomallei infection
is endemic in Southeast Asia and Northern Australia. Car-
diovascular complications resulting in mycotic aneurysms
are very rare. To our knowledge, there have only been 6
isolated case reports published in the literature to date. We
report 6 cases of melioidosis in Singapore that presented as
Melioidosis, an infection caused by Burkholderia pseudomallei,
is a notifiable disease in Singapore. The most common clinical
presentation is pneumonia, followed by skin, visceral, and gen-
itourinary system abscesses. Melioidosis presenting as mycotic
aneurysm is rare and is associated with high morbidity, mor-
tality, and relapse rates [1–6]. We report our experience with
the management of this disease.
Patients and methods.
We reviewed data for all patients
with melioidosis and mycotic aneurysms admitted to 1 of 3
hospitals in Singapore from January 1992 through December
2003. All patients had culture-confirmed melioidosis. We also
performed a MEDLINE search, using the following terms, for
cases reported in the literature during 1966–2003: “melioi-
dosis,” “Burkholderia pseudomallei infections,” “Pseudomonas
pseudomallei,” “abdominal aortic aneurysm,” “pseudoaneu-
rysm,” “mycotic aneurysm,” “bacteremicmelioidosis,”and“re-
Patient 2, a 66-year-old man with a history
of dyslipidemia and coronary artery disease, was admitted to
Received 11 June 2004; accepted 25 August 2004; electronically published 8 December
Reprints or correspondence: Dr. Jenny Guek Hong Low, Infectious Diseases Unit, Dept. of
Internal Medicine, Singapore General Hospital, Outram Rd., Singapore 169608 (jenny
Clinical Infectious Diseases 2005;40:193–8
? 2004 by the Infectious Diseases Society of America. All rights reserved.
the hospital without fever and with a 1-week history of left-
side abdominal pain (table 1). A nontender pulsatile mass was
felt in the left side of the abdomen. Blood tests revealed a WBC
count of 8900 cells/mm3(with a normal neutrophil count) and
a hemoglobin level of 11.7 g/dL. CT of the abdomen showed
an infrarenal abdominal aortic aneurysm (AAA), and the pa-
tient underwent repair of the AAA. After surgery, he developed
new fever with wound discharge and leukocytosis of increasing
severity. A second laparotomy revealed fluid in the pelviccavity
and pus around the para-aortic region. Cultures of blood and
pus obtained from the peritoneal cavity and para-aortic area
yielded B. pseudomallei, confirming the diagnosis of mycotic
aneurysm. Patient 2 also developed septic arthritis in the left
knee, and culture of an aspirate yielded B. pseudomallei with
the same antibiogram as the previously isolated strain. He was
treated with intravenous ceftazidime for 8 weeks and was dis-
charged from the hospital receiving maintenance doxycyline
Four years later, patient 2 presented to the hospital with
fever and abdominal pain while he was still receiving doxy-
cycline. CT of the abdomen confirmed a loculated fluid col-
lection around the upper abdominal aorta, with splenic mi-
croabscesses. The abdominal aortic graft was intact. Patient
2 underwent resection of the mycotic abdominal pseudo-
aneurysm, which involved removal of the infected graft, and
ligation of the infrarenal abdominal aorta and both common
iliac arteries with axillobifemoral bypass. Culture of tissueand
blood clot specimens yielded B. pseudomallei and methicillin-
resistant Staphylococcus aureus. Patient 2 was treated with in-
travenous ceftazidime and vancomycin and oral trimethoprim-
sulfamethoxazole (TMP-SMZ) for 6 weeks and was prescribed
lifelong oral doxycycline and TMP-SMZ therapy. Five years
later, the patient’s most recent follow-up examination revealed
that he remained healthy.
Patient 6, a 60-year-old man with type 2 diabetes mellitus
and hypertension, was admitted to the hospital with a 3-week
history of fever, chills, and rigors. Examination revealed that
he was febrile (temperature, 38.2?C), and hepatosplenomegaly
was detected. Blood testing showed a WBC count of 16,400
cells/mm3(with 87.4% neutrophils) and a hemoglobin level of
11.8 g/dL. The patient was treated empirically with intravenous
ceftriaxone and metronidazole. Fever persisted during the next
48 h, with new central abdominal pain; antibiotic therapy was
switched to high-dose ceftazidime for possible melioidosis in-
fection. CT of the abdomen revealed an infrarenal AAA. The
patient underwent ligation and excision of the AAA with right
by guest on May 15, 2011
198 • CID 2005:40 (1 January) • BRIEF REPORT
drainage of abscess and reinforcement with muscular flap or
omentum can be performed, with the administration of a sec-
ond course of intravenous antibiotic therapy. If there is anas-
tomotic dehiscence, treatment options include a second pros-
thetic replacement or direct suture reinforcement followed by
placement of a muscular flap. Another alternative is extra-an-
atomical bypass and resection of the prosthesis with suturing
of the arterial stumps. However, this procedure still involves
the risk of recurrent prosthetic infection and/or aortic stump
Mycotic aortic aneurysm due to melioidosis remains a dif-
ficult disease to manage. Morbidity and mortality are high de-
agement. We propose that, in areas of endemicity, the diagnosis
of melioidosis should always be considered for persons with
appropriate risk factors who present with a mycotic aneurysm,
so that suitable antibiotic therapy can be initiated as early as
possible before surgical intervention. A course of intravenous
ceftazidime with a minimum duration of 4–6 weeks should be
considered, and maintenance therapy should include a regimen
of ?2 drugs, to reduce the risk of relapse.
We would like to thank C. N. Lee, K. H. Chia, B. H. Tan, and A. Kurup
for their contribution to this article.
Potential conflicts of interest.
All authors: no conflicts.
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