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False iliac artery aneurysms on a psoas abscess revealing tuberculosis disease: About a case report and review of the literature

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Introduction and importance Tuberculosis is re-emerging globally, including in Morocco. Common iliac artery aneurysms induced by tuberculosis are very rare and severe due to the risk of infection and hemorrhage, making treatment choice crucial. Only a few cases have been reported in the literature. Case presentation In this article, we report a new case involving a 54-year-old man admitted to the emergency department of the university hospital for skin necrosis in the groin area with a pulsating mass in front and altered general condition, associated with night fevers that led to a chest X-ray revealing miliary tuberculosis. An emergency CT angiography showed a false aneurysm of the left common iliac artery, measuring 55 mm in diameter. The patient underwent resection of the friable portion of the iliac artery and restoration of arterial continuity through an end-to-end arterial anastomosis. Histological analysis of the surgical samples confirmed the tuberculous origin of the false aneurysm. The patient was placed on anti-tuberculous treatment, and the postoperative course was uneventful. After 6 months, the patient was asymptomatic, and the iliac axis was patent on the follow-up CT angiography. Clinical discussion Mycotic aneurysms are rarely reported, including in the carotid, iliac, femoral, and popliteal arteries. Contamination of the artery by the tuberculous mycobacterium results either from direct extension of the infection through contact with an adjacent focus or from hematogenous dissemination. Based on published cases, the evolution after appropriate medical and surgical treatment is generally favorable; however, the choice of therapy and the approach to restoring arterial continuity—vein versus prosthesis—are not well represented in the literature and depend on clinical and radiological contexts. The mortality rate remains high, with reported causes of death including aneurysmal rupture and septicemia. Conclusion The combination of anti-bacillary treatments and antibiotics, along with either open or endovascular surgery, represents the optimal therapeutic choice to ensure good outcomes and effective disease control.
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Case report
False iliac artery aneurysms on a psoas abscess revealing tuberculosis
disease: About a case report and review of the literature
Asma Jdar
*
, Mehdi Lekehal, Ayoub Bounssir, Tarik Bakkali, Brahim Lekehal
Mohammed V University in Rabat, Rabat, Morocco
Vascular Surgery Department, Ibn Sina University Hospital Centre, Rabat 10104, Morocco
SUMMARY
Introduction and importance: Tuberculosis is re-emerging globally, including in Morocco. Common iliac artery aneurysms induced by tuberculosis are very rare and
severe due to the risk of infection and hemorrhage, making treatment choice crucial. Only a few cases have been reported in the literature.
Case presentation: In this article, we report a new case involving a 54-year-old man admitted to the emergency department of the university hospital for skin necrosis
in the groin area with a pulsating mass in front and altered general condition, associated with night fevers that led to a chest X-ray revealing miliary tuberculosis. An
emergency CT angiography showed a false aneurysm of the left common iliac artery, measuring 55 mm in diameter. The patient underwent resection of the friable
portion of the iliac artery and restoration of arterial continuity through an end-to-end arterial anastomosis. Histological analysis of the surgical samples conrmed the
tuberculous origin of the false aneurysm. The patient was placed on anti-tuberculous treatment, and the postoperative course was uneventful. After 6 months, the
patient was asymptomatic, and the iliac axis was patent on the follow-up CT angiography.
Clinical discussion: Mycotic aneurysms are rarely reported, including in the carotid, iliac, femoral, and popliteal arteries. Contamination of the artery by the
tuberculous mycobacterium results either from direct extension of the infection through contact with an adjacent focus or from hematogenous dissemination. Based
on published cases, the evolution after appropriate medical and surgical treatment is generally favorable; however, the choice of therapy and the approach to
restoring arterial continuityvein versus prosthesisare not well represented in the literature and depend on clinical and radiological contexts. The mortality rate
remains high, with reported causes of death including aneurysmal rupture and septicemia.
Conclusion: The combination of anti-bacillary treatments and antibiotics, along with either open or endovascular surgery, represents the optimal therapeutic choice to
ensure good outcomes and effective disease control.
1. Introduction
Tuberculosis is experiencing a signicant resurgence worldwide,
despite the efforts made.
Iliac aneurysms and false aneurysms represent 12.8 % to 18 % of all
intra-abdominal aneurysms [1,2]. They are generally secondary to
atherosclerosis and mainly affect the common iliac artery [2,3]. Mycotic
iliac aneurysms are quite rare (315 %), especially those linked to
tuberculous arteritis. The association of miliary tuberculosis and
tuberculous mycotic false aneurysm is even rarer. Iliac aneurysms are
often asymptomatic (55 %) and can be revealed by rupture in more than
36 % of patients. This is a rst case in the literature describing a false
iliac aneurysm complicated by extensive skin necrosis. In the absence of
appropriate treatment, they pose a risk to life due to the danger of
rupture and sepsis. Currently, surgery coupled with appropriate anti-
biotic therapy represents a reliable treatment to achieve satisfactory
results [25]. In this article, we describe the case of a massive tuber-
culous aneurysm of the left common iliac artery complicated by skin
necrosis adjacent to the abdominal mass, which presents a challenge for
restoring arterial continuity as well as for skin closure in an infected
environment.
2. Case report
Our patient, a 54-year-old man with no notable medical history,
presented to the emergency department with skin necrosis adjacent to a
mass in the left iliac fossa (Fig. 1), associated with abdominal pain and a
recent deterioration in his general condition (GGC), with a weight loss of
over 15 kg in the last two months.
The history of the disease dates back more than 4 months, with the
onset of GGC and signicant weight loss accompanied by abdominal
pain and lumbar pain radiating to the left lower limb, without any his-
tory of trauma or previous surgery.
Upon admission to the emergency department, his systolic blood
pressure was 90 mmHg, with a mean arterial pressure greater than 65
mmHg, tachycardia at 130 beats per minute, and a respiratory rate of 30
* Corresponding author at: Vascular Surgery Departement, Centre Hospitalier Universitaire IBN SINA, Rabat 10104, Morocco.
E-mail address: jdarasma8@gmail.com (A. Jdar).
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports
journal homepage: www.elsevier.com/locate/ijscr
https://doi.org/10.1016/j.ijscr.2024.110380
Received 6 September 2024; Received in revised form 24 September 2024; Accepted 28 September 2024
International Journal of Surgery Case Reports 124 (2024) 110380
Available online 30 September 2024
2210-2612/© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited. This is an open access article under the CC BY-NC-ND license
( http://creativecommons.org/licenses/by-nc-nd/4.0/ ).
cycles per minute; the patient was febrile with a temperature of 38.8 C.
On examination: The abdomen was tender and painful, with a large
pulsatile mass present and skin compromise in the left iliac fossa. The
distal pulses were present and symmetrical. Blood tests showed hemo-
globin at 10 g/dL, white blood cells at 13.5 g/L, platelets at 231 g/L, and
a CRP of 180 mg/L. An angiogram of the aorta and lower limbs was
performed (Figs. 2, 3), revealing a contained hematoma suggesting a
ruptured and occluded giant false aneurysm in the retroperitoneal space
of the left common iliac artery, displacing both the internal and external
iliac arteries, measuring approximately 55 mm in the long axis, with an
abscess collection along the psoas muscle.
In the preoperative phase, given the nocturnal fever and GGC, an
inammatory assessment was conducted, which returned positive, as
did the sputum cultures for mycobacteria tuberculosis. A chest X-ray
revealed numerous diffuse micronodules with regular contours, sug-
gesting miliary tuberculosis. At the same time, serologies were requested
in the context of investigating other infectious etiologies or potential
immunodeciency. Antituberculosis treatment was initiated by the
pulmonologists.
The patient was placed on intravenous ceftriaxone (1 g every 12 h)
and ciprooxacin (500 mg every 12 h). In the operating room, after
dissection and control of the left common iliac artery (CIA), the external
and internal iliac arteries (EIA and IIA), the sac of the false aneurysm
was punctured and drained, and samples were sent for pathological and
bacteriological study (Figs. 4, 5). Subsequently, extensive debridement
and irrigation with saline solution and Betadine were performed,
followed by resection of the damaged arterial wall at the site of the
defect located at the level of the iliac bifurcation (Fig. 6). The decision
was made to restore continuity of the iliac arterial axis by an end-to-end
anastomosis between the left CIA and EIA, with ligation of the internal
iliac artery (IIA) (Fig. 7).
The postoperative course was uneventful, with daily dressing
changes to monitor the healing of the surgical approach and the evo-
lution of the scar. The patient was discharged on the 20th postoperative
day with a nine-month course of antituberculosis treatment and a daily
dose of antiplatelet agents at 75 mg. Histological examination showed
areas of caseous necrosis and aggregates of epithelioid histiocytes
compatible with a diagnosis of tuberculosis. One month after the oper-
ation, the patient was asymptomatic, with good patency of the iliac axis
conrmed by arterial Doppler.
3. Discussion
Osler rst described the term mycotic aneurysm in 1885 as a vege-
tation resembling a fungus at the orice of the aortic arch, but the mi-
croorganisms involved were generally bacterial rather than mycotic [6].
False mycotic aneurysms are easily recognizable by their typically
Fig. 1. skin necrosis opposite the beating mass in the left iliac fossa.
FALS E ANEUR YSM
Fig. 2. CT cross-section showing the false aneurysm of the primitive iliac arch.
Fig. 3. sagittal section on angioscan showing the false aneurysm of the left
iliac arch.
Fig. 4. Median laparotomy showing the enormous false aneurysm pushing back
the adjacent structures to the extent of the primitive iliac arch. The common
iliac artery placed on lake.
A. Jdar et al.
International Journal of Surgery Case Reports 124 (2024) 110380
2
saccular appearance. Tuberculous aneurysms are typical, but involve-
ment of the iliac arteries is very rare, with approximately 10 cases re-
ported in the literature [7,8].
False aneurysms of tuberculous origin mainly affect men (3 men for
every 1 woman), likely due to the association of infectious aortitis with
cardiovascular risk factors, which are more frequent in men [9,10].
Rarely reported locations include the carotid, iliac, femoral, and popli-
teal arteries. Contamination of the artery by mycobacteria occurs either
through direct extension of the infection by contact with an adjacent
focus [7,11]. or through hematogenous dissemination [8,1115]. Inoc-
ulation occurs via the vaso vasorum and lymphatic vessels, following
direct damage to all three tunics of the arterial wall or due to septic
emboli [8]. Additionally, aneurysms can develop contiguously following
BCG treatment for bladder cancer [16]. The discovery of an asymp-
tomatic aneurysm in the iliac artery is often incidental during abdominal
or pelvic imaging. The deep position of this artery makes clinical diag-
nosis difcult. Sometimes, the mode of presentation is atypical, with
misleading urinary, rectal, venous, or nerve symptoms, which may be
due to compression of neighboring organs or to gluteal claudication, but
is very rare in the presence of a necrotic skin swelling [8,12,17,18].
Iliac aneurysms are often asymptomatic (55 %), but they present a
high risk of rupture in the absence of appropriate treatment, and the risk
is increased with a mycotic origin [1,2,17]. Currently, surgery combined
with appropriate antibiotic therapy or antituberculous treatment ac-
cording to the etiology represents a reliable treatment for achieving
satisfactory results [4,5,7,17]. Surgical treatment of iliac artery aneu-
rysms is indicated for a diameter of 30 mm or greater [18]. Other in-
dications include symptomatic cases due to compression of adjacent
structures, rupture, and signs of ischemia. Rupture can be treated by
conventional or endovascular surgery. Surgical options include pros-
thetic replacement, interposition of arterial or venous allografts, as well
as restoration using an inverted autologous venous graft.
In this case, the greater saphenous vein, supercial femoral vein, or
cephalic vein may be used. If not available, some centers recommend the
use of cryopreserved allografts to reduce operative time and minimize
the risk of infection [4]. Restoring arterial continuity using an end-to-
end arterial anastomosis remains a good approach, although it is not
always viable and depends on the extent of the arterial lesion and offers
the advantage of avoiding the use of in situ grafts. In our case, the de-
cision was made following dissection and control of the iliac artery
upstream and downstream of the false aneurysm's origin, allowing for
the restoration of arterial axis through a terminal-to-terminal
anastomosis.
The advantage of conventional surgery over endovascular treatment
is the ability to safely evacuate the hematoma, abscess, and perform
extensive surgical cleaning through debridement and excision of infec-
ted tissue. The only downside was the difculty of dissection in the
presence of multiple inammatory adhesions around the infected site
[5].
In 2010, Bachmeyer et al. discovered a tuberculous false aneurysm of
the right common iliac artery in a 38-year-old man [15], successfully
treated by atting the false arterial aneurysm combined with ligation of
the common iliac artery and restoration of the iliac axis through an
aorto-iliac prosthetic bypass, along with anti-tuberculous therapy,
yielding a good result.
The possibility of endovascular treatment with iliac stents has been
proposed by some authors, but there is not enough experience to assess
its role in this type of aneurysm [17]. It is an evolving and tempting
technique, akin to prosthetic bypass in an infected environment, and it
can be dangerous if the infection is unknown and uncontrolled. Endo-
vascular surgery remains invasive and effective, but its success depends
on several conditions and clinical, paraclinical imaging, and technical
parameters [1,3,8,14].
Based on published cases, the outcome after surgical treatment
combined with abscess drainage and appropriate anti-tuberculous
therapy is generally favorable, but the mortality rate remains high.
Fig. 5. l The contents of the false aneurysm shell.
Fig. 6. residual cavity of the false aneurysm shell requiring debridement of
surrounding tissue. The common iliac artery is clamped.
Fig. 7. after arterial restoration by termino terminal anastomosis of the com-
mon iliac artery, and debridement of necrotic tissue.
A. Jdar et al.
International Journal of Surgery Case Reports 124 (2024) 110380
3
Reported causes of death have included aneurysmal rupture and septic
shock [1,1113].
4. Conclusion
Iliac aneurysms secondary to mycotic infections, specically tuber-
culous infections, are severe and very rare, putting the patient's life at
risk. Endovascular surgery is innovative and non-invasive, but there has
been little experience compared to conventional surgery in the treat-
ment of infectious and mycotic false aneurysms, especially with an
abscessed collection around it, where open surgery allows better control
of local infection and offers a variety of techniques for restoring arterial
continuity, such as end-to-end anastomosis for short arterial lesions,
using a prosthetic or venous graft, or through anatomical or extra-
anatomical bypass pathways.
The cornerstone of effective treatment for tuberculous false aneu-
rysms of the iliac arteries is conventional surgery combined with anti-
tuberculous therapy, to avoid various complications and ensure good
long-term control.
Ethical approval
The ethics approval is not required for case reports or case series
considered as long as they do not constitute research in our institution:
CHU IBN SINA RABAT.
Funding
None.
Author contribution
JDAR Asma: Conception, Methodology, software, Data curation,
Writing Original draft preparation.
LEKEHAL Mehdi: Data Collection.
BOUNSSIR Ayoub: Data curation, analysis.
BAKKALI Tarik: Critical revision, Approval of the manuscript.
LEKEHAL Brahim: Critical revision, Approval of the manuscript.
Guarantor
JDAR ASMA.
Research registration number
N/A.
Declaration of competing interest
The authors report no declarations of interest.
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