Campylobacter Fetus-Associated Infrarenal Abdominal Aortic Aneurysm

VASCULAR DISEASE MANAGEMENT 2023;20(2):E28-E35

Abstract

Infected abdominal aortic aneurysms are usually associated with poor outcomes. The management of this rare entity is demanding and requires a devoted joint multidisciplinary team. The aim of this article is to discuss diagnosis and management features of abdominal aortic aneurysms due to Campylobacter fetus bacteremia.

Introduction

It has been demonstrated that Campylobacter fetus bacteria has an affinity for vascular endothelium.¹ Although rare, different vascular pathologies related to C. fetus include thrombophlebitis,^2,3 endocarditis,^4,5 and mycotic aneurysms.^4-10 The aorta remains the main location of C. fetus-associated aneurysms. Given the increased risk of rupture in mycotic aneurysms, early diagnosis and rapid therapeutic management remain vital. Here, we report a case of abdominal aortic aneurysm (AAA) in a patient with C. fetus infection. Urgent surgical treatment was chosen following a large increase of the aneurysm diameter within 1 month of follow-up.

Case Report

A 61-year-old man with a history of cerebral stroke, hypertension, dyslipidemia, appendectomy, sinusitis, hiatal hernia, smoking, and alcohol abuse was admitted to the internal medicine department for investigation of a digestive disorder. Anamnesis revealed chronic intermittent abdominal pain associated with diarrhea and nausea. A loss of 12 kg over 6 months was reported. At his first admission, physical examination identified a thin, febrile patient (temperature: 39° C [102° F;] body mass index, 18.3 kg/m²) with a normal heart rate. The abdomen was slightly tender and painful at palpation without any other anomalies. Samples of blood, stool, and urine were obtained for culture. All of the cultures were negative except for the blood culture that grew C. fetus. Additional laboratory tests showed hemoglobin count, 14.2 g/dL; platelets, 242 G/L; leukocytes, 8 G/L; creatinine clearance, 98 mL/min; potassium, 3.9 mmol/L; calcium, 2.6 mg/dL; and albumin, 41.6 g/L. C-reactive protein (CRP) and natremia were abnormal at 174 mg/L and 127 mmol/L, respectively. A positron emission tomography scan showed esophagitis with an intense fixation at the stomach, and a fixation at the left colic angle as well. Fibroscopy and a thoraco-abdomino-pelvic computed tomography (CT) scan revealed no particularities. However, an infrarenal AAA was seen, measuring 42 mm x 33 mm (Figure 1).

Total colposcopy with resection of 3 polyps at the left colon showed tubular adenoma with low-grade dysplasia. Bronchoscopy with bronchoalveolar lavage as well as serology of human immunodeficiency virus, hepatitis B and C, Lyme disease, Epstein-Barr virus, prostate-specific antigen, and lactate dehydrogenase were negative. The patient was diagnosed with C. fetus colitis and was given IV amoxicillin clavulanate (1 g 3 times/day for 10 days). One month later, he was readmitted for recurrence of the same symptoms. This time, testing showed a patent biologic inflammatory syndrome (anemia, 9.4 g/dL; thrombocytosis, 1038 G/L; and CRP, 229 mg/L). An abdomino-pelvic CT scan identified left pyelocaliceal dilation without a detected obstacle and an empyema measured at 35 mm plus abscessed collections measuring at most 25 mm. The aortic aneurysm had increased in diameter, reaching 65 mm x 40 mm and 79 mm at its greatest axis (Figure 1). Ureterohydronephrosis of the left kidney was also identified. Findings on transthoracic echocardiogram were normal. A transesophageal echocardiogram ruled out endocarditis. Blood culture grew C. fetus, and urine and feces cultures were sterile. Ultimately, strong IV antibiotic therapy was immediately initiated based on a consult from infectious disease specialists (amoxicillin clavulanate 2 g/4 hours and gentamicin 180 mg/24 hours). Given the high risk of rupture, an urgent surgical repair of the AAA was considered, preceded by the placement of a double J stent to treat ureterohydronephrosis. Through a midline laparotomy, an excision of the mycotic aneurysm and establishment of vascular continuity using allograft bypass in the infrarenal aortic bilateral common iliac arteries were performed (Figure 2). Pre- and post-operative courses were uneventful except for a blood transfusion.

After 48 hours of surveillance in the intensive care unit, the patient was transferred to the internal medicine and infectious disease departments for management of undernutrition and close monitoring of antibiotic response. As cultures of all surgical specimens yielded C. fetus, the antibiotic regimen was continued for 6 weeks after surgery. Gentamycin was suspended after 2 weeks of treatment. The patient was discharged home on his 16th postoperative day. Findings of clinical and biological systemic inflammatory syndrome were completely regressed at the first follow-up (first month). The angio-CT scan showed no anomalies (Figure 3). The patient later benefited from removal of the double J stent.

Discussion

There are limited cases documenting aneurysms in patients with C. fetus.¹¹ The first case of AAA associated with C. fetus bacteremia was reported by Dolev in 1971.¹² Our review of the literature revealed that these aneurysms were seen in the abdominal aorta exclusively. However, different arteries may be involved as well (Table). Among the mechanisms implicated in mycotic aneurysms are septic emboli (endocarditis), local injury in cases of IV drug abuse, local extension of infection to the adjacent arteries, and bacteremia in the context of sepsis.¹³ These mechanisms can intertwine and result in a multifactorial disease.¹⁴ We assume that the reported case of aortic aneurysm was due to C. fetus bacteremia in a fragile predisposed patient. It was recorded that atherosclerosis appears to be a favoring factor for contamination of the arterial wall.¹⁵ Other prerequisite situations weakening the vessel have been identified, including advanced age, malignant diseases, immunosuppressive treatment, diabetes, and liver cirrhosis.^16-21C. fetus infections are seen in patients with iatrogenic risk, including infections due to endovascular manipulations or implanted medical devices.²¹

The patient in question had multiple risk factors that predisposed him to C. fetus bacteremia. He had numerous cardiovascular risk factors (dyslipidemia, hypertension, cerebral stroke, and chronic tobacco abuse) and probably an atheromatous aortic aneurysm that predated the bacteremia. We believe that C. fetus bacteremia had a tremendous impact on the rupture of atherosclerosis in the wall of the abdominal aorta, eventually causing a rapid enlargement of the aneurysm within 1 month.

M = male; F = female; FA = femoral artery; AA = abdominal aorta; As A = ascending aorta, PA =  popliteal artery; DFA = deep femoral artery; CA = carotid artery; IIA = internal iliac artery; SFA = superficial femoral artery; PA = popliteal aneurysm; ABF = axillobifemoral; ND = not described

It is important to emphasize that infected aneurysms correspond only to 2% to 3% of all aneurysms.^22,23 The fact that this pathology is rare makes its management challenging. The diagnosis of an infectious cause of AAA was highly suspected by aspects of the patient’s clinical course and confirmed by imaging and microbiological findings. Given the well-described association between AAA and endocarditis in patients with C. fetus bacteremia, it seems reasonable to perform cardiac workups.

C. fetus AAA management requires a multidisciplinary, medical-surgical team approach:

Medical component: It corresponds to early initiation of an adequate antibiotic regimen, antipyretics, and analgesics to relieve the patient’s symptoms.

Surgical component: Various surgical options of mycotic AAA were described. It is represented essentially by in situ reconstruction; using usually cryopreserved allografts, rarely autografts; or extra-anatomical revascularization bypass. Thanks to advances in antibiotics, resection of mycotic aneurysms and immediate revascularization using allografts was the method of choice adopted by many authors.^24-27 Extra-anatomic reconstruction, widely advocated in the 1970s,^28-32 seems to be a perfect feedback option in case of unavailability of the appropriate graft, immediate limb-threatening ischemia, or in cases of patients with instability.¹⁴

The management of mycotic peripheral arterial aneurysms and AAA has been revolutionized by the development of endovascular grafts. The arrival of these devices has had a tremendous impact on surgeons' decisions. Nowadays, a trend toward endovascular repair has been seen. According to a European study,³³ endovascular aneurysm repair can be a durable treatment option for mycotic aortic aneurysms. However, literature on this approach outcome is still scarce.^33-36 More studies comparing these therapeutic options are required.

Conclusions

C. fetus-associated AAA is a rare vascular disease but is an emergent condition associated with high mortality and morbidity. The therapeutic use of antibiotic irrigation and surgical management of the mycotic aneurysm have shown good outcomes. Results of the operation can be improved by prolonged monitoring. n

The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no financial relationships or conflicts of interest regarding the content herein.

Manuscript accepted December 19, 2022. 

Address for correspondence: Sara Mokhtari, MD, Universite Mohammed Premier Oujda, Oujda, Morocco. Email: saramokhtari1904@gmail.com

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