Submitted by Dr LAU Chun Wing Arthur on 23 Feb 2009
Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
| {morfeo 14} |
Known diabetes mellitus for 3 years on diamicron and metformin, hyperlipidaemia, history of acute inferior myocardial infarction (coro: LAD 80% occlusion), chronic hepatitis B carrier
c/o chest discomfort, fever, night sweats
CXR: cardiomegaly, enlarged aortic knuckle, trachea deveiated to R side
Transferred to ICU for respiratory distress.
CT thorax was done. What is the diagnosis?
Click here for the answer.
URGENT CONTRAST CT THORAX, ABDOMEN AND PELVIS (DEDICATED TO AORTA) FINDINGS: A lobulated extra-luminal collection of contrast measuring 46.6×65.1×58.2mm (TSxAPxLS) with a crescentic hyperdensity around the collection is seen arising from the anterolateral wall of the aortic arch, just distal to the origin of left subclavian artery. Perilesional hypodense fluid is also seen. No periaortic gas collection is seen. No intimal flap is noted. Mildly increase in fat stranding in the soft tissue anterior to the aortic arch is seen. No abnormal dilatation of the ascending aorta, descending aorta and abdominal aorta is seen. Major branches of aorta are patent. Shotty to enlarged mediastinal lymph nodes are seen. Hyperdense surgical materials in the heart are noted, compatible with prior cardiac procedures. Pericardial effusion with maximal thickness measuring up to 19mm is seen. Consolidation-collapse is seen over both lower lobes the left lingular lobe. Ground glass opacity and consolidation is seen in the right upper lobe. Pleural effusion over both sides is seen. No definite haemothorax is seen. An endotracheal tube in-situ with its tip 4.8cm above the carina is seen. Sclerosis around the left sacroiliac joint is seen.
Blood culture grew Salmonella group D (sensitive to ampicillin, ceftriaxone, chloramphenicol, ciprofloxacin, co-trimoxazole)
Answer: Salmonella Group D aortitis
Discussion
Most patients with Salmonella aortitis have pre-existing atherosclerotic disease at the site of the subsequently aneurysm. Diabetes mellitus is a risk factor, and the ischaemic heart disease in our patient is also a marker of some underlying atherosclerotic condition. Most frequent sites of involvment are infra-renal portion of abdominal aorta and thoracic aorta.
Treatment:
1. Resection of the infected aorta with wide debridement with in situ grafting or extra-anatomic bypass grafting
2. High dose antibacterial therapy for at least 6 weeks after operation
3. Life-long suppressive therapy with a bactericidal antibiotic
(suggested treatment only, recommendation not based on large controlled trials)
References
Other case reports of Salmonella aortitis: