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Letters to the Editor |
Aristotle University Medical School, AHEPA University Hospital, Department of Thoracic and Cardiovascular Surgery, Thessaloniki, Greece
Received 12 May 2009; accepted 3 June 2009.
* Corresponding author. Address: Department of Thoracic and Cardiovascular Surgery, AHEPA University Hospital, 1 Stilponos Kiriakidi Street, Thessaloniki 54636, Greece. Tel.: +30 2310 994868; fax: +30 2310 994871. (Email: chrarokoposnick{at}hotmail.com).
Key Words: Infective endocarditis • Intra-abdominal bleeding • Mycotic aneurysm • Septic emboli • Splenic artery aneurysm
We appreciate and read with great interest the article by Winearls et al. reporting a rare case where the diagnosis of Enterococcus faecalis endocarditis was established after intra-abdominal bleeding due to rupture of the spleen [1].
We recently experienced a case of a sudden, fatal, massive intra-abdominal bleeding from splenic artery rupture due to a mycotic aneurysm. A 52-year-old man presented with high-grade fever and malaise. Clinical examination revealed a generalised abdominal tenderness and a long systolic cardiac murmur. A trans-thoracic echocardiogram confirmed severe mitral valve regurgitation with vegetation on the posterior mitral valve leaflet (1.3 cm x 1.1 cm). Blood cultures on admission were positive for Staphylococcus aureus, and therefore intravenous antibiotic treatment was commenced. An abdominal computed tomography (CT) scan revealed multiple, small, acute infarcts in the liver and spleen, consistent with septic emboli, as well as an intramural haematoma in the stomach. At the same time, the patient became unstable and inotropic support was needed. Thus the decision for an emergency operation was made, and an urgent mitral valve replacement was performed using a 31-mm Carbomedics (SORIN BIOMEDICA CARDIO S.r.l., Sallugia, Italy) mechanical valve. Following surgery, the patient recovered and was discharged from the intensive care unit on the third postoperative day. He became mobile on the fourth postoperative day, and no abdominal complaints were noted. The treatment plan was to have the patient complete a full course of intravenous antibiotic treatment specific for infective endocarditis complicated by visceral septic embolisation.
On postoperative day 13, the patient suddenly collapsed. Resuscitation efforts proved unsuccessful for more than 20 min. Significant abdominal distension was noted during resuscitation. As a desperate effort, the patient was taken to the operating room and an emergency laparotomy was performed, which revealed massive intra-abdominal bleeding with the presence of 4 l of fresh blood and rupture of a splenic artery mycotic aneurysm. Unfortunately, the patient died in the operating room despite resuscitative efforts.
Special attention should be paid to patients with infective endocarditis and multiple emboli following surgical treatment of the endocarditis. The postoperative period can be complicated by the consequences of septic embolisation, one of which could be infective aneurysm formation. The peripheral vessels affected by septic emboli can develop aneurysmal changes; the natural history of which is rapid growth and rupture, if not excised [3]. Of the six cases of infected splenic artery aneurysm that are reviewed in the literature, rupture had occurred in three [2]. Visceral emboli should be carefully monitored during the postoperative period until the patient's complete recovery and healing of any embolic foci. The risk of extracranial mycotic aneurysm formation, despite its reported low incidence, should be considered as it requires early recognition and prompt treatment [3].
References
This article has been cited by other articles:
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  J. R. Winearls, J. C. Lee, and J. F. Fraser Reply to Charokopos et al. Eur. J. Cardiothorac. Surg., October 1, 2009; 36(4): 784 - 785. [Full Text] [PDF]
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