Case Presentation:

A 78–year–old man presented with a 3–week history of suprapubic post–prandial abdominal pain, fevers, and anorexia. Two weeks prior he was admitted for acute mental status changes, fatigue, and anorexia, with diagnosis of transient ischemic attack and urinary tract infection. He was discharged on hospital day 3 and completed a five–day course of ciprofloxacin. Urine cultures showed no growth. Anorexia and malaise recurred prompting his return. History was remarkable for coronary artery disease, hypertension, and prostate cancer. On admission the patient was afebrile, hemodynamically stable, and with an unremarkable physical exam. Laboratory values included a leukocyte count of 12,600 cells/mL, ESR of 82 mm/hr, CRP of 134 mg/L, and urinalysis with 10 white blood cells but many squamous epithelial cells. A contrast–CT scan of the abdomen and pelvis revealed soft tissue thickening of the aorta just below the level of the renal arteries with mural thrombus, consistent with aortitis. The patient was admitted to the medical service with surgical consultation. Within 24 hours, admission blood cultures resulted preliminarily positive for gram–negative rods. Urine culture was negative. Broad–spectrum antibiotics were started for presumed infectious aortitis. The patient elected surgical intervention. He first underwent an axillobifemoral bypass with an 8 mm polytetrafluoroethylene graft. The aorta was then transected from below the superior mesenteric artery to above the renal arteries, and the surrounding tissue was debrided and resected (see figure 1). Histological examination showed areas of acute and chronic inflammation with diffuse reactive stromal cell atypia and atherosclerosis. The aortic tissue grew Escherichia coli, as did his pre–operative blood cultures. The patient recovered and was later discharged home to complete 6 weeks of ceftriaxone.

Discussion:

Infectious aortitis is exceedingly rare, with a highly variable and non–specific presentation ranging from asymptomatic to fever, back or abdominal pain, anorexia, leukocytosis, bacteremia, and death. It typically afflicts men greater than 50 years of age with atherosclerosis. The natural course, after bacterial seeding of the vaso vasorum, includes weakening of the aortic wall by bacterial enzymes and inflammatory infiltration. This invasion can rapidly lead to aneurismal dilatation and rupture, more frequently caused by gram–negatives. Salmonella is found in up to a third of cases, but Streptococcus pneumonia, Staphylococcus, and rarely E. coli are also encountered. Mortality ranges from 21 to 44% but is even higher in cases treated with appropriate antibiotics alone; timely surgical resection is the standard of care.

Conclusions:

Diagnosis of infectious aortitis requires a high index of suspicion. Early treatment with appropriate antibiotics and surgical resection can improve outcomes in these patients.

Figure 1Resected aorta.