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LETTER TO EDITOR
Year : 2021  |  Volume : 38  |  Issue : 2  |  Page : 201-202  

Pseudomonas-associated mycotic pulmonary artery aneurysm with endovascular management


1 Department of Respiratory Medicine, INHS Asvini, Mumbai, Maharashtra, India
2 Department of Radiology, INHS Asvini, Mumbai, Maharashtra, India

Date of Submission24-Nov-2020
Date of Acceptance04-Jan-2021
Date of Web Publication02-Mar-2021

Correspondence Address:
Manjit Sharad Tendolkar
Department of Respiratory Medicine, INHS Asvini, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_906_20

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How to cite this article:
Tyagi R, Tendolkar MS, Sivasankar R. Pseudomonas-associated mycotic pulmonary artery aneurysm with endovascular management. Lung India 2021;38:201-2

How to cite this URL:
Tyagi R, Tendolkar MS, Sivasankar R. Pseudomonas-associated mycotic pulmonary artery aneurysm with endovascular management. Lung India [serial online] 2021 [cited 2021 Apr 16];38:201-2. Available from: https://www.lungindia.com/text.asp?2021/38/2/201/310563



Sir,

We report case of a 60-year-old male, diabetic, who presented to the outpatient department with complains of cough with purulent expectoration, fever, and right-sided pleuritic chest pain for 2 weeks. His symptoms were progressive. There was no history of significant weight loss or hemoptysis. On examination, he was febrile (100.4° Fahrenheit), had tachycardia (pulse rate of 120/min) and was tachypneic (respiratory rate of 28/min). On auscultation, bronchial breath sounds were noted over the right infrascapular and infraaxillary areas. The other systems examination was unremarkable. On the basis of clinical examination, a provisional diagnosis of the right lung pneumonia was suspected and the patient underwent a chest radiography, hemogram, and serum biochemistry for liver and renal functions. Chest X-ray documented a non-homogeneous opacity with an air bronchogram in the right lower zone. His total leukocyte count was raised (15,000 cells/mm3). Serum biochemistry for liver and renal functions was normal. His arterial blood gas was suggestive of a Type I respiratory failure with mild hypoxemia (PaO2/FiO2 = 290). Blood sugar was deranged (HbA1c of 8.2 gm/dl). Serum procalcitonin was raised. His blood and sputum investigations were sent for bacterial cultures. Sputum was also tested for mycobacterial infections with a cartridge-based nucleic acid amplification test (CBNAAT) and liquid culture with mycobacterial growth indicator tube. The patient was managed with empirical broad-spectrum antibiotics and an atypical microorganism cover (injection ceftazidime 1 gm intravenous (IV) 8 hourly + injection azithromycin 500 mg IV 24 hourly) while the microbiological investigations were awaited. Insulin regimen was optimized to control his blood sugar. Over the next 48 h, his symptoms continued to progress and he started developing hemoptysis (30–50 ml/day). Sputum bacterial culture grew pseudomonas aeruginosa which was resistant to ceftazidime but sensitive to carbapenems. Sputum CBNAAT and acid-fast bacilli smear was negative. Blood culture had no growth. His antibiotics were modified as per sensitivity (injection Meropenem 1 gm IV 8 hourly). In view of new onset of hemoptysis patient underwent contrast-enhanced computed tomography (CECT) of chest to localize the site of bleeding and plan an intervention if symptoms continued to progress. CECT chest revealed consolidation with a cavitary lesion in the right lower lobe surrounding a large fusiform aneurysm of the descending branch of right pulmonary artery [Figure 1]a and [Figure 1]b. The patient had no clinical features of connective tissue disorder in the form of joint pain, rash, photosensitivity, dryness of eyes or mouth, and nasal septal deformity. Anti-nuclear antibodies (ANAs) and anti-neutrophil cytoplasmic antibodies (ANCA) were negative. Urine examination did not have proteinuria or red blood cells. The patient underwent a bronchoscopy to confirm microbiological diagnosis and rule out coexisting tuberculosis which is endemic in the country. Broncho alveolar lavage from right lower lobe grew pseudomonas aeruginosa on bacterial culture while mycobacterial culture and CBNAAT were negative. Over the next 4 days, his fever subsided and total leukocyte count was within normal limits. Serum procalcitonin was on a declining trend. However, have 30–50 ml hemoptysis per day. There was no hemodynamic instability. In view of pulmonary artery aneurysm and persistent hemoptysis, the patient underwent endovascular management. A 6 French (F) right common femoral vein access was taken and pulmonary angiogram performed using a 5 F pigtail catheter. Angiogram revealed a large fusiform aneurysm involving the descending branch of the right pulmonary artery [Figure 1]c with the involvement of multiple segmental arteries. 5 F catheters (C1, Slip Cath, Cook) was navigated over an 0.035” hydrophilic wire (Terumo) into the main pulmonary artery. Multiple pushable coils were used to occlude 03 aneurysmally dilated segmental arteries. Thereafter, a 2.1 F microcatheter was passed into the descending aneurysm and multiple guglielmi detachable coils placed in the aneurysm till proximal artery. Subsequent runs showed occlusion of aneurysm [Figure 1]d. Post procedure, patient's hemoptysis had subsided. He was managed with sensitive antibiotics for 14 days while he became asymptomatic and had shown significant clinicoradiological improvement. Sputum bacterial culture had no growth at the time of discharge. The patient has been asymptomatic for 3 months and he continues to have a regular outpatient department follow-up.
Figure 1: (a) Sagittal reconstruction of CECT chest showing right lower lobe consolidation with a cavity surrounding an aneurysm (arrow) of the descending pulmonary artery. (b) CECT chest showing right lower lobe consolidation with a cavity surrounding an aneurysm (arrow) of the descending pulmonary artery. (c) Right lower lobe segmental angiogram shows aneurysmally dilated artery. (d) Post coiling angiogram shows exclusion of the aneurysmal segment of the pulmonary artery from circulation. CECT: Contrast-enhanced computed tomography

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Mycotic aneurysms are commonly reported in intracranial arteries, followed by visceral and upper or lower extremity arteries.[1] Pseudomonas has been implicated in two cases of abdominal aortic mycotic aneurysm.[2],[3] This is the first reported case of pseudomonas causing Mycotic Pulmonary Artery Aneurysm (MPAA) and has been successfully managed with sensitive antibiotics and endovascular coiling. Thus, highlighting the importance timely diagnosis and appropriate therapeutic intervention in the management of mycotic pulmonary artery aneurysm.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435-86.  Back to cited text no. 1
    
2.
Dick J, Tiwari A, Menon J, Hamilton G. Abdominal aortic aneurysm secondary to infection with Pseudomonas aeruginosa: A rare cause of mycotic aneurysm. Ann Vasc Surg 2010;24:692.e1-692.e4.  Back to cited text no. 2
    
3.
Mazzalai F, Ragazzi R, Iurilli V, Toniato A, Da Giau G, Ballotta E. Pseudomonas aeruginosa-infected infrarenal abdominal aorta pseudoaneurysm secondary to laparoscopic colorectal surgery: Failure of endovascular stent graft treatment after primary open repair failed. Can J Surg 2009;52:E193-4.  Back to cited text no. 3
    


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