A rare condition in adults, mycotic aneurysm of the thoracic aorta is even rarer in children and adolescents.1 Diagnosing the condition is often difficult, which leads to delayed surgeries and high mortality rates.2,3 We report a case of mycotic aortic aneurysm secondary to community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) in a previously healthy adolescent boy. Case ReportIn September 2013, a 15-year-old boy presented at the emergency department of his local hospital with a 4-day history of intermittent sharp pain in his upper-left chest that radiated to his back. He also reported a 2-to 3-week history of general malaise without fever. The patient's medical history included the repair of an anterior cruciate ligament tear in his right knee, made necessary after a sports injury at 13 years of age. Results of the patient's physical examination, chest radiograph, and electrocardiogram were normal. A diagnosis of musculoskeletal chest pain was made, and the patient was discharged with instructions to take ibuprofen for pain as needed. The ibuprofen only partially relieved his chest pain, so he returned to the emergency department the next day and was discharged with the same diagnosis. On the 3rd day, he returned with chest pain, a fever (temperature, 102 °F), nausea, vomiting, and worsening fatigue. He also had oral lesions suspicious for herpes labialis. His white blood cell count was 8,800/µL, with 84 polymorphs and 4 bands of neutrophils. Blood and urine samples were obtained.The patient was admitted to the hospital with the diagnosis of presumed sepsis. Vancomycin, ceftriaxone, and acyclovir were started. The chest radiograph showed normal results (Fig. 1A). The next day, the patient continued to have intermittent fever and developed nontender erythematous macules resembling Janeway lesions on his left palm. Infective endocarditis was suspected. A transthoracic echocardiogram (TTE) showed a structurally normal heart with normal left ventricular systolic function. This initial echocardiogram also showed normal dimensions of the aortic arch and proximal descending thoracic aorta. Blood cultures were positive for MRSA. On the 4th day of hospitalization, a chest radiograph showed widening of the superior mediastinum (Fig. 1B), and a computed tomographic angiogram (CTA) of the chest revealed a 4-cm saccular aneurysm involving the distal transverse aortic arch, proximal descending thoracic aorta, and proximal left subclavian artery (Fig. 2). A para-aortic arch abscess was also noted.
Atrial septal hematoma (ASH) has been reported mostly in adult patients to occur after spontaneous ascending aortic dissection (Circulation 46(3):537-545, 1972) and after surgery for coronary artery (Anesthesiology 83(3):620-621, 1995), mitral valve, and aortic valve (Rev Esp Cardiol 55(8):867-871, 2002). ASH in the pediatric age group is rare, and to our knowledge only two cases have been published (Am J Perinatol 27(6):481-483, 2010; J Am Soc Echocardiogr 1087-1089, 1998). We report a case of ASH diagnosed by intraoperative transesophageal echocardiography in a 28-month-old child who underwent mitral valvuloplasty and left main coronary arterioplasty for anomalous origin of the left coronary artery from pulmonary artery. ASH subsided on its own within 24 h.
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