Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature

Abstract

Background Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates.Case presentationA 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death.ConclusionsIn this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy.A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases.Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy).We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

Clostridium septicum aortitis: A kiss of the devil

“…It is postulated that the organism grows in the hypoxic necrotic milieu of the tumor and induces necrosis via α‐toxin, thereby leading to mucosal ulceration and hematogenous spread . Hematogenous seeding of the aorta specifically leads to the development of mycotic aneurysm within a week, which is always lethal in the absence of surgical intervention . The 6‐month mortality rate among the patients who underwent surgical intervention ranged between 44% with in situ grafts vs 66.7% with axillobifemoral bypass .…”

“…Hematogenous seeding of the aorta specifically leads to the development of mycotic aneurysm within a week, which is always lethal in the absence of surgical intervention . The 6‐month mortality rate among the patients who underwent surgical intervention ranged between 44% with in situ grafts vs 66.7% with axillobifemoral bypass . This difference in outcome is related to the complications frequently seen with extra‐anatomic revascularization of infected aortic aneurysms (as seen in axillobifemoral bypass), aortic stump blowout (20%), lower limb amputation due to bypass failure (20%‐29%), and reinfection (20%) .…”

“…This difference in outcome is related to the complications frequently seen with extra‐anatomic revascularization of infected aortic aneurysms (as seen in axillobifemoral bypass), aortic stump blowout (20%), lower limb amputation due to bypass failure (20%‐29%), and reinfection (20%) . Homografts are reported to be superior to prosthetic grafts in preventing further infection, especially if omental coverage is used …”

“…Other causes of aortitis include Escherichia coli, Kliebsella pneumoniae, Streptococcus sp., Candida sp., Aspergillus sp., and Listeria monocytogenes . The hallmark of aortitis due to C. septicum is the presence of periaortic gas as reported in 92.6% of cases . Presence of this feature should prompt immediate medical and surgical intervention as delays in diagnosis could be fatal.…”

Clostridium septicum-infected Stanford type A acute aortic dissection: a case report

“…There were several reports of C. septicum-infected aortitis, associated with high mortality up to 80% [4][5][6]. According to them, the sites of aortitis included ascending/ arch (n = 15), descending (n = 6), thoracoabdominal (n = 6), and abdominal (n = 20).…”