Kamphol Laohapensang

Vascular pythiosis in a thalassemic patient.

Pythium insidiosum is a fungus that causes disease in both animals and humans. Human pythiosis is an emerging disease in the tropical, subtropical, and temperate regions of the world, occurring in localized and systemic or vascular forms. Most patients with arterial pythiosis have an underlying hemoglobinopathy, such as thalassemia. A case is presented of a thalassemic horse stable worker who developed an ulcerative cutaneous lesion on the lower left leg followed by progressive ascending involvement of the arteries of that extremity with a necrotizing arteritis with aneurysm formation. P. insidiosum was not isolated from the ulcer by culture or wet potassium hydroxide preparations but was diagnosed by histopathologic study of a biopsy. P. insidiosum infection was quickly confirmed by immunoblot method, aiding in preoperative decision making. Many systemic antibiotics or antimycotics have not been effective in the treatment of systemic pythiosis, and radical surgical removal of all infected tissue is the only method to ensure patient survival. An orally administered saturated solution of potassium iodide, amphotericin B-oral solution, and terbinafine has succeeded only in the cutaneous form but had no favorable effect on vascular pythiosis. It is likely that immunotherapy, successfully used in animal pythiosis, may be beneficial in the treatment of human vascular pythiosis.

Management of the Infected Aortoiliac Aneurysms

PURPOSE We have reviewed ruptured and nonruptured infected aortoiliac aneurysms to study the clinical presentation, management and eventual outcome of patients managed with in situ prostheses, axillofemoral prostheses grafts and endovascular reconstruction. DESIGN A retrospective chart review of 16 cases treated at a single institution. METHODS From January 2007 to March 2008, a total of 93 patients with aortoiliac aneurysms underwent surgical repair at our institution. Among these, 16 patients (17.2%) were shown to be infected aneurysms of the infrarenal (n = 6), juxtarenal (n = 2), and pararenal aorta (n = 1); the others were 5 common, 1 external, and 1 internal iliac arteries. Fourteen patients were male and 2 were female with the mean age of 66 years (range, 45-79). In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered at least 1 week, unless in patients need emergency operations. At the time of an operation, all were saccular and were classified as primary infected aortoiliac aneurysms. Thirteen patients had surgical debridement with in situ graft interposition and omental wrapping, 2 underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass, 1 underwent aneurysmectomy of left external iliac artery and polytetrafluoroethylene (PTFE) graft interposition, and 1 underwent endovascular exclusion. The parenteral antibiotics were continued in the postoperative period for 4-6 weeks. Chronic renal disease was present in 37.5% (6/16), with diabetes mellitus present in 31.25% (5/16). The most common pathogen was Salmonella sp. (n = 6) and E. coli (n = 5). Thirty-seven percent (6/16) of the patients presented late, with a 37.5% (6/16) incidence of ruptured (4 contained, 2 free ruptured) that needed emergency surgery. RESULTS Disease-specific mortality was 31.25% (5/16). The 30-day mortality rate of ruptured cases is high 67% (4/6), because patients present late in the course of the disease. One patient who underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass died 6 months later from burst aortic stump. Salmonella and E. coli are the most common pathogens. CONCLUSIONS Early diagnosis followed by surgical intervention with proper antibiotic coverage provides the best results. Mortality rate was still high in patients with sepsis and rupture. An in situ graft interposition and omental wrapping is a safe option for revascularization of infected aneurysms of the iliac arteries and infrarenal aorta.

Decrease in the incidence of Buerger's disease recurrence in northern Thailand.

PurposeBuergers disease is a peripheral arterial occlusive disease (PAOD), which occurs mainly in young male smokers. It is common in Asia, the Middle East, and Eastern European countries, but rare in North America and Western European countries. We investigated the changes in the prevalence and recurrence of Buergers disease at a referral hospital in northern Thailand.MethodsWe conducted a retrospective study of patients with Buergers disease admitted to Chiang Mai University Hospital between January 1988 and December 2002. Buergers disease was diagnosed according to Shionoyas clinical criteria.ResultsWe evaluated 78 patients with Buergers disease, with a collective total of 108 admissions. Forty-one patients were admitted for initial treatment, and 37 patients had a history of treatment and were admitted for worsening of Buergers disease. Between 1988 and 1995, 23 patients were admitted with newly diagnosed Buergers disease, 52 were admitted because of Buergers disease exacerbation, and 372 were admitted for a PAOD; whereas between 1996 and 2002, the respective numbers were 18, 15, and 632 (2.9 ± 1.9/year vs 2.6 ± 1.3/year, P = 0.25; 6.5 ± 1.1/year vs 2.1 ± 1.1/year, P = 0.001; 54.1 ± 6.7/year vs 81.6 ± 5.2/year, P < 0.0001). Of the 78 patients with Buergers disease, 76 were men and 2 were women, with a mean age at onset of 34.1 ± 5 years. The predominant symptom on admission was burning pain in the feet and hands in 75%, digital gangrene in 74%, and a digital ulcer in 43.5%.ConclusionsThe incidence of recurrence of Buergers disease seems to be decreasing in our institution, whereas the incidence of this disease and its recurrence both seem to be decreasing in Western countries and Japan.

Mycotic Abdominal Aortic Aneurysm Due to Streptococcus Suis: A Case Report

BACKGROUND Streptococcus suis is a common infection of pigs. Human infection is often related to accidental inoculation through skin injuries during occupational exposure to pigs and pork. The disease may present as meningitis, bacteremia, and less commonly endocarditis, arthritis, or bronchopneumonia. METHODS Case report and review of the literature. RESULTS We report a case of bacteremia and severe sepsis caused by S. suis serotype 2 complicated by septic arthritis in a 56-year-old male with history of a prior contact with unprocessed pork. The causative agent was isolated from blood cultures and aspirated synovial fluid. The patients condition improved after treatment with penicillin, but he was found subsequently to have an abdominal aortic aneurysm, confirmed by computed tomography (CT) scan. The mycotic aneurysm was successfully repaired using an in situ graft reconstruction. Tissue samples analyzed using polymerase chain reaction identified S. suis serotype 2 as the causative organism. After completion of two weeks of parenteral antibiotics, an oral form of ciprofloxacin (0.25 g twice a day) was continued for one month. The patient was discharged from our institution after uncomplicated recovery. Clinical review, a CT scan, and inflammatory markers nine months after surgery revealed no evidence of infection. CONCLUSION This is the first report of mycotic aneurysm caused by S. suis, which may be an etiologic agent of mycotic aneurysms, especially when complicated by bacteremia in adults with a recent history of contact with pigs or unprocessed pork.

An Unusual Complication of EVAR, Spontaneous Rectus Sheath Hematoma: A Case Report.

OBJECTIVE To report a successful conservative management in a case of spontaneous rectus sheath hematoma (SRSH) after Endovascular Aneurysmal Repair (EVAR) of infrarenal Abdominal Aortic Aneurysm (AAA). CASE PRESENTATION An 84-year-old woman with a 6 cm in diameter infrarenal AAA underwent EVAR at our hospital. During the procedure, intravenous heparin was administered to keep the activated clotting time around 300 seconds. One hour after the procedure, the patient complained of pain on her right side abdomen. Physical examination revealed a tender mass in the right lower abdominal wall. Laboratory studies showed a fall in hemoglobin from 12.7 g/dl to 9.3 g/dl. Ultrasound (US) examination demonstrated an 8 × 5 cm hematoma within the right rectus muscle. Follow-up US examination revealed that the hematoma had enlarged and a computed tomography (CT) examination of the lower abdomen was performed. CT scan showed a smooth-shaped mass within the layers of the anterolateral abdominal wall leading to enlargement of the right rectus abdominis muscle without signs of active bleeding. A conservative management was considered. RESULT The clinical course was uneventful with a stable hemodynamic state. The patient was discharged 12 days later and was doing well at the 2 week follow-up. CONCLUSION Spontaneous rectus sheath hematoma is an unusual complication of a patient on anticoagulant therapy during EVAR. A prompt radiological investigation may prevent unnecessary surgical procedures in this unusual complication.

A pararenal abdominal aortic aneurysm with iliac arteries stenosis

A 67-year-old Thai woman had a periumbilical pulsatile mass and abdominal pain for 3 months. Ultrasound imaging of the abdomen revealed a 4.8-cm fusiform dilatation of the abdominal aorta just below the superior mesenteric artery. Her medical history was significant for active smoking and hypertension. On systemic review, she had no history of low back pain, claudication, or postprandial pain. The physical examination revealed decreased femoral pulses and abnormal ankle-brachial indices of 0.57 in the right lower limb and 0.54 in the left lower limb. Computed tomography angiography demonstrated an upper abdominal aortic aneurysm, 4.4 cm 5.0 cm in size, just below the celiac axis origin, with involvement of bilateral renal arteries (A). Calcification along the aortic wall with diffuse thick mural thrombus in the aneurysm was seen. The diameter of the patent lumen was w1.5 cm, and maximal thickness of the thrombus was w1.8 cm. Length of the distal abdominal aorta occlusion was w5.2 cm, from the lower part of the aneurysm just below the renal artery origin to 2.4 cm above the aortic bifurcation. Extensive calcification of the occluded aorta, bilateral common iliac arteries, and proximal external iliac arteries was noted (B/Cover and C). A volume-rendered image showed severe stenosis of the common iliac and external iliac arteries, with reconstitution of the bilateral common femoral arteries by bilateral deep circumflex arteries and inferior epigastric arteries via collateral pathway on bilateral abdominal walls that joined with the superior epigastric arteries and internal mammary arteries (D). Surgical repair of the aneurysm and aortoiliac occlusive lesions was offered but was declined by the patient. The patient consented to the publication of this report.

Aorto-enteric Fistula After Endovascular Abdominal Aortic Aneurysm Repair for Behcet's Disease Patient: A Case Report

Introduction A 42 year old male with Behcets disease (BD) had endovascular treatment of a symptomatic infrarenal abdominal aortic aneurysm (AAA). Thirteen months later he developed haematemesis and melaena. Methods Computed tomography (CT) and angiography showed an aorto-enteric fistula with migration and kinking of the stent graft. Explantation of the infected graft and axillobifemoral bypass, aneurysm sac debridement, and jejunal repair with omental interposition was performed on this severely contaminated patient. Discussion There are no reports of an aorto-enteric fistula secondary to endovascular repair in the literature and this case describes the potential consequences of endovascular repair of AAA in BD. The aorto-enteric fistula was associated with persistent inflammatory aortitis, stent graft kinking, and infection. Five cases of secondary aorto-enteric fistulas following open AAA repair in BD patients have been reported including this case resulting from endovascular repair.

Management of the infected aortic endograft

Although the incidence of abdominal and thoracic aortic endograft infection is infrequent, ranging between 0.2% and 5%, stent-graft infection carries significant morbidity and mortality and exemplifies a formidable therapeutic challenge. The treatment goal is to eradicate the infectious process by endograft explantation, regional tissue debridement, and arterial reconstruction by either an extra-anatomic or in situ grafting procedure using autologous vein, cryopreserved allograft, or antibiotic-soaked prosthetic grafts. Successful treatment should maintain normal arterial perfusion to the visceral arteries and lower extremities. Important treatment adjuncts included antibiotic therapy based on cultures, specific bacterial isolates, and coverage of the repair or aortic stump using an omental wrap. Nonoperative treatment in patients with severe comorbidities that preclude endograft explantation may be appropriate in the setting of low-grade biofilm infection. Percutaneous drainage of the perigraft abscess followed by continuous antibacterial irrigation of the cavity can be utilized, but is associated with a high clinical failure rate.