International Journal of Infectious Diseases 14S (2010) e381–e382
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Medical Imagery
Mycotic iliac aneurysm associated with Burkholderia pseudomallei
Figure 1. MRI–angiography showing a saccular aneurysm of the left common iliac artery.
A 60-year-old African man, without any significant medical history or immunodeficiency, was admitted to the hospital with a one-week history of fever, jaundice, and abdominal pain. On admission, he was febrile (temperature 40 8C) and tachypneic. Physical examination revealed crepitant rales in the lung bases, abdominal sensibility, with a maximum of pain, and a vascular souffle in the left flank quadrant. Laboratory studies showed a white blood cell count of 23.6 109 cells/l, increased C-reactive protein (190 mg/l), and cholestasis with hyperbilirubinemia (114 mmol/l). Abdominal ultrasonographic examination and magnetic resonance imaging (MRI)–angiography showed a saccular aneurysm in the left common iliac artery, measuring 55 mm in transversal diameter (Figure 1). The diagnosis of mycotic aneurysm was strongly suspected. Resection of the aneurysm with implementation of an aorto-iliac allograft was realized within 24 h. Blood and arterial cultures grew an unusual Gram-negative bacillus, Burkholderia pseudomallei (Figure 2), the cause of vascular, lung and liver melioidosis in our case. The patient’s clinical course was favorable under parenteral antimicrobial therapy (imipenem
Figure 2. Wrinkled colonies of Burkholderia pseudomallei visible after 72 h incubation on chocolate agar at 37 8C.
and ciprofloxacin) for 5 weeks, followed by oral antibiotic therapy (trimethoprim–sulfamethoxazole) for 5 months. At the last review, 6 months after stopping antibiotics, there was no clinical, biological, or radiological evidence of relapse. Mycotic aneurysms of the arterial system are rare and the usual etiological agents implicated are Staphylococcus aureus and nontyphoidal Salmonella species. Melioidosis is an infectious disease caused by Burkholderia pseudomallei, which is endemic in Southeast Asia and northern Australia, and has also been reported from non-endemic areas of the world. B. pseudomallei is an important pathogen in humans and in a wide variety of animal species.1 In France, the bacillus was first isolated in 1975 from a Przewalski horse; the origin of the contagion was determined to be horses imported from Iran, an area where the disease has been recognized in these animals since 1943.2,3 The most common clinical presentation of melioidosis is pneumonia, followed by skin, visceral, and genitourinary system abscesses. Melioidosis presenting as mycotic aneurysm has only rarely been reported and is associated with high morbidity and mortality.4 In the absence of a
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Medical Imagery / International Journal of Infectious Diseases 14S (2010) e381–e382
severe purulent infection, repair using prosthetic grafts is recommended; conversely, in the presence of a severe purulent infection, an extra-anatomical bypass is generally required.5,6 Alongside the surgical management of mycotic aneurysm, the treatment of choice is ceftazidime or imipenem, maintained until clinical improvement, followed by oral treatment (trimethoprim– sulfamethoxazole) for at least 3–6 months.6,7 Authors following this therapeutic method did not note any relapse in the infection during 1–2 years of surveillance; however, patients should be followed closely for the rest of their lives in order to ensure an optimal survival rate.6,8,9 Conflict of interest: No conflict of interest to declare.
References 1. Low Choy J, Mayo M, Janmaat A, Currie BJ. Animal melioidosis in Australia. Acta Trop 2000;74:153–8. 2. Mollaret HH. L’affaire du jardin des plantes de Paris’’ ou comment la me´lioı¨dose fit son entre´e en France. Med Mal Infect 1988;18:643–54. 3. Ladds PW, Thomas AD, Pott B. Melioidosis with acute meningoencephalo-myelitis in a horse. Aust Vet J 1981;57:36–8. 4. Low JG, Quek AM, Sin YK, Ang BS. Mycotic aneurysm due to Burkholderia pseudomallei infection: case reports and literature review. Clin Infect Dis 2005;40:193–8.
5. Kyriakides C, Kan Y, Kerle M, Cheshire NJ, Mansfield AO, Wolfe JH. 11-Year experience with anatomical and extra-anatomical repair of mycotic aortic aneurysms. Eur J Vasc Endovasc Surg 2004;27:585–9. 6. Rao J, Kaushal AS, Hoong CK. Abdominal aortic pseudoaneurysm secondary to melioidosis. Asian J Surg 2009;32:64–9. 7. White NJ. Melioidosis Lancet 2003;361:1715–22. 8. Azizi ZA, Yahya M, Lee SK. Melioidosis and the vascular surgeon: Hospital Kuala Lumpur experience. Asian J Surg 2005;28:309–11. 9. Tanyaowalak W, Sunthornyothin S, Luengtaviboon K, Suankratay C, Kulwichit W. Mycotic aneurysm caused by Burkholderia pseudomallei with negative blood cultures. Scand J Infect Dis 2004;36:68–70.
Taoufik Amezyane*, Ste´phane Lecoules, Jean-Pierre Algayres Department of Internal Medicine, Val-De-Grace Hospital, Port Royal, Cedex 5, Paris, France *Corresponding author. Tel.: +0033140514412; fax: +0033140515148 E-mail address:
[email protected] (T. Amezyane) Corresponding Editor: Karamchand Ramotar, Ottawa, Canada 18 April 2009
