An unusual presentation of mycotic aneurysm of popliteal artery and the challenges faced: a case report

Mycotic aneurysm of popliteal artery is a very rare condition, most commonly caused by gram positive organisms. This term was coined by William Osler describing aneurysms associated with bacterial endocarditis. Though cases of peripheral vessel mycotic aneurysm are very rare, it is a dangerous condition as it can go for rupture/ thrombosis. The treatment of choice is resection and revascularization, preferably by using autologous vein graft along with antibiotics. A 35-year-old female who presented with features of cerebrovascular accident, during the course of stay was diagnosed to have mycotic aneurysm of the left popliteal artery. We describe the clinical course, investigation findings and challenges faced in management of the case.

Mural Endocarditis and Embolic Pneumonia Due to Trueperella pyogenes in an Adult Cow with Ventricular Septal Defect

Bacterial endocarditis represents one of the most frequently acquired cardiac diseases in adult cattle. Congenital heart diseases as a ventricular septal defect can facilitate bacterial endocarditis as a consequence of turbulent blood flow through the defect, causing damage to the endocardium. We describe a case of mural endocarditis associated with a ventricular septal defect in an eight-year-old female Holstein Friesian cow. The cow’s history revealed that she had presented dysorexia and a sudden decrease of milk production in the last 10 days prior to the examination. On clinical examination, jugular pulses, tachycardia with irregular heart rate and tachypnea with harsh bronchovesicular sounds were evident. Electrocardiographic examination allowed the diagnosis of an atrial fibrillation with high ventricular response rate. Transthoracic echocardiography revealed a large vegetation originating from the endocardium between the tricuspid and pulmonic valves in the right ventricle outflow. On post-mortem examination, a small muscular septal defect under the right coronary cusp of the aortic valve and a mural vegetative endocarditis were found. An abscess in the chondro-costal junction of the third right rib and metastatic pneumonia were also observed. This case report describes a rare consequence of a small ventricular septal defect that had not been previously diagnosed in an adult cow.

Complications of epi- and endocardial pacing in children

Aim To analyze complications of cardiac pacing in children depending on the implantation method. Actuality Recently epicardial lead implantation becomes more and more popular either due to more serious complications of transvenous pacing or due to possibility of choice of hemodynamically optimal pacing zone. Methods and materials 242 patients with pacemakers are under our supervision. Epicardial pacemakers were implanted to 145 patients, endocardial – to 97 patients. In “old era” in most children the primary epicardial implantations were performed at RV free wall. In 27 children, having primary implantation at our Institute lately, the epicardial lead was placed at LV apex, or endocardial – at RV apex. Results The comparative analysis of complications of epi- and endocardial implantation showed the following results: 22% of complications at epicardial stimulation, and at transvenous stimulation – 45%. The most often complications at epicardial stimulation (53%) were connected with hemodynamic disorders – dyssinchronous cardiomyopathy. Hemodynamic complications, connected with dyssinchrony of endocardial RV pacing, were disclosed in 16%. The most often complication of endocardial stimulation was TV insufficiency (32%). Venous vessel thrombosis was diagnosed in 9%. Epicardial and transvenous lead failure was discovered in similar percentage ratio (28%). Infectious complications of transvenous pacing, especially, bacterial endocarditis, took place in 6,8%. Thus, progressive bacterial endocarditis and TV insufficiency (3d deg.) appeared in one patient in 10 years after the primary implantation. Afterwards, elimination of endocardial system by open surgery, TV plasty followed by epicardial pacing implantation are required. Infection of pacing site was disclosed in both types of implantation (1%). Perforation of atrial endocardial lead was found in two cases (4%). A case of mechanical complication (cardiac strangulation) was diagnosed in a child (3%) in four years after the primary implantation of epicardial pacing system. Pericarditis was recorded immediately after the epicardil pacemaker implantation in 9% of cases. Our center performs epicardial lead implantation with the help of midline sternotomy that provides clear approach to right atrium. However, the difficulties of lead fixation at LV apex appear here. It concerns, especially, the patients after CHD correction as the repeated sternotomy in them presents high risk of RV insufficiency. Nevertheless, the given approach is still the best possible with epicardial pacing if there is a “preclude”, sufficient experience of CHD correction. Conclusion The possibility of choice of optimal epicardial pacing site exceeds risks of leads and midline sternotomy. Any primary pacemaker implantation in children of any age with ventricular lead should be epicardial. FUNDunding Acknowledgement Type of funding sources: None.

A rare case of Streptococcus anginosus infectious intracranial aneurysm: Proper management of a poor prognosis

Background: Infectious intracranial aneurysms (IIAs), sometimes referred to as cerebral mycotic aneurysms, are an uncommon but feared compilation of bacterial endocarditis, occurring in up to 5% of all bacterial endocarditis cases. While IIAs carry a low risk of rupture, a ruptured mycotic aneurysm carries devastating neurologic consequences with up to an 80% mortality rate secondary to subarachnoid and intracerebral hemorrhage. Case Description: A 69-year-old man undergoing antibacterial therapy for Streptococcus anginosus endocarditis with aortic insufficiency and root abscess presented to the ED with multiple seizures and left-sided weakness. MRI of the head revealed right frontal and temporal abscesses with evidence of scattered septic emboli and subarachnoid hemorrhage. CTA of the head revealed a ruptured 1 mm distal middle cerebral artery mycotic aneurysm. Prior to undergoing surgery, the patient began to decline, becoming lethargic, and failing to respond to commands. The patient underwent endovascular Onyx embolization. After the procedure, the patient remained with partial status epilepticus and was discharged to rehabilitation. Over the following months, the patient made a great recovery and was able to undergo aortic and mitral valve replacement 5 months after neurosurgical intervention. Conclusion: This favorable outcome is the result of a tremendous deal of long-term coordination and efficient communication between neurosurgery, cardiology, neurology, physical medicine and rehabilitation, and primary care.

Right-sided endocarditis caused by polyclonal Staphylococcus aureus infection

We present a case of bacterial endocarditis with both methicillin-sensitive and methicillin-resistant Staphylococcus aureus, which based on typing, originated from two distinct clones. Such a case may be misinterpreted by microbiology lab automation to be a monoclonal multi-drug resistant Staphylococcus aureus, while simple microbiology techniques will instantly reveal distinct clonality.

Re-emphasising the importance of histopathological diagnosis in suspected bacterial endocarditis

Infective endocarditis (IE) carries a high risk of morbidity and mortality. Timely diagnosis, effective treatment and prompt recognition of complications are essential to favourable patient outcomes. A collaborative, multidisciplinary team approach to the management of IE has been shown to improve prognosis. However, the clinical heterogeneity of IE and atypical presentations pose challenges to the endocarditis team. We present a case highlighting the role of valve histopathology in suspected IE, where there may be diagnostic uncertainty.

Dental Management of a Patient with Pulmonary Atresia and Ventricular Septal Defect

Pulmonary atresia with ventricular septal defect (PA/VSD) is one of the congenital heart diseases that results in cyanosis, susceptibility to bacterial endocarditis, and increased risk of complications during general anesthesia. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common inherited genetic disorder affecting the red blood cells. We aimed to elaborate the potential dental management for patients with this serious condition. This report presents the single-visit dental treatment of a three-year-old female with PA/VSD, G6PD deficiency and rampant caries. The complexity of dental treatments, high incidence of dental caries, lack of cooperation, and the systemic condition limit treatment options to providing service under general anesthesia and hospitalization. Careful monitoring of oxygen saturation during general anesthesia and antibiotic prophylaxis are essential due to the invasive nature of dental treatments. It appears that single-visit dental management under general anesthesia minimizes the risk of treatment of patients at high risk of bacterial endocarditis.