Looking In All The Wrong Places: A Pseudoaneurysm Story
William M. DeCampli, MD, PhD1, Tain-Yen Hsia, MD, MS1, Michael Farias, MD, MBA1, Gabriel Krivenko, BS2, Sukumar Narasimhulu, MBBS, MPH1, Kathryn Tarulli, M.S., PA-C3, Kevin de la Roza, M.D.1, Elise Riddle, M.D.1.
1College of Medicine, University of Central Florida & Arnold Palmer Hospital for Children, Orlando, FL, USA, 2College of Medicine, University of Central Florida, Orlando, FL, USA, 3Arnold Palmer Hospital for Children, Orlando, FL, USA.
Objective: Diagnosis and localization of a mycotic pseudoaneurysm can be vexing; treatment may be challenging. In this case report, we describe pitfalls in diagnosis and perioperative maneuvers facilitating safe resection. Our abstract intentionally leaves the audience to guess the true nature of the lesion as the presentation unfolds. Methods: A 2-year-old with HLHS s/p Norwood and BDG sustained blunt chest trauma and presented two weeks later with a pulsatile right upper parasternal mass. In hospital, blood cultures grew Staph lugdunensis. Echocardiogram was unrevealing. Aortic angiography showed only dense, large right chest wall collaterals. On antibiotics and after procoagulant copolymer injection into the mass (Fig), pulsatility resolved but recurred several weeks later. Microbial cell-free DNA for S. lugdunensis was detected in the blood. After a circuitous diagnostic workup including repeat cath/angiography, the child underwent an operation. Results: The child underwent complete resection of the lesion. Because of its unusual location, cardiopulmonary bypass was used. Tissue cultures grew S. lugdunensis and IV antibiotic therapy was continued. The patient recovered uneventfully and was discharged on post-operative day 13. 2 ½ months later the patient is asymptomatic and thriving off antibiotics. Conclusions: Localization and full description of a mycotic aneurysm requires compulsive, often multi-modality imaging. Staph lugdunensis is an infrequent but potentially aggressive pathological organism and is rarely a "contaminant". Careful preoperative preparation can minimize the risk of operative hemorrhage.
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