Case
A 76-year-old man presented to our emergency department complaining of
febrile sensation since 9 days. The initial blood pressure was 180/100
mmHg and heart rate was 115 beats per minute. His body temperature was
38.6°C, white blood cell count was 19,410 cells/μL, and C-reactive
protein (CRP) was 31.0 mg/dL. Computed tomography (CT) revealed a
pseudoaneurysm at the descending thoracic aorta, which was consistent
with mycotic aneurysm (Figure 1-A). Empirical antibiotic therapy was
initiated (vancomycin 1g IV q 12 h, piperacillin/tazobactam 4.5g IV q 8
hours) immediately after drawing two pairs of peripheral blood samples
for culture.
Surgical aortic replacement or thoracic endovascular aortic repair
(TEVAR) were recommended, but the patient delegated the decision to his
family, who refused these procedures. Despite the empirical antibiotic
therapy, intermittent fever continued. After 4 days, the patient
complained of dyspnea, and chest X-ray revealed a large pleural effusion
(Figure 2-HD5). Blood pressure was 129/61 mmHg and heart rate was 96
beats per minute at that time. CT revealed no evidence of contrast
leakage into the pleural space (Figure 1-B). Therefore, a closed
thoracostomy was performed, and 1200 mL of yellowish exudative effusion
was drained. Following this, the patient remained stable. On the same
day, blood culture revealed Streptococcus pneumoniae, and antibiotic
therapy was adjusted (vancomycin 1g IV q 12 hours, ceftriaxone 2g IV q
14 hours).
Next day, more than 2 L of fresh blood was drained abruptly and the
patient developed acute hypovolemic shock. Following the family’s
informed consent the patient proceeded for emergency TEVAR. This was
performed successfully using a Seal Thoracic Stent Graft 34 × 120mm
(S&G Biotech, Yongin-si, South Korea); however, a large hematoma and
ruptured abscess remained in the left pleural space, causing mediastinal
shifting (Figure 2-HD6, post-TEVAR). Therefore, video-assisted thoracic
surgery (VATS) was performed to remove hematoma and ruptured abscess and
two plastic tubes remained for drainage. Four days later, the patient
was transferred to the general ward. Further blood culture revealed no
microorganisms. Vancomycin was discontinued on day 41 of
hospitalization. On day 62, intravenous ceftriaxone was changed to oral
cefpodoxime (100mg bid), and the patient was discharged without
complications. Cefpodoxime was maintained for 6 months. At the latest
follow-up, 1 year after TEVAR, he remained stable without any signs of
infection, and CT revealed no stent-related complications.