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.