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Infectious Diseases in Clinical Practice:
doi: 10.1097/01.idc.0000203896.77101.69
Case Reports

Ruptured Thoracic Aortic Aneurysm Infected With Listeria monocytogenes: Case Report and Review of World Wide Literature

Daoud, Ehab MD; Martin, Douglas MD; Yodice, Paul MD

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Author Information

The Miriam Hospital, Brown Medical School, Providence, RI.

Address correspondence and reprint requests to Ehab Gamil Daoud, MD, The Miriam Hospital, Providence, RI02906. E-mail: ehab_daoud@hotmail.com.

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Abstract

Abstract: Listeria monocytogenes is an increasingly recognized cause of human disease especially in immunosuppressed hosts; vascular infections involving Listeria had been rarely reported in the literature. We are reporting a case of L. monocytogenes infection in the descending thoracic aorta in a non-immunosuppressed patient presenting only with hemoptysis after contained rupture of the aneurysm by the lung. This was treated successfully by surgery and 6 weeks of oral levofloxacin.

We also summarized all the available literature of listerial vascular infection since the first report by Navarrette in 1965.

Listeria monocytogenes is an aerobic, gram-positive rod that can cause a number of infections in human beings, including central nervous system, food-borne infections, and neonatal infections. Most of those infections occur in immunosuppressed patients and extreme of ages. Rarely, this organism can infect the vascular system causing endocarditis or mycotic aneurysms. There have been very few reports in the literature about listerial infections causing vascular aneurysms, most commonly the aorta, and other smaller arteries.

We are presenting a case of Listeria aortitis, which presented in a different manner than the previously reported cases; it was treated successfully with surgery and antibiotics.

This review stresses on the importance of infections as one of the etiologies and or consequences of aortic aneurysms, and it also stresses that hemoptysis could be the only presentation of ruptured thoracic aortic aneurysm.

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CASE

An 83 years old man presented to the emergency room with the complaint of mild hemoptysis started the same day; he has a past medical history of coronary artery disease with a bypass graft twenty years earlier, left-sided nephrectomy 5 years earlier for renal cell carcinoma with chronic renal insufficiency, and gastric arteriovenous malformations. Remainder of history, physical exam, and posteroanterior chest x-ray were all none rewarding.

Patient underwent noncontrast computerized tomography scan of the chest (Fig. 1).

Figure 1
Figure 1
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Subsequently, the patient undergone magnetic resonance imaging with angiography (Figs. 2A and B).

Figure 2
Figure 2
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In the operating room, a large descending thoracic aortic aneurysm with localized extension into the lung parenchyma with contained rupture was resected, and the aorta was repaired with a 20-mm tube graft. The resected specimen was sent for pathology (Figs. 3A and B) and microbiology (Figs. 4A and B).

Figure 3
Figure 3
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Figure 4
Figure 4
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A final culture of the specimen was conclusive for L. monocytogenes, blood cultures were negative and transthoracic echocardiography was negative for endocarditis. Patient was started on Ampicillin for which he developed rash, was switched to trimethoprim-sulfamethoxazole for which he also developed rash, and finally was switched to levofloxacin for a course of 6 weeks.

Patient was discharged home on the 8th day postoperative and doing well after 6 months follow-up.

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DISCUSSION

Listeria is an aerobic and facultatively anaerobic, motile, beta hemolytic, non-spore-forming, catalase-positive, oxidase-negative, short gram-positive rod that exhibits tumbling motility by light microscopy at 25°C. L. monocytogenes is the only strain of the 7 Listeria species that infects humans. There are at least 16 serotypes or serovars of Listeria monocytogenes, but almost 90% of disease are due to types 4b, 1/2a, and 1/2b.1,2

Listeria is an important cause of zoonoses and is a primary habitant in soil, decaying materials, and fecal flora of many mammals including 5% of healthy humans. Listeriosis counts for about 1,850 cases per year in the United States and is responsible for about 425 deaths per year. Except for vertical transmission from mother to fetus, human-to-human infection has not been reported.3,4

Since Nyfeldt5 first described human infection with L. monocytogenes in 1929, several reviews had comprehensively summarized the microbiology and epidemiology of the organism and its clinical manifestations. In the United States, between 55% and 85% of patients with listerial infections present with meningitis, 25% present with bacteremia, 7.5% with endocarditis, and 6.5% with nonmeningitic CNS infections. Food-borne illness and gastroenteritis, endophthalmitis, osteomyelitis, peritonitis, and endometritis constitute the remaining manifestations.6 Predisposing factors for listerial infections include steroids, solid tumors and hematological malignancies, organ transplantation, extremes of ages, diabetes mellitus, AIDS, pregnancy, and other causes of impaired cell-mediated immunity.3

Sir William Osler7 first described the term "mycotic aneurysm" in the Gulstonian lectures of 1885 to describe a mushroom-shaped aneurysm that developed in a patient with subacute bacterial endocarditis, but it was till 1965 when Navarrette reported the first case of aortic aneurysm infected with L. monocytogenes.8 Since then, there have been very few reports in the world literature about listerial infections causing vascular aneurysms most commonly the aorta, and other smaller arteries, most of those infections in native arteries and few in synthetic grafts. Those reports and their outcome are summarized in Table 1.

Table 1
Table 1
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In summarizing those reports, the median age of patients were 68 years (range from 18 to 85), 3 were 22 males (78%) and 6 females (22%) with a ratio 1:3.6, the most common affected vessel was the aorta (13 cases); others included: the popliteal artery (4 cases), synthetic grafts (4 cases), the iliac artery (3 cases), the femoral artery (2 cases), and the mesenteric and supraceliac arteries (1 case each). The overall mortality is 25% (7 of 28 patients): 6 patients were treated only medically, 4 of whom died (mortality of 66.6%), and 22 patients were treated with combination of medical and surgical treatments, 3 of whom died (mortality of 10.7%).

The symptoms and signs of mycotic aneurysms in general are nonspecific; the most common signs are fevers, sepsis of unknown origin, or rupture of the aneurysm that is usually fatal. Isolating the organism from the vessel tissue or from the blood (positive in about one third of the cases) with the presence of an aneurysm usually makes the diagnosis, also recently validated are the appearances of the infected aneurysms using the usual imaging studies as computerized tomography, magnetic resonance imaging, and nuclear studies.28

In regards to treatment, there have been no controlled trials for the optimal choice or duration of an antimicrobial for L. monocytogenes but it appears that combined surgical excision of the aneurysm with concurrent long-term antibiotics offers the best treatment options.29 Ampicillin is still considered by many experts to be the drug of choice against L. monocytogenes, trimethoprim-sulfamethoxazole, vancomycin, erythromycin, rifampin, and chloramphenicol are other choices available in patients with penicillin allergies or can not tolerate penicillin.1,2 Endovascular Stent grafts combined with antibiotic therapy may be an alternative to conventional thoracotomy in managing mycotic aneurysms of the descending thoracic aorta.30,31 Despite the improvement in surgical techniques, mycotic aneurysms still have high mortality of about 30-50%, with recurrence rate of about 15%.32

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CONCLUSIONS

It is unknown if the infectious agents are the precursors of the mycotic aneurysm or they simply infect a preexisting aneurysm, nonetheless infections by either L. monocytogenes or other more common bacteria like Staphylococci, Streptococci, and Salmonella are important etiologies in development of arterial mycotic aneurysms especially of the aorta. Mycotic aneurysms are estimated to represent about 0.7-2.6% of all arterial aneurysms33 and should be looked for in lots of cases as the addition of long-term antibiotics to surgical repair might decrease recurrence and improve mortality.

This case stresses that hemoptysis could be the only presentation of ruptured thoracic aortic aneurysm, hence, the need to expand the differential diagnosis of hemoptysis beyond the common bronchopulmonary diseases, and should be investigated thoroughly and without delay given the high mortality rates of such a condition.34

This case is an addition to the less than 30 cases of arterial aneurysms infected with L. monocytogenes in the worldwide literature over the course of forty years, and it also adds a new class of antimicrobials (quinolones) to the previously mentioned list of antimicrobials that are capable of fighting this infection.

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