Mycotic hepatic artery aneurysm is a vascular pathology associated with bacterial endocarditis. It is rare in occurrence after the introduction of effective antibiotics. We present a young patient with injection drug abuse associated staphylococcal endocarditis which was successfully treated with antibiotics and valve replacement who presented with abdominal pain. He was found to have mycotic aneurysm of hepatic artery which was successfully treated with coil embolization. 1. Introduction Hepatic artery aneurysm is an uncommon vascular lesion. Mycotic hepatic artery aneurysm is rare but recognized complication of bacterial endocarditis. The incidence of mycotic aneurysm has decreased following the widespread use of effective antibiotics. We present a case of hepatic mycotic aneurysm in a patient with staphylococcal bacterial endocarditis. 2. Case A 27-year-old male presented with complain of chest pain and abdominal pain. Patient had recent history of Methicillin Resistant Staphylococcus aureus (MRSA) aortic valve endocarditis and septic emboli to coronary arteries requiring double vessel bypass grafting with aortic valve replacement 5 months ago. He also had history of hepatitis C. He denied dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fever, or chills. He also denied melena, hematochezia, or change in bowel habits. He had previous history of smoking and self-injecting drug abuse. Family history and review of system were unremarkable. Physical exam was significant for systolic heart murmur 3/6 in intensity, otherwise unremarkable systemic examination. His home medicines included aspirin, carvedilol, plavix, lisinopril, and sertraline. Laboratory data revealed white blood cell count (WBC) 10.5/L, potassium (K) 3.1？meq/l, total bilirubin 0.5？mg/dL, aspartate transaminase/alanine transaminase 12/10？IU/L, and alkaline phosphate level 75？U/L; urine drug screen positive for cannabinoids; chest X ray: no acute lung process; electrocardiogram (EKG): no acute ST-T changes. The patient was admitted to rule out acute coronary event, and infectious disease was consulted for further treatment recommendation. Computed tomography (CT) abdomen/pelvis was ordered for unexplained abdominal pain which revealed possible hepatic pseudo-aneurysm and CT Abdomen/pelvis angiography revealed right hepatic artery aneurysm of 1.2 × 1.0？cm size with no flow distal to aneurysm and left hepatic artery aneurysm of 5 × 6？mm size (Figure 1). Patient underwent coiling and successful embolization with nine coils in right hepatic artery aneurysm and four coils in left hepatic artery
References
[1]
W. K. Lee, P. J. Mossop, A. F. Little et al., “Infected (mycotic) aneurysms: spectrum of imaging appearances and management,” Radiographics, vol. 28, no. 7, pp. 1853–1868, 2008.
[2]
L. M. Messina and C. J. Shanley, “Visceral artery aneurysms,” Surgical Clinics of North America, vol. 77, no. 2, pp. 425–442, 1997.
[3]
G. A. Kim, H. C. Lee, Y. J. Jin, et al., “A case of ruptured mycotic hepatic artery aneurysm successfully treated using arterial embolization,” Yeungnam University Journal of Medicine, vol. 29, no. 1, pp. 24–27, 2012.
[4]
B. H. Stack, J. T. Rankin, and R. J. Bentley, “Hepatic artery aneurysm after staphylococcal endocarditis,” British Medical Journal, vol. 3, no. 5619, pp. 659–660, 1968.
[5]
M. Jordan, S. Razvi, and M. Worthington, “Mycotic hepatic artery aneurysm complicating Staphylococcus aureus endocarditis: successful diagnosis and treatment,” Clinical Infectious Diseases, vol. 39, no. 5, pp. 756–757, 2004.
[6]
K. Mojab, L. T. Lim, F. Esfahani, and L. Portela, “Mycotic aneurysm of the hepatic artery causing obstructive jaundice,” American Journal of Roentgenology, vol. 128, no. 1, pp. 143–144, 1977.
[7]
L. L. Porter, M. C. Houston, and S. Kadir, “Mycotic aneurysms of the hepatic artery: treatment with arterial embolization,” The American Journal of Medicine, vol. 67, no. 4, pp. 697–701, 1979.
[8]
A. N. Sukerkar, C. C. Dulay, E. Anandappa, and S. Asokan, “Mycotic aneurysm of the hepatic artery. Case diagnosed with radionuclide imaging and ultrasound,” Radiology, vol. 124, no. 2, p. 444, 1977.
[9]
A. B. Tierney and F. J. Palmer, “Mycotic aneurysm of the right hepatic artery presenting with obstructive jaundice,” Australasian Radiology, vol. 31, no. 1, pp. 50–52, 1987.
[10]
P. Hulsberg, J. L. Garza-Jordan, R. Jordan, P. Matusz, R. S. Tubbs, and M. Loukas, “Hepatic aneurysm: a review,” The American Surgeon, vol. 77, no. 5, pp. 586–591, 2011.
[11]
V. S. Jones, M. S. Chennapragada, D. J. E. Lord, M. Stormon, and A. Shun, “Post-liver transplant mycotic aneurysm of the hepatic artery,” Journal of Pediatric Surgery, vol. 43, no. 3, pp. 555–558, 2008.
[12]
A. Stengal and C. C. Wolferth, “Mycotic aneurysms of intravascular origin,” Archives of Internal Medicine, vol. 31, no. 4, pp. 527–554, 1923.
[13]
M. A. Abbas, R. J. Fowl, W. M. Stone et al., “Hepatic artery aneurysm: factors that predict complications,” Journal of Vascular Surgery, vol. 38, no. 1, pp. 41–45, 2003.
[14]
Y. Nakata, S. Shionoya, and K. Kamiya, “Pathogenesis of mycotic aneurysm,” Angiology, vol. 19, no. 10, pp. 593–601, 1968.
[15]
I. W. Park, T. W. Park, S. G. Han, et al., “Delayed rupture of mycotic hepatic artery aneurysm in a patient with infective mitral endocarditis-first case in Korea,” Korean Circulation Journal, vol. 37, no. 1, pp. 43–46, 2007.
[16]
R. Dogan, E. Yildirim, and S. Gokturk, “Gastrointestinal hemorrhage caused by rupture of a pseudoaneurysm of the hepatic artery,” The Turkish Journal of Gastroenterology, vol. 23, no. 2, pp. 160–164, 2012.
[17]
N. N. Harlaftis and J. T. Akin, “Hemobilia from ruptured hepatic artery aneurysm: report of a case and review of the literature,” American Journal of Surgery, vol. 133, no. 2, pp. 229–232, 1977.
[18]
J. T. Stauffer, M. D. Weinman, and T. E. Bynum, “Hemobilia in a patient with multiple hepatic artery aneurysms: a case report and review of the literature,” American Journal of Gastroenterology, vol. 84, no. 1, pp. 59–62, 1989.
[19]
C. C. Kibbler, D. L. Cohen, J. K. Cruicshank, et al., “Use of CAT scanning in the diagnosis and management of hepatic artery aneurysm,” Gut, vol. 26, no. 7, pp. 752–756, 1985.
[20]
A. B. Christie, D. B. Christie III, D. K. Nakayama, and M. M. Solis, “Hepatic artery aneurysms: evolution from open to endovascular repair techniques,” The American Surgeon, vol. 77, no. 5, pp. 608–611, 2011.
