Mycotic Aneurysm of Native Renal Artery : Case Report and Review of the Literature

C l i n M e d International Library Citation: Luca A, Luigi DM, Charlie A, Jeanchristophe P, Santiago AJ, et al. (2015) Mycotic Aneurysm of Native Renal Artery: Case Report and Review of the Literature. Clin Med Rev Case Rep 2:051. doi.org/10.23937/2378-3656/1410051 Received: April 13, 2015: Accepted: August 26, 2015: Published: August 28, 2015 Copyright: © 2015 Luca A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Clinical Medical Reviews and Case Reports


Introduction
Mycotic aneurysm is defined as a localised and irreversible destruction of arterial wall by bacterial infection.It results in a segmental dilatation of native vessel to at least one and a half times its normal diameter [1].Renal artery localisation is uncommon.Physiopathology recognises permeation of septic emboli to the vasa vasorum, often during endocarditis or others causes of septicaemia [2]; infection of endovascular devices, such as renal stent, has also been described [3][4][5][6].
Lesions are often asymptomatic until rupture and, usually, clinical manifestations may include massive hematuria as observed which a clear role of steroids and immunosuppressive treatments is documented [7].
One interesting finding, in the reported case, is that the mycotic aneurysm occurred in the proximal native renal artery instead of transplant renal artery, as is its common occurrence.Furthermore, to our knowledge, the present case is the first report of proximal localisation.Figure 3 shows the distribution of localisation and the treatment based on our review of literature.
According to the literature, MANRA increases in size quickly and early leakage is frequent, as occurred in the presented case [2].Acute evolution of MANRA seems to be more frequent and earlier than in atherosclerotic renal artery aneurysm in which, apart from occurrence during pregnancy, rupture is a rare event.The incidence of acute evolution of MANRA is under 5%, but the mortality can rise up to 80% [7][8][9].
Reported therapeutic options include targeted antibiotic therapy, often followed by endovascular or open surgical repair.
Literature doesn't support any evidence-based treatment: a complete review of the case report since 1977 is shown in table 1.
The few cases of MANRA describes often occurred in patients affected by important co-morbidity such as lupus erythematosus, rheumatoid arthritis, diabetes and cardiac risk factors for endocarditis, that is present in the half of the patients [2,3,[11][12][13][14][15]. Scleroderma has never been reported in association with MANRA.We cannot state that scleroderma is a risk factor for MANRA considering that the presented case reports the history of a patient under immunosuppressive treatment after renal transplantation.
Analysing the 13 cases reported in literature, localisation of the lesions seems to be decisive factor in the choice of treatment.
Emergency nephrectomy was necessary in 30% of cases reported in literature: in case of involvement of the mean trunk of renal artery or in presence of massive renal infarction [4,14,16,17].Coils embolization was successful and uncomplicated in 80% of cases [2,3,13,15,16].
An early elective surgical or endovascular treatment may be recommended and the conservative medical management has to be reserved only for the very small intra-renal lesions [10][11][12].
Endovascular coils embolization, stenting exclusion or booth, appears to be preferred for the management of distal or intra-renal localisations, with a morbidity of 20% [16].
At present, proximal localisation of the MANRA and failure of endovascular procedure still requires open surgery; in the second case, nephrectomy is often mandatory.The post-operative course was uneventful; Cefturoxime was administered until the 20 th post-operative dayand the patient was discharged at post-operative day 25.
No recurrence was found 21 months after surgery.

Discussion
Natural history of mycotic aneurysm of native renal artery (MANRA) is still unclear.The cases in literature often report infected aneurysm of the grafted renal artery in transplanted patients, in

Following
abdominal aorta clamping, above the renal arteries, aneurysmectomy with proximal aortic tangential resection and distal arterial ligation was performed.Arterial revascularisation wasn't necessary because of the renal atrophy.Primary closure of the aortic renal ostium was carried out by separate stitches.Histological and bacterial examination confirmed the clinical suspicion of infected aneurysm with gram positive cocci germs; the culture of arterial biopsy revealed the growth of Streptococcus Agalactiae, sensitive to Cefturoxime.During the hospital stay, the multiple sets of blood cultures were negative.Transthoracic echocardiography revealed no vegetation.

Figure 3 :
Figure 3: Distribution of localisation and treatment options; APT: antibiotic prolonged therapy.

Table 1 :
Complete review of the literature since 1977.