Left Anterior Descending Coronary Artery and Multiple Peripheral Mycotic Aneurysms Due to Mycobacterium Bovis Following Intravesical Bacillus Calmette-Guerin Therapy: A Case Report

Abstract

The use of live attenuated intravesicular Bacillus Calmette-Guerin (BCG) therapy is a generally accepted safe and effective method for the treatment of superficial transitional cell carcinoma (TCC) of the bladder. Although rare, < 5% of patient's treated with intravesicular BCG therapy may develop potentially serious complications, including localized infections to the genitourinary tract, mycotic aneurysms and osteomyelitis. We present here a case of a 63-year-old male who developed left coronary and multiple peripheral M. Bovis mycotic aneurysms as a late complication of intravesicular BCG therapy for superficial bladder cancer. The patient initially presented with acute onset pain and swelling in the left knee > 2 years following initial therapy, and initial workup revealed a ruptured saccular aneurysm of the left popliteal artery as well as incidental bilateral common femoral artery aneurysms. Following endovascular treatment and additional workup, the patient was discovered to have additional aneurysms in the right popliteal artery and left anterior descending artery (LAD). Surgical pathology and bacterial cultures obtained from the excised femoral aneurysms and surgical groin wounds were positive for Mycobacterium Bovis, and the patient was initiated on a nine-month antimycobacterial course of isoniazid, rifampin and ethambutol. Including the present case, there has been a total of 32 reported cases of mycotic aneurysms as a complication from intravesicular BCG therapy, which we will review here. The majority of reported cases involve the abdominal aorta; however, this represents the first known reported case of a coronary aneurysm.

Keywords: BCG; Bacillus Calmette-Guerin; Mycobacterium bovis; Mycotic aneurysm; intravesicular.

Figure 1

A 63-year-old male with acute left knee pain and swelling due to a ruptured left popliteal artery mycotic aneurysm. Findings: (a) - Sagittal gray-scale ultrasound (US) of the left popliteal fossa shows a large non-compressible acute hematoma (yellow asterisk). (b) - Transverse color Doppler US of the left medial knee shows a small amount of “ying-yang” flow within a partially thrombosed saccular aneurysm sac (white arrow). (c, d) - Transverse color Doppler US demonstrates an incidental partially thrombosed saccular aneurysm arising from the left common femoral vein (CFV; white asterisk). Technique: GE Logiq E9 linear 8.4 Mhz transducer.

Figure 2

A 63 year-old-male with an acute ruptured left popliteal aneurysm. Findings: (a) - Axial CTA demonstrating a mixed density acute left popliteal hematoma with focal active arterial extravasation (blue arrow). (b, c) - Axial and 3D volume rendered CTA of the lower pelvis demonstrating a left (white arrow) and bilateral (yellow arrow) saccular aneurysms arising from the distal common femoral arteries. Technique: Siemens SOMATOM Definition Flash, 128 channel, mAs 10,283, kVP 100, slice thickness 3 mm; Contrast material: 125 mL Omnipaque 350 mg/ml injected at a rate of 5 ml/s.

Figure 3

A 63 year-old-male with acute onset right knee pain due to ruptured right popliteal artery mycotic aneurysm. Findings: (a) - Sagittal grayscale (left) and color Doppler (right) US demonstrating an acute hematoma (asterisk) adjacent to a 5.7 × 2.7 cm irregular-shaped mycotic aneurysm arising from the popliteal artery (arrow). (b) - Sagittal spectral Doppler US demonstrating a “to-and-fro” flow pattern within the aneurysm sac, compatible with pseudoaneurysm (yellow calipers). Technique: Protocol: GE Logiq E9 Curvilinear 4 MHz transducer.

Figure 4

A 63 year-old-male undergoing covered stent placement of a right popliteal mycotic aneurysm. Findings: (a) - Carbon dioxide digital subtraction angiogram (DSA) demonstrating a saccular aneurysm arising from the above-knee popliteal artery (yellow arrow) with active extravasation (curved black arrow). (b) - A Storq guidewire was used to cross the aneurysm in the mid SFA. (c) - Placement of a 8 mm × 10 cm balloon-expandable Viabahn covered stent. (d) - Post DSA angiogram demonstrating successful exclusion of the aneurysm sac following placement of the covered stent. Technique: Siemens AXIOM Artis, Fluoroscopy time 8.6 minutes, KAP 605 mGym2, kVP 66, Contrast material: Carbon dioxide and Visipaque, hand-injected.

Figure 5

A 63 year-old-male status post bilateral covered popliteal artery covered stent placement for ruptured mycotic aneurysms. Findings: (a) - 3D-volume rendered and (b) oblique coronal maximum intensity projection CTA demonstrating patent bilateral covered popliteal stents with successful exclusion of the popliteal aneurysm sacs (arrows). Technique: GE Lightspeed, 16 channel, mAs 1,066, kVP 120, slice thickness 2.5 mm; Contrast material: 125 mL Omnipaque 350 mg/ml injected at a rate of 5 ml/s.

Figure 6

A 63-year-old-male status undergoing surveillance CTA status post bilateral interposition femoral vein grafts and bilateral popliteal covered stent placement. Findings: (a, b) - Axial CTA; (c, d) - 3D-volume rendered CTA; (e) - coronal CTA through the right common femoral artery demonstrating incidental saccular pseudoaneurysms arising from the proximal (white arrow) and distal (yellow arrow) attachment sites of the surgical interposition grafts. Technique: GE Lightspeed, 16 channel, mAs 56,703, kVP 120, slice thickness 2.5 mm; Contrast material: 125 mL Omnipaque 350 mg/ml injected at a rate of 5 ml/s.

Figure 7

A 63-year-old-male undergoing placement of a bifurcated aortoiliac stent graft and coil embolization of a distal right CFA mycotic pseudoaneurysm. Findings: (a, b, d) - Coronal oblique DSA demonstrating saccular mycotic aneurysms arising from the (a, arrow) proximal and (b and d, arrow) distal attachment sites of a common femoral surgical interposition graft. (c) - Coronal DSA following successful placement of an Endologix AFX bifurcated aortoiliac stent graft. (e) - Coronal DSA showing a deployment of coils into the distal aneurysm sac. (f) - Post-coil DSA demonstrating successful exclusion of the distal mycotic aneurysm sac. Technique: Siemens AXIOM Artis, Fluoroscopy time 37.8 minutes, KAP 6,036 mGym2, kVP 66–73, Contrast material: 30 mL Omnipaque 300 mg/mL.

Figure 8

63 year-old-male undergoing surveillance CTA following coil-embolization of a right CFA mycotic aneurysm. Findings: (a) - Curved planar CTA; (b) - Oblique coronal CTA; (c) - 3D-volume rendered CTA demonstrating patent right common femoral surgical interposition grafts (arrows) with successful coil exclusion of a mycotic aneurysm at the distal graft attachment site (asterisk). Technique: GE Lightspeed, 16 channel, mAs 28,497, kVP 120, slice thickness 2.5 mm; Contrast material: 125 mL Omnipaque 350 mg/ml injected at a rate of 5 ml/s.

Figure 9

A 63 year-old-male undergoing CTA of the lower extremities for increasing pain and swelling behind the right knee. Findings: (a, b) - Axial CTA demonstrating an enlarging 8.1 × 5.9 cm right popliteal hematoma (red arrow) surrounding a patent popliteal stent graft. The hematoma previously measured 7.4 × 5.2 cm three weeks earlier. (c, d) - Axial CTA of the lower chest demonstrates a 5.7 × 4.1 cm thrombosed aneurysm (cyan arrow) which appears to arise from the LAD (yellow arrow). In retrospect, this aneurysm was present on screening CTA of the chest performed 49 days earlier and measured 1.6 × 1.6 cm at that time (white arrow). Technique: GE Lightspeed, 16 channel, mAs 10,400, kVP 120, slice thickness 2.5 mm; Contrast material: 125 mL Omnipaque 350 mg/ml injected at a rate of 5 ml/s.

Figure 10

A 63 year-old-male undergoing coronary CTA for evaluation of a left coronary artery mycotic aneurysm. Findings: (a–d) - Axial pre-contrast (a), arterial-phase (b) and 3D-volume rendered (c, d) coronary CTA demonstrating a large saccular aneurysm with sluggish internal flow (blue arrow) arising from the mid left anterior descending (LAD) artery (yellow arrow). Significant mass effect and compression on the left ventricular outflow tract (LVOT) is noted (purple arrow). Technique: Siemens SOMATOM Definition Flash, 128 channel, mAs 1,683, kVP 120, slice thickness 0.75 mm; Contrast material: 97 mL Omnipaque 350 mg/ml injected at a rate of 5 ml/s.

Figure 11

A 63 year-old-male undergoing left main coronary catheter angiography. Findings: (a–d) - Dynamic images obtained during injection of the left main coronary artery (white arrow) demonstrates a focal caliber change in the mid LAD (blue arrow). An amorphous collection of contrast is noted adjacent to the mid LAD, which progressively fills a large saccular aneurysm sac arising from the mid LAD (curved red arrow). There is no opacification of the LAD distal to the aneurysm site, indicating occlusion of the distal LAD. The left circumflex artery appears normal (curved yellow arrow). Technique: Fluoroscopy time 6.2 minutes; DAP 49 mGy-m2; Contrast material: 70 mL Omnipaque 350 mg/ml.