Ruptured mycotic aneurysm of intercostal arteries associated with vertebral osteomyelitis: a case report

Abstract

Background: Here, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention.

Case presentation: A 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient's right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications.

Conclusions: Intercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

Keywords: Endovascular intervention; Intercostal artery pseudoaneurysm; Massive hemothorax; Mycotic aneurysm; Pyogenic spondylodiscitis.

Fig. 1

T2-weighted magnetic resonance imaging (MRI) image showing hyperintense signal in T9-10 disc space (white arrow)

Fig. 2

T2-weighted magnetic resonance imaging (MRI) image showing an enlarged hyperintense signal area in the T9/10 disc space (white arrow) and a hyperintense signal in the anterior part of the vertebral body that may be a paravertebral abscess(*)

Fig. 3

Chest plane radiograph shows massive hemothorax in the right lung

Fig. 4

Contrast-enhanced computed tomography(CT) of the chest reveals a pseudoaneurysm in the right eighth intercostal artery (white arrow)

Fig. 5

Intercostal arteriography revealed a pseudoaneurysm in the right eighth intercostal artery (white arrow)

Fig. 6

Computed tomography(CT) after N-butyl cyanoacrylate (NBCA) embolization showing that the eighth intercostal artery aneurysm was not apparent (white arrow)

Fig. 7

Chest plain radiograph shows the disappearance of a massive hemothorax in the right lung and improvement in lung field permeability