Cryptogenic Mycotic Aneurysm

Abstract

THERE are three basic contributions on which the concept of mycotic aneurysm rests. The first is the report of Tufnell, in 1853, which clearly sets forth the mechanism of origin of a peripheral aneurysm by embolic transfer of material from an endocardial growth. It is aptly titled The Influence of Vegetations on the Valves of the Heart in the Production of Secondary Arterial Disease.“ 12 The second is Osier's classic description of subacute bacterial endocarditis, in 1885, which included mention of secondary infectious aneurysms and which he termed ”mycotic.“8 Finally, Eppinger, in 1887, devoted one section of his monograph on aneurysms to ”Das Mycotisch Embolische Aneurysina.“3 He described the inflammatory arteritis and its direct relationship to septic embolization. In the same year, Goodhart also recognized the pathogenesis and morbid anatomy of the lesion.4 In 1909, Lewis and Schrager referred to a type of mycotic aneurysm associated with degenerative arterial disease.7 Subsequently, Karsner classified three forms of mycotic aneurysm.6 The first arises as a result of extension from a neighboring focus of purulent inflammation; the second by embolization from a bacterial endocarditis; the third is due to dissemination of organisms in the blood stream either from an obvious focus or from some unidentified portal of entry It was not until 1937 that the term primary mycotic aneurysm appeared.2 Crane used this adjective to categorize those lesions arising by direct extension from a neighboring suppurative focus, as well as those aneurysms arising in the absence of an obvious inflammatory lesion elsewhere in the body. This term was later used by Revell9 and by Harkins and Yeager.5 We have been led by our experience to employ a more finite term to describe those mycotic aneurysms arising in the absence of any evident infectious process, local or distant Our cases have been characterized by the absence of systemic disease, other than arteriosclerosis, by the insidious nature of the onset, by the dramatically rapid sequence of clinical events and by the serious threat to life and limb of these middle-aged patients. We prefer cryptogenic mycotic aneurysm as being more indicative of the pathogenesis and preferable to primary in that it does not include lesions arising by local extension, as used by Crane