A 73- year -old retired civil officer presented to the emergency department with bilateral thigh swellings for 8 months. The swelling initially appeared in the left mid-thigh, progressively increasing without associated redness, tenderness or discharge. Two months later he noticed a similar swelling in the right thigh. Additionally, he had a one year history of   knee swelling and mild pain. He denied history of trauma, fever or any other body swelling. Systemic review was unremarkable apart from anorexia and weight loss of 7Kg.There was a remote history of animal contact but he did not consume raw milk or undercooked meat.
The vital signs were normal. Local examination revealed bilateral mid-thigh swellings. The swellings were pulsatile, oval in shape 6 x 4 cm and 4 x 4cm in the left and right thigh respectively. There was no erythema, discharge or sinuses. All peripheral pulses were bilaterally palpable with no delays. Rest of the systemic examination was normal. Routine investigations including CBC, chemistry and lipid profile were normal. C-reactive protein was 54 mg/dl, erythrocyte sedimentation rate 64mm/hr. CT scan at presentation to our hospital showed fusiform aneurysms involving both SFA measuring 2 cm in the right and 1.7 cm in the left side. The aneurysm dilatation is surrounded by multiloculated collection about 4 by 3cm which was consistent with a haematoma. In addition there was evidence of right knee joint effusion. The rest of the CT scan of chest, abdomen and pelvis were reported as normal (Fig. 1).
The differentials diagnosis included atherosclerosis, vasculitis, infective endocarditis, mycotic aneurysms secondary to tuberculosis, brucellosis, and syphilis. The autoimmune workup for vasculitis was all negative. Blood culture was sterile including prolonged incubation for brucella. HIV, brucella and syphilis serology were also negative. Both trans-thoracic (TTE) and transoesophageal (TEE) echocardiography were normal.
He was planned for surgical correction of the aneurysm, debridement and to obtain tissue for histopathology, microbiology and molecular testing. Unfortunately, the patient rejected surgery but agreed for conservative management. Bilateral stenting of the superficial femoral arteries was undertaken and placement of a flexible, self-expanding endoluminal endoprosthesis with heparin bioactive surface was carried out with preservation of peripheral pulses. The stents consisted of an expanded polytetrafluoroethylene (ePTFE) lining with an external nitinol (titanium). Post operatively the patient remained stable however he started complaining of (L) scrotal swelling and pain. Ultrasound scrotum revealed bilateral epididymitis and two left testicular fluid collections (Fig. 2). Fluid aspirate gram stain and culture did not grow bacterial pathogen. He was discharged home on oral ciprofloxacin.
6 weeks later, he presented with worsening thigh swellings. A repeat CT angiogram showed development of a new pseudo aneurysm at the proximal segment of inferior mesenteric artery. A new enlargement of necrotic aorto-caval lymph nodes was also noted. Multiple collections were observed in the left testis (Fig. 3A and B). There was increase in the size of the multiloculated collection surrounding the femoral aneurysms of both the thighs however no leakage from the stent was identified(Fig. 4). In addition a whole body PET scan confirmed an enlarged (L) adrenal with a hypermetabolic activity.
A reddish brown fluid was aspirated from the femoral perianeurysmal collection. PCR for MTB was reported as positive; fortunately, the gene for rifampicin resistance was not detected. CT Chest showed innumerable miliary nodules particularly in the upper lobes (Fig. 5B). In retrospect the lower CT chest cuts of the initial admission CT angiogram showed more extensive miliary shadows than the current one (Fig. 5A). He was started on Isoniazid 300mg, rifampicin 600mg, ethambutol 1200mg and pyrazinamide 1.5 gm once daily. Eventually cultures of sputum, right and (L) thigh drainage grew fully sensitive MTB.
On follow up after 2 weeks, the patient complained of pain and further increase in the size of femoral swellings. At this point he was prescribed anti-inflammatory agent and advised to continue on his antitubercular medications and attend the infectious disease clinic.
Unfortunately, approximately 6 weeks later he developed a massive gastrointestinal bleeding from which he could not be resuscitated and died.