osler first used the term  mycotic aneurysm  in 1885 to describe a mushroom - shaped aneurysm in a patient with subacute bacterial endocarditis .
, mycotic aneurysm is still used for all extracardiac or intracardiac aneurysms caused by infections , except for syphilitic aortitis . the term  infected aneurysm ,  proposed by jarrett and associates , is more appropriate , since few infections involve fungi .
mycobacterium and fungi , such as candida albicans and aspergillus , are rare causes of infected aneurysms and only few cases of such multiple chronic granulomatous mycotic abdominal aorta aneurysms have been reported as per our literature search .
depending on the location , mycotic aortic aneurysm usually manifests as abdominal pain with or without a pulsatile mass , causing aneurysmal mass effect , chest pain , dysphagia , hoarseness , and the complications include fistula , perforations , bleeding , and rupture . multidetector computerized tomography ( ct ) angiography allows early detection and characterization of abdominal aortic aneurysms . identifying the underlying etiology is important in deciding the appropriate management of the aneurysm .
a 28-year - old indian male with chronic weakness , loss of appetite , and a pulsatile mass in the abdomen was referred to our department for radiological evaluation .
the patient was normotensive , non - smoker , non - diabetic , and was admitted for alteration of his general state , including weight loss , dizziness , and mild fever ( 38c ) for past 1 month .
laboratory evaluation evidenced elevated white cell count [ 20,000 per cubic mm ( normal 300011,000 ) ] and c - reactive protein ( crp ) .
blood culture result was negative for staphylococcus and streptococcus species , salmonella , gram - negative bacteria , such as escherichia coli , klebsiella , and pseudomonas mycobacterium , and fungi , such as c. albicans and aspergillus .
abdominal ultrasound ( usg ) showed mild hepatosplenomegaly and multiple significantly enlarged , heterogeneous , necrotic , conglomerate retroperitoneal lymph nodes including periportal and peripancreatic nodes .
color flow doppler examination demonstrated multiple variable - sized aneurysms of abdominal aorta with pulsatile flow in the center and thrombus at the periphery .
a ct angiography of whole abdomen was performed and the images were evaluated using multiplanar reconstruction and 3d volume rendering techniques .
the ct angiography revealed multiple saccular aneurysms with thin irregular walls , arising from the abdominal aorta [ figures 1 and 2 ] .
two aneurysms were seen , one at suprarenal aorta and measuring 5.2  2.5 cm and the other involving infrarenal abdominal aorta and measuring 4.5  4 cm .
one of the aneurysms was causing near - total compression of right renal artery , resulting in chronic renal parenchymal changes secondary to ischemia [ figure 3 ] .
multiple enlarged ( largest 2.8 cm in short - axis dimension ) para - aortic lymph nodes were identified in the vicinity of the aneurysms showing evidence of internal necrosis [ figure 4 ] .
no evidence of any abnormally enhancing mass lesion or bowel wall thickening could be identified .
a usg - guided core biopsy of the retroperitoneal ( pre - para aortic ) lymph node was performed .
the lymph node biopsy revealed central caseous necrotic material with epithelioid cells and macrophages consistent with tubercular etiology [ figure 5 ] .
based on the biopsy results , a presumptive diagnosis of tubercular aneurysm was made , and the patient was put on anti - tubercular treatment and advised surgical management of abdominal aortic aneurysms . on follow - up , the patient responded well to the anti - tubercular drug therapy , as there was reduction in the size of the retroperitoneal lymph nodes including pre - para aortic and peripancreatic nodes , as compared to previous pre - treatment scans .
post anti - tuberculosis treatment , the patient was advised open surgical / endovascular stenting procedures .
28-year - old male presenting with nonspecific symptoms of abdominal pain weakness and pulsatile abdominal mass on examination later diagnosed with mycotic abdominal aneurysm underwent computerized tomography angiography ( cta ) of abdomen .
3d reconstructed image shows two large saccular aneurysms ( arrows ) arising from the abdominal aorta , one arising anteriorly and the other arising posteriorly .
28-year - old male presenting with nonspecific symptoms of abdominal pain weakness and pulsatile abdominal mass on examination later diagnosed with mycotic abdominal aneurysm underwent computerized tomography angiography of abdomen . maximum intensity projection reformatted image in sagittal plane of abdomen shows two abdominal aortic saccular aneurysms ( arrows ) .
28-year - old male presenting with nonspecific symptoms of abdominal pain weakness and pulsatile abdominal mass on examination later diagnosed with mycotic abdominal aneurysm underwent computerized tomography angiography of abdomen .
cect abdomen with maximum intensity projection reformatted image in axial plane shows pre - para aortic necrotic lymphadenopathy ( white straight arrow ) compressing right renal artery at its origin , thus causing chronic renal parenchymal changes on the right side ( white arrowhead ) .
28-year - old male presenting with nonspecific symptoms of abdominal pain weakness and pulsatile abdominal mass on examination later diagnosed with mycotic abdominal aneurysm underwent computerized tomography angiography of abdomen .
contrast - enhanced ct axial section of abdomen shows enlarged para - aortic lymph nodes ( arrowhead ) in the vicinity of aneurysm ( black arrow ) .
28-year - old male presenting with nonspecific symptoms of abdominal pain weakness and pulsatile abdominal mass on examination later diagnosed with mycotic abdominal aneurysm underwent computerized tomography angiography of abdomen .
microphotograph of core biopsy specimen from the retroperitoneal lymph node ( hematoxylin and eosin , 400 magnification ) shows caseous necrosis with surrounding epithelioid cells ( modified macrophages , black arrows ) , suggesting a tubercular etiology .
infected aneurysm ( or mycotic aneurysm ) is defined as an infectious break in the wall of an artery with formation of a blind , saccular out - pouching that is contiguous with the arterial lumen .
the aorta is the most commonly involved artery and can be involved either by hematogenous diffusion or extension from a contiguous focus , either direct or indirectly via the lymphatic , such as lymph node , or a nearby infectious lesion .
mycotic aneurysm secondary to chronic granulomatous infection of the aorta is a rare and life - threatening disease . depending on the location
, infective aortic aneurysm usually manifests as abdominal pain with or without a pulsatile mass causing aneurysmal mass effect , chest pain , dysphagia , hoarseness , and the complications include fistula , perforations , bleeding , and rupture .
this patient discussed here presented with a 1 month history of non - specific constitutional symptoms and signs of chronic infection like fever , weight loss , loss of appetite , and abdominal pain . in our case , based on the histopathology of the retroperitoneal lymph node , we made a presumptive diagnosis of tubercular abdominal aortic aneurysms .
blood culture result was negative for mycobacterium , and it has been reported in the literature that sterile blood cultures occur in 1850% of patients with infected aneurysms .
we reviewed all the cases of mycotic aneurysms reported in the english language scientific literature from 1945 till date .
a patient presenting with constitutional symptoms and pulsatile abdominal mass should raise a suspicion of infective mycotic aneurysm .
multidetector ct angiography is the imaging modality of choice for the detection and characterization of infected aneurysms .
the imaging features of infected aneurysms of the aorta vary from the typical features of atherosclerotic aneurysms in both pattern of involvement and location of aneurysms
. early changes of aortitis preceding aneurysmal formation include an irregularly thickened arterial wall , peri - aortic edema , and a peri - aortic soft tissue mass .
tubercular abdominal aortic aneurysms are of saccular type having multilobulated appearance with thickened , hazy , and interrupted wall , along with adjacent necrotic lymphadenopathy and vertebral erosions .
the other differential diagnoses include aneurysms secondary to cystic medial necrosis and lymphomas due to other malignant retroperitoneal infiltrative lymph nodal masses
. the specific management of an infected aneurysm must be individualized and is dependent on the characteristics of the aneurysm ( location , morphology , and presence and extent of hemorrhage ) , patient characteristics , and available expertise .
therapeutic options include open surgery , endovascular stent placement , endovascular embolization , medical therapy , or a combination of these .
in general , small , asymptomatic , and unruptured infected aneurysms can be managed with a trial of intravenous antibiotics for 46 weeks along with surveillance imaging .
our patient was put on anti - tubercular drug therapy for 9 months and on follow - up , the patient responded well to drug therapy as there was reduction in the size of the retroperitoneal lymph nodes compared to the previous pre - treatment scans . following drug therapy
, the patient underwent endovascular stenting procedure and is doing well at present without any postoperative complications .
large , ruptured , or symptomatic infected aneurysms require emergent or urgent open surgery in combination with antibiotic therapy .
infected aneurysms show a mixed response to medical therapy , and there are no predictive imaging features .
they can undergo complete thrombosis , decrease in size , or enlarge , or new infected aneurysms can develop . enlarging or residual aneurysms at surveillance imaging are triaged to surgical management .
newer endovascular techniques remain controversial because the introduction of a foreign body within an infected field is against general surgical principles .
worldwide , the incidence of tuberculosis is increasing with cases reported from the western world due to its association with acquired immunodeficiency disease / human immunodeficiency virus ( hiv ) infection .
early detection of aortic tubercular lesions in patients should play a key role in the efficiency of tubercular aortic aneurysm treatment .
tuberculosis is a common disease in developing countries and can affect any organ system , with unusual features and systemic manifestations .
tuberculosis is endemic in developing countries and its incidence has also increased in the western world , especially among patients with hiv infection .
this case report presents a case of multiple mycotic aneurysms of abdominal aorta of tubercular etiology in a young male to highlight the unusual manifestations of systemic tuberculosis .
multidetector ct is an essential tool in identifying the etiology , pathogenesis , protean manifestations of systemic tuberculosis , and ultimately deciding the course of treatment .
 infective mycotic aneurysm of the aorta is a rare and life - threatening disease . 
 a patient presenting with constitutional symptoms and pulsatile abdominal mass should raise a suspicion of mycotic aneurysm . 
 early detection of aortic mycotic lesions in such patients should play a key role in the treatment of aortic aneurysms . 
 multiple mycotic aneurysms of abdominal aorta in a young male are a rare manifestation of the disease . multidetector computerized tomography ( ct ) 
 is an essential tool in identifying the etiology , pathogenesis , protean manifestations of systemic tuberculosis , and ultimately deciding the course of treatment . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION
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