We postulate that the hematogenous spread of bacteria from a laceration in the leg as well as the presence of the pancreaticoduodenal fistula was likely the cause of the infectious EA in this case, considering the patient’s underlying uncontrolled T2DM. The patient’s prior left lower extremity vascular graft also may have provided a nidus for spreading to the aorta. Other reported underlying diseases of EA include aortic atherosclerosis, T2DM, diverticulitis, colon cancer, underlying aneurysm, immune-compromised status, and the presence of a medical device or open surgery.4-7,9
To our knowledge, this is the first case of EA associated with a pancreaticoduodenal fistula related to intraductal papillary mucinous neoplasm (IPMN). Fistulation of a main duct IPMN is rare, occurring in just 6.6% of cases.10 It can occur both before and after malignant degeneration.
EA requires rapid diagnosis, antibiotic therapy, and consultation with a vascular surgeon for immediate resection of the infected artery and graft bypass. The initial treatment of suspected infectious aortitis is IV antibiotics with broad antimicrobial coverage of the most likely pathologic organisms, particularly staphylococcal species and Gram-negative rods. Surgical debridement and revascularization should be completed early because of the high mortality rate of this condition. The intent of surgery is to control sepsis and reconstruct the arterial vasculature. Patients should remain on parenteral or oral antibiotics for at least 6 weeks to ensure full clearance of the infection.8 They should be followed up closely with serial blood cultures and CT scans.8 The rarity of the disorder, low level of awareness, varying presentations, and lack of evidence delineating pathogenesis and causality contribute to the challenge of recognizing, diagnosing, and treating EA in patients with T2DM and inflammation.
Conclusions
This case report can help bring awareness of this rare and potentially life-threatening condition in patients with T2DM. Clinicians should be aware of the risk of AE, particularly in patients with several additional risk factors: recent skin/soft tissue trauma, prior vascular graft surgery, and an underlying pancreatic mass. CT is the imaging method of choice that helps to rapidly choose a necessary emergent treatment approach.