Streptococcus bovis - Gundersen Lutheran Health System

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eferenCeS 1. Houghton A, Aston N. Appendicitis complicating colonoscopy. Gastrointest Endosc. 1988;34:489. 2. Vender R, Larson J, Garcia J, Topazian M, Ephraim P. Appendicitis as a complication of colonoscopy. Gastrointest Endosc. 1995;41:514-516. 3. Hirata K, Noguchi J, Yoshikawa I, et al. Acute appendicitis immediately after colonoscopy. Am J Gastroenterol. 1996;91:2239-2240. 4. Lipton S, Estrin J. Postcolonoscopy appendicitis: a case report. J Clin Gastroenterol. 1999;28:255-256. 5. Srivastava V, Pink J, Swarnkar K, Feroz A, Stephenson BM. Colonoscopically induced appendicitis. Colorectal Dis. 2004;6:124-125. 6. Izzedine H, Thauvin H, Maisel A, Bourry E, Deschamps A. Post-colonoscopy appendicitis: case report and review of the literature. Am J Gastroenterol. 2005;100:2815-2817. 7. Rosen MJ, Sands BE. Acute appendicitis following colonoscopy. J Clin Gastroenterol. 2005;39:78. 8. Volchok J, Cohn M. Rare complications following colonoscopy: case reports of splenic rupture and appendicitis. JSLS. 2006;10:114-116. 9. Petro M, Minocha A. Asymptomatic early acute appendicitis initiated and diagnosed during colonoscopy: a case report. World J Gastroenterol. 2005;11: 5398-5400. 10. Chang HS, Yang SK, Myung SJ, et al. The role of colonoscopy in the diagnosis of appendicitis in patients with atypical presentations. Gastrointest Endosc. 2002;56:343-348. 11. Johnson TR, DeCosse JJ. Colonoscopic diagnosis of grumbling appendicitis. Lancet. 1998;351:495. CoLonoSCopiC diAGnoSiS of AppendiCitiS 12. Uehara A, Ohta H, Nagamine M, Kawashima T, Kuribayashi H, KohgoY. Colonoscopic diagnosis of asymptomatic acute appendicitis. Am J Gastroenterol. 2000;95:3010-3011. 13. Nyam DC, Davendran K, Seow-Choen F. An endoscopic diagnosis of appendicular intussusception in chronic appendicitis. Singapore Med J. 1997;38:131. 14. Said M, Ledochowski M, Dietze O, Simader H. Colonoscopic diagnosis and treatment of acute appendicitis. Eur J Gastroenterol Hepatol. 1995;7:569-571. 15. Chen YY, Soon MS, Yen HH. Images of interest. Gastrointestinal: colonoscopic features of acute appendicitis. J Gastroenterol Hepatol. 2005;20:1940. 16. Courtney ED, Melville D, Leicester RJ. Chronic appendicitis diagnosed incidentally by colonoscopy. Hosp Med. 2003;64:434-435. 17. Theilmann L, Bachmann K, Kuhl PG. An unusual presentation of chronic appendicitis. Endoscopy. 2003;35:377. 18. Johnson EA, Spier BJ, Mozena MG, Pfau PR. Colonoscopic clues cinch the diagnosis. Am J Med. 2007;120:942-944. 19. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006;241: 83-94. 20. Digestive Disorders & Injuries. Illinois Personal Injury Legal Resource Web site. //www.il-injury.com/html/digestive-disorders-injuries.html. Accessed March 24, 2008. 21. Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis and the use of diagnostic imaging. J Am Coll Surg. 2005;201:933-939. River Fog at Dawn Daniel Schraith Pathology Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009 17
Authors: Abhishek Tandon, MD Department of Medical Education Gundersen Lutheran Medical Foundation Steven B. Pearson, MD Department of Internal Medicine Gundersen Lutheran Health System Todd J. Kowalski, MD Section of Infectious Disease Gundersen Lutheran Health System Address for correspondence: Todd J. Kowalski, MD Mail Stop C02-007 Gundersen Lutheran Health System 1900 South Avenue La Crosse, WI 54601 Telephone: (608) 775-6882 Facsimile: (608) 775-5542 email: tjkowals@gundluth.org W Intracranial Mycotic Aneurysm Due to Streptococcus bovis Endocarditis AbStrACt illiam Osler first used the term mycotic aneurysm in his 1885 Gulstonian Lecture series1 to refer to an aneurysm resulting from an infectious process of the arterial wall, although a more accurate term might have been endovascular infection or infective vasculitis, because mycotic aneurysms are not due to a fungal organism. Intracranial mycotic aneurysms (ICMAs) complicate about 2% to 3% of infective endocarditis (IE) cases, although as many as 15% to 29% of patients with IE have neurologic symptoms. 2-4 Of all intracerebral aneurysms, only 2% to 6% have an infectious etiology. Signs and symptoms of mycotic aneurysms may be misleading during the early stages, resulting in misdiagnosis and delays in treatment. 5 Early diagnosis of ICMA is the cornerstone of effective treatment. CASe report A 63-year-old man had a 2-month history of headaches, malaise, decreased appetite, night sweats, low-grade intermittent fevers, and unintentional 10-pound weight loss. His headaches were spasmodic and intense, and would partially remit with acetaminophen. He reported no history of trauma, new neurological deficits, visual changes, sensory or visual aura, radiation to the neck, or positional variation. He denied use of tobacco, alcohol, and illicit drugs. The patient had an extensive medical history, including a remote history of hemorrhagic stroke, subacute bacterial endocarditis, sigmoid colon cancer with successful resection, and ischemic stroke. Post-stroke deficits included moderate weakness in his left arm and left leg, and moderate vocal cord impairment. Family history was significant for stomach cancer. The patient was in no acute distress. His vital signs were: temperature, 36.6°C; blood pressure, 140/100 mm Hg; respiratory Mycotic aneurysm usually appears as a painful, pulsatile, and often enlarging mass in a patient with associated systemic features of infection. This condition is usually fatal without treatment. We report the case of a patient with infective endocarditis who exhibited neurological signs and symptoms and was subsequently found to have multiple intracranial mycotic aneurysms. We also review the recent literature on the diagnosis and treatment of intracranial mycotic aneurysms. rate, 18 breaths/min; heart rate, 76 beats/min; and oxygen saturation, 100% on room air. He had a 2/6 systolic ejection murmur over the mitral area on cardiac examination. Pulses were equal bilaterally, and no pedal edema was noted. He had residual left-sided weakness and decreased sensation in his left arm and left leg. No meningeal or cerebellar signs were noted, and findings from examination of the cranial nerve were normal. Laboratory studies revealed hematuria, an elevated erythrocyte sedimentation rate (49 mm/hr), and an elevated white blood cell count (15 400/µL). Computed tomographic (CT) scan of the head revealed an acute right hemispheric hemorrhagic stroke with right basil ganglion hemorrhage. Computed tomographic angiography (CTA) was recommended by neurosurgery to evaluate for vasculitis or arteriovenous malformation, and revealed multiple cerebral aneurysms. When compared with old imaging studies, CTA showed a new, large aneurysm that, based upon its appearance, was believed to be mycotic. A new, lobulated, irregular aneurysm of the distal right internal carotid artery, a left internal maxillary artery aneurysm, and a left external carotid pseudoaneurysm—versus mycotic aneurysm—were noted. Blood cultures subsequently grew Streptococcus bovis in all bottles. Echocardiogram demonstrated bileaflet mitral valve prolapse with posterior leaflet rupture and vegetations on the mitral valve consistent with endocarditis. Neurosurgical consultation was obtained, and nonoperative management of the aneurysms was recommended due to their location and number. Thus, with this recommendation and the infectious nature of the disease, ceftriaxone was initiated. Unfortunately, the patient developed worsening hemodynamic parameters, specifically hypotension, and was transferred to the intensive care unit. Despite vigorous medical management, over the next several days he experienced 2 grand mal seizures and became unresponsive. A repeat CT scan of the head demonstrated extensive, 18 Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009
Page 1 and 2: Th e Gundersen Lu T h e r a n M e d
Page 3 and 4: editor David E. Hartman, PhD, BC-AN
Page 5 and 6: through our online Scholarly Activi
Page 7 and 8: competition practice of each subjec
Page 9 and 10: effect. These data suggest that the
Page 11 and 12: Authors: David E. Hartman, PhD, BC-
Page 13 and 14: discharge. Twelve patients (2%) dev
Page 15 and 16: pneumonia rates of 2.4%, versus 5.4
Page 17 and 18: Authors: Alexander D. Wade, MD Depa
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Page 25 and 26: figure 1. Radiograph depicting a 4-
Page 27 and 28: Authors: Meghana Raghavendra, MB, B
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Page 31 and 32: and nerve root avulsion. Simmel, in
Page 33 and 34: Authors: Brian E. Udermann, PhD, AT
Page 35 and 36: figure 2. Longtime LEHP member Don
Page 37 and 38: Summer Splendor Kelly Hodgson Kline

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