Uncovering the unforeseen: pericarditis and mycotic coronary aneurysm at previous stent site

Article information

Korean J Intern Med. 2023;38(5):779-780

Publication date (electronic) : 2023 June 9

doi : https://doi.org/10.3904/kjim.2023.124

Sook-Jung Kim ¹^,², Osung Kwon ¹^,², Jeong-Eun Yi ¹^,², Joon-Kyu Kang ³, Yun-Seok Choi ²^,⁴

¹Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

²Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea

³Department of Thoracic and Cardiovascular Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seou, Koreal

⁴Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Correspondence to: Yun-Seok Choi, M.D., Ph.D., Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea, Tel: +82-2-2258-6783, Fax: +82-2-536-3810, E-mail: cys71@catholic.ac.kr, https://orcid.org/0000-0002-1659-1728

Received 2023 March 14; Revised 2023 March 22; Accepted 2023 March 27.

A 72-year-old man with persistent pericarditis who had been treated for Dressler’s syndrome but did not show improvement of symptoms was transferred to our hospital. He had had right coronary artery stenting for ST-elevation myocardial infarction a month earlier and was prone to cholangitis. An echocardiogram revealed decreased pericardial effusion, and Escherichia coli was detected in a blood culture test after admission. Because the patient had cholangitis, endoscopic retrograde cholangiopancreatography (ERCP) was performed. Blood tests revealed elevated levels of myocardial enzymes and inflammatory markers even after ERCP and antibiotic treatment. An echocardiogram was performed to confirm increased pericardial effusion. Computed tomography revealed a 3-cm-sized contrast-enhanced lesion around the right coronary artery (Fig. 1). Consequently, coronary angiography was performed, and a massive right coronary aneurysm near the previous stent was confirmed (Fig. 2), indicating a mycotic coronary aneurysm. Thus, we decided to perform coronary artery bypass surgery with aneurysm resection. Massive adhesions and abscess formation were detected when the pericardium was dissected, and the ruptured aneurysm was discreetly covered by the brittle adhesive inflammatory pericardium. The final echocardiogram revealed no pericardial effusion after 4 weeks of antibiotic treatment.

Figure 1

Abdomen computed tomography scan revealed a fresh pericardial effusion with rim enhancement. The yellow arrow indicates a rim enhencement lesion near the right coronary aneurysm.

Figure 2

Coronary angiography reveled a huge right coronary aneurysm adjacent to the previously placed stent. The yellow arrow indicates the site of the previous stent.

An infected coronary artery aneurysm is an extremely rare complication of percutaneous coronary intervention (0.3% to 0.6%) [1], and its combination with pericarditis is an even rarer but potentially fatal condition [2]. Interestingly, in this case, the ruptured aneurysm was concealed by massive adhesions, saving the patient from shock or unstable condition. Because lesions > 1 cm in diameter increase risk of aneurysm growth and rupture, coronary artery bypass surgery and aneurysm resection were required to avoid fatal rupture and uncontrolled infection.

Notes

Credit Authorship Contributions

Sook Jung Kim: writing - original draft, writing - review & editing; Yun-Seok Choi: conceptualization, writing - review & editing, supervision; Osung Kwon: conceptualization, writing - original draft, writing - review & editing; Jeong Eun Yi: validation, supervision; Joon-Kyu Kang: supervision

Conflicts of interest

The authors disclose no conflicts.

Funding

None

References

1. Chen IC, Chao TH, Wu IH, Kan CD, Fang CC. Afebrile mycotic aneurysm with rupture in right coronary artery after bare-metal stent implantation. Acta Cardiol Sin 2012;28:344–8.

2. Berrizbeitia LD, Samuels LE. Ruptured right coronary artery aneurysm presenting as a myocardial mass. Ann Thorac Surg 2002;73:971–3.

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Figure 1

Abdomen computed tomography scan revealed a fresh pericardial effusion with rim enhancement. The yellow arrow indicates a rim enhencement lesion near the right coronary aneurysm.

Figure 2

Coronary angiography reveled a huge right coronary aneurysm adjacent to the previously placed stent. The yellow arrow indicates the site of the previous stent.