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Mycotic aneurysm of the left pulmonary artery in a child with tetralogy of Fallot and Streptococcus viridans infective endocarditis

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A 2 year 8 month old girl with tetralogy of Fallot and a right modified Blalock-Taussig shunt was seen in January of 1998 with fever of a month’s duration. The shunt had been created 11 months previously following a life threatening hypercyanotic spell. She had the physical signs of tetralogy as well as pneumonia. The shunt murmur was no longer audible.

A Streptococcus viridans organism was cultured on two occasions from her blood. Echocardiography showed large masses consistent with vegetations proximal to the pulmonary valve and extending into the main pulmonary artery. Both branches of the pulmonary artery were dilated. After six weeks of antibiotic treatment she underwent cardiac catheterisation. This confirmed the clinical and echocardiographic diagnosis and showed the aneurysm. The figure is a digitally subtracted image obtained during angiography (left anterior oblique projection with cranial angulation). The tip of the catheter lies in the right ventricular outflow tract and contrast is seen to fill the main pulmonary artery and both branches. There is an aneurysm in the left pulmonary artery, which is 1.8 cm diameter at its widest point.

The patient underwent full repair on cardiopulmonary bypass. At surgery the mycotic aneurysm could not be seen as it was within the parenchyma of the left lung. The wall of the right pulmonary artery was indurated. There were no vegetations within the pulmonary arteries. The repair and subsequent postoperative course were uneventful. The patient was well 10 months after her initial illness.