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Magnetic resonance angiography (MRA) and transoesophageal echocardiography together are very useful imaging techniques in the evaluation of thoracic aortic pseudoaneurysms. A 63 year old hypertensive man was admitted to a community hospital by his primary care physician with three weeks history of night sweats, chills, fever, fatigue, and generalised myalgia. Blood cultures done in the outpatient clinic revealed group D salmonella bacteraemia. Transthoracic echocardiogram, abdominal computed tomography (CT), and ultrasound were normal. CT of the chest showed increased density within the anterior mediastinum, suspicious of an aortic pseudoaneurysm.
MRA of the thoracic aorta (left) showed two infected pseudoaneurysms, one in the descending aorta starting below the aortic arch (A), extending 7 cm caudally, and another smaller one in the lesser curve of the aortic arch (B). The latter (B) was missed on transoesophageal echocardiography, although the former (A) was seen clearly. Preoperative coronary angiography showed critical three vessel disease. The patient successfully underwent resection of aneurysms with Dacron patch repair of the lesser curve and Hemashield tube graft repair of the descending aorta. He was given ceftriaxone for a week and later switched to levofloxacin, which he has been taking long term.
Once invariably a fatal condition, infected aortic pseudoaneurysms can now be cured in most cases if diagnosed early and treated with appropriate surgical technique and antibiotic. Both MRA and transoesophageal echocardiography complement each other in the evaluation of this condition.