Carotidynia and Fever

After the holiday weekend, people are back in action and solved/managed this complex case today. 53 yo F presenting with fevers, productive cough, nausea/vomiting/diarrhea with left neck/shoulder pain x 3 days. Tenderness was localized to area right below the angle of the jaw and overlying the carotid bifurcation.

She was eventually found to have a mycotic carotid aneurysm with thrombosis and concurrently also diagnosed with new MR and a mitral vegetation. She was transferred to the Vascular Surgery team and planned for surgical correction with resection of the arterial section and reconstruction with autologous vein while being covered with antibiotics.

Take home points:

• A mycotic aneurysm is a localized arterial dilation due to destruction of vessel wall by infection (commonly occlusion of vaso vasorum with bacteria/inflammation)
• Organisms with greatest affinity for arterial wall and likely etiological agents were found to be Staph and Salmonella
• CT angiogram can be used to determine if the aneurysm is infective vs inflammatory. Features to indicate infectious/mycotic origin: a)saccular/eccentric/multilocular aneurysm; b) soft tissue inflammation aorund it; c) intramural or surrounding air; and d) perivascular fluid collection
• Recommended antibiotics: vanc + zosyn/fluoroquinolone/ceftx
• Surgical resection +/- vascular reconstruction has better outcomes than endovascular repair if surgical risk is acceptable

Similar case report + review.