Infective endocarditis complicated by aortic graft infection and osteomyelitis: case report and review of literature

Elie Zouein,¹ Robert Wetz,¹ Neville Mobarakai,¹ Samer Hassan,¹ Iris Tong<sup>2

1</sup>Department of Medicine, Staten Island University Hospital, New York, NY USA; ²Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA

Abstract: Primary aortic graft infection early after aortic graft insertion is well described in the literature. Here, we present a unique case of late aortic graft infection 5 years after insertion secondary to mitral valve endocarditis, resulting from cellulitis in a patient with severe venous varicosities. A 63-year-old male presented for severe low back pain, constipation, and low-grade fever. An abdominal computed tomography scan with oral and intravenous contrast showed a normal spine and urinary tract. Blood and urine cultures, done at the same time, grew Staphylococcus aureus. A transesophageal echocardiogram confirmed the diagnosis of endocarditis. Subsequently, a gallium scan showed increased uptake in the vertebral bodies, aortic graft, left patella, and left ankle. After 3 months of antibiotic therapy, the patient's low back pain resolved with normalization of his laboratory values. He remained free of infection at a 2-year follow-up. We reviewed the literature concerning the atypical presentation of infective endocarditis, with a focus on distant metastases at initial presentation, such as osteomyelitis and aortic graft infection, as well as the different treatment modalities. This report describes successful medical treatment with intravenous followed by oral antibiotics for an infected endovascular graft without any surgical intervention.

Keywords: endocarditis, osteomyelitis, aortic graft infection, septic emboli, endovascular abdominal aortic aneurysm repair (EVAR)