Occluded mycotic popliteal aneurysm secondary to infective endocarditis.

Introduction brachial pressure index of 0.23. Urgent ultrasound examination of the popliteal fossa showed the popliteal A patient with infective endocarditis required an emerartery to be of normal calibre, with no embolic source identified. The following day, angiography demgency mitral valve replacement. During this illness, he developed sudden calf pain initially diagnosed as onstrated focal dilatation of the artery, with an embolus occluding a suspected mycotic popliteal aneurysm. deep venous thrombosis. He in fact had an ischaemic leg secondary to a mycotic popliteal aneurysm. Both The anterior tibial artery was patent, supplied by a large medial genicular branch with unusually high lesions were resected simultaneously. take-off. Simultaneous resection of the mycotic popliteal aneurysm and mitral valve replacement was performed Case Report six days after the originally scheduled valve replacement. A two-centimetre, occluded popliteal anA 50-year-old African male presented with previously eurysm, exuding pus, was noted and resected using undiagnosed infective endocarditis. Echocardiography a reversed long saphenous vein interposition graft. demonstrated large mitral valve vegetations and Full-length, three-compartment fasciotomies were persevere mitral regurgitation. He required urgent mitralformed. When opened, the resected aneurysm was valve replacement. Intravenous benzylpenicillin, fluseen to house a large ‘vegetation embolus’, which cloxacillin and gentamicin therapy was started imcompletely occluded it (Fig. 1). A second large vegetamediately. Streptococcus intermedius, fully sensitive to tion was seen in place of the mitral valve. This was these antibiotics, was grown from blood cultures taken replaced with a Starr–Edwards prosthesis. The patient prior to starting this therapy. made an uneventful postoperative recovery, with no Four days after admission, he developed suddenresidual symptoms or signs of leg ischaemia. onset, severe calf pain, with muscle tenderness but no leg-swelling. Initially, a deep venous thrombosis was suspected and he was anticoagulated. However, Discussion neither venous duplex-ultrasound examination (nor venography) showed any evidence of venous thromThe mortality from infective endocarditis was virtually bosis. Subsequently, upon surgical review, he was 100% until the introduction of penicillin, when it found to have an ischaemic leg. The dorsalis pedis dropped to 30–40%. There has been little further artery only could be Doppler-insonated, with an ankle– reduction since, probably because of the increasing diversity of causative organisms, the inherent sus∗ Please address all correspondence to: C. F. Mann, 2 Wharfedale ceptibility to infection of prosthetic valves, and an Terrace, Linton Road, Collingham, Wetherby, Yorkshire LS22 5BT, U.K. ageing population. Emergency surgery is required