Infection of Aortic Endograft Caused by Coccidioidomycosis

Coccidioidomycosis (Valley fever) is an infection caused by the soil-inhabiting molds, Coccidioides immitis or Coccidioides posadasii.¹ Southern Arizona is an endemic region for this fungus, posing a unique challenge to the patients residing in this area. Of the 150,000 new coccidioidomycosis infections occurring annually in the United States, approximately 1% are disseminated infections and one-third of these cases are often fatal.^2, 3, 4

The incidence of endograft infection following endovascular abdominal aortic aneurysm repair is less than 1%.⁵ Overall, implanted prosthetics are devoid of microcirculation, which result in their increased risk of infection.⁶ Synthetic material grafts such as polytetrafluoroethylene (PTFE), Teflon^TM, and polyethylene terephthalate (PET), a form of polyester (Dacron or Terylene), are associated with a higher risk of infection compared to biological prosthetics such as homografts, xenografts, and autografts. Aortic endograft infection can be eradicated by graft excision and in situ or extra-anatomic replacement. This procedure is often associated with early postoperative morbidity and mortality. Occasionally there is a need for graft removal at a later time, secondary to the risk of reinfection. The incidence of endograft infection is less than 1%, but it is associated with a mortality rate of 25% in all types of infection.⁷ Coccidioides infections of aortic endograft are nearly devoid in the literature. There are reports exclusively detailing endograft infections with Candida species and Aspergillus species.⁸

Here we report a 76-year-old Caucasian male with notable prior Endologix Trivascular Ovation® stent graft platform placement in March 2013 for an abdominal aortic aneurysm. He presented to our institution in March 2018 with severe constitutional symptoms including night sweats, weight loss, as well as abdominal pain. He had a notable social history of being a 30 pack-year smoker, who quit decades ago, as well as occasional marijuana smoking. Vital signs were within normal limits at presentation and no salient physical examination findings other than midline abdominal tenderness were noted. He had no marked leukocytosis or elevated inflammatory markers. An initial magnetic resonance (MR) angiogram of the abdomen with contrast showed an infrarenal abdominal aortic aneurysm measuring 5.0 × 4.9 × 9.0 cm with findings of acute aortitis extending through the length of the endograft (Figure).

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-James Bardwell, DO, MBA^a, Jessica August, MD^b, Sumaya Farran, MD^b, Catalin Florita, MD^b, Fariba Donovan, MD, PhD^b,c, Tirdad T. Zangeneh, DO^b,c