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This case highlights the aggressive nature of E. coli mycotic aneurysms and the complexities in managing supraceliac involvement.

May 20, 2026

B49-09 Escherichia Coli Supraceliac Mycotic Aneurysm: Explosive Growth Over Five Days

Key Points

This case highlights the aggressive nature of E. coli mycotic aneurysms and the complexities in managing supraceliac involvement.
Case presentation of a 79-year-old male with acute abdominal pain and E. coli bacteremia.
Imaging via CT scan revealed a rapidly growing supraceliac aneurysm with inflammatory changes.
Multidisciplinary evaluation to discuss intervention options and goals of care.
Initial aneurysm size was 3.2 cm, which increased to 5.0 cm by day 5 with new ulceration.
Patient was deemed a poor candidate for surgical repair and transitioned to hospice care.
No definitive surgical intervention was performed due to high risks and infection concerns.

Abstract

Abstract Background Infected (mycotic) aortic aneurysm is uncommon but highly lethal. Gram negative organisms comprise roughly one-third to one-half, with Escherichia coli (E. coli) reported in only 5-15% of positive culture cases. Although less common, E. coli associated with mycotic aortic aneurysms can be particularly aggressive and has rapid morphologic progression. Supraceliac involvement is less frequent than infrarenal, yet it is associated with greater rupture risk and requires complex repair due to its proximity to critical visceral branches. Presentation A 79-year-old male with history of hypertension, iron deficiency anemia, atherosclerosis risk factor (remote tobacco use) and chronic poor dentation (poor oral hygiene), frequent animal exposure (stray cats) presented to the hospital with acute, severe abdominal pain. He was found to have leukocytosis and multiple blood culture positive for E.coli; no urinary, gastrointestinal or oral source was identified. Initial computed tomography (CT) scan was significant for 3.2 cm aneurysm located between the celiac axis and superior mesenteric artery (SMA) with multiple penetrating ulcers and a large peri-aortic inflammatory collection concerning for containedrupture. Broad-spectrum intravenous (IV) antibiotics were initiated. Planned transfer for vascular evaluation to tertiary care center was delayed; repeat on day 5 due to worsening abdominal pain showed interval enlargement of the aneurysm to 5.0cm with new anterior ulceration. Imaging findings were concerning for impending rupture. Multidisciplinary review deemed patient poor candidate for open supraceliac repair. Palliative endovascular exclusion using a physician-modified endograft with prolonged IV antibiotics was discussed; risks included persistent infection/reinfection of the graft. After goals-of-care discussions, no intervention was performed. He transitioned to hospice and died shortly thereafter. Microbiologic confirmation was limited to blood cultures (no tissue obtained). Discussion This case shows alarming signs for infected aneurysm- Gram-negative bacteremia, saccular morphology with penetrating ulcers, peri-aortic inflammation, and rapid interval growth in days. Which were all present and supported the diagnosis despite the absence of tissue cultures. The supraceliac location amplifies rupture risk and creates limited options for intervention: definitive management usually requires complex open reconstruction, while endovascular repair in an infected field may temporize rupture risk, the procedure leaves infected tissue and a foreign body in situ, with risk of reinfection and substantial failure risk. In non-surgical candidates, management is a palliative balance betweenpreventing near-term rupture and mitigating infectious complications, aligned with patient’s goals. Rapid morphologic change plus Gram-negative bacteremia should trigger presumptive infected-aneurysm treatment, urgent multidisciplinary planning, and if feasible, timely, patient-centered palliative decision-making. This abstract is funded by: None

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