Intended for healthcare professionals

Endgames Case Review

Pyrexia in an older man, months after emergency

BMJ 2018; 362 doi: (Published 20 September 2018) Cite this as: BMJ 2018;362:k3224
  1. S M Moledina, FY2,
  2. A Dimarco, ST6 cardiology,
  3. H Sinclair, ST5 cardiology,
  4. S Arianayagam, consultant geriatrician
  1. Basingstoke and North Hampshire Hospitals, Basingstoke, UK
  1. Correspondence to Saadiq Moledina: saadiqmoledina786{at}

An 85 year old caucasian man presented to hospital with a three day history of feeling generally unwell. He had undergone emergency endovascular aortic aneurysm repair five months before presentation and had made a poor recovery, regaining limited function. On examination, he was febrile and drowsy with a Glasgow coma scale score of 13. Blood tests showed an elevated C reactive protein (250 mg/L, reference range <4) with a normal leucocyte count. His serum creatinine was 151 mmol/L (59-104) and albumin was 19 g/L (34-50). High sensitivity troponin I was raised at 2823 ng/L (<50), and there were no electrocardiographic changes suggestive of myocardial ischaemia and no history of chest pain. These features are suggestive of a type 2 myocardial infarction; however, blood cultures grew Staphylococcus aureus. The man underwent a computed tomography scan (fig 1).

Fig 1

Computed tomography scan slice at the level of the aortic graft shows gas bubbles (arrow) in the peri-graft space


  • 1. What is the most likely diagnosis?

  • 2. How is this diagnosis confirmed?

  • 3. How would you manage this patient?


1. What is the most likely diagnosis?

The air bubbles around the vascular graft indicate endovascular graft infection. This is most commonly associated with Staphylococcus aureus or Staphylococcus epidermidis, and can lead to infective endocarditis. Consider intraoperative contamination, haematogenous spread, and postoperative colonic ischaemia as potential causes. Other sources of Staphylococcus bacteraemia include cellulitis, pneumonia, osteomyelitis, and discitis. Predisposing factors include immunocompromised status, pre-existing prosthetic material, dialysis, or indwelling venous catheters.


Endovascular abdominal graft infection is rare, with an incidence of around …

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