Damage to the vasa vasorum of blood vessels due to vasculitis may result in the formation of cerebral mycotic aneurysm that can rupture and result in massive intra cranial bleeding. We report an adolescent boy who presented with hemorrhagic stroke due to ruptured mycotic aneurysm associated with Klebsiella endocarditis of aortic valve cusps.

A 14-year-old boy presented with right hemiparesis and aphasia with a history of fever, joint pain, palpitations and left sided chest pain. His blood pressure was more than 95th percentile; fundus examination showed multiple superficial and deep hemorrhages. He had anaemia, polymorphonuclear leukocytosis, elevated ESR, elevated ASO titer and positive C-reactive protein. Blood culture reported growth of Klebsiella pneumoniae. Renal profile, coagulation profile and renal doppler studies were normal; anti-nuclear antibodies were negative.

2D and M-mode echocardiography revealed eccentric closure of aortic valve cusps suggestive of cusp damage and moderate aortic regurgitation. There were vegetations involving anterior aortic valve extending into left ventricle. Brain computed tomography (CT) revealed intra-cerebral bleed in the left middle cerebral artery territory. CT angiogram was suggestive of ruptured mycotic aneurysm with perifocal edema and mass effect (Fig. 1). The patient was managed conservatively with decongestive measures and intravenous antibiotics for 6 weeks. Neurological status of child improved with residual paresis at the time of discharge.

Fig. 1 CT angiogram demonstrating intracerebral bleeding in the left parieto-occipital lobe with outpouching in the distal branch of left middle cerebral artery suggestive of ruptured mycotic aneurysm.

Mycotic aneurysm rupture often has a disastrous clinical course in which morbidity and mortality can be reduced by early diagnosis and appropriate antimicrobial therapy [1,2]. Klebsiella endocarditis, though rare, can have far more devastating consequences [3]. Current management options for mycotic aneurysm include medical, surgical and endovascular therapy. Solitary mycotic aneurysm is known to resolve with medical therapy and surgical intervention is reserved only when these are multiple, enlarging or not responding to conservative treatment [4].

Acknowledgements: Dr Sachin Mukundan Unny and Dr Monika Lazrus.

1. Singla V, Sharma R, Nagamani AC, Manjunath CN. Mycotic aneurysm – A rare and dreaded complication of infective endocarditis. BMJ Case Rep. 2013; doi 10.1136/bcr-2013-200016.

2. Regelsberger J, Elsayed A, Matschke J, Lindop G, GryzyskaU, Vanden Boom L, et al. Diagnostic and therapeutic considerations for "mycotic" cerebral aneurysms: 2 case reports and review of the literature. Cent Eur Neurosurg. 2011;72:138-43.

3. Anderson MJ. Tanoff EN. Klebsiella endocarditis: Report of two cases and review. Clin Infect Dis. 1998;26:468-74.