Mycotic aneurysm is a much-feared complication of vascular surgery. Management in the non-transplant situation often utilises placement of an endovascular prosthetic graft and long-term antibiotics. In formally immunosuppressed patients the ongoing likely infection of the prosthesis is of great concern.

We describe the case of a 29-year-old recipient of a liver small bowel transplant who developed a mycotic aneurysm of the donor aortic conduit two months after transplantation.

She had undergone an isolated liver transplant at the age of two for alpha 1 antitrypsin deficiency. This was complicated after transplantation by a volvulus of her small bowel, leaving her with 30 cm of jejunum and dependent on parenteral nutrition till the age of 13. Graft failure, 27 years later, necessitated the need for re-transplantation and at this stage a liver small bowel transplant was performed.

Four weeks post-transplant, she developed a pyrexia of unknown origin and at that stage cross sectional imaging was unremarkable. This was repeated two weeks later and still no source of sepsis could be determined. A Further CT two weeks later demonstrated a 2 cm mycotic aneurysm in the mid portion of the donor aortic conduit, (Image 1).

Initial management involved endovascular stenting and antibiotics to gain immediate control, followed by a definitive surgical intervention.

A third-party donor thoracic aortic conduit was acquired (blood group compatible) and at laparotomy the infected graft and stent were removed and replaced with the new conduit. Culture of the stent and aortic tissue grew vancomycin resistant enterococci (VRE) and Candida glabrata, necessitating six weeks of antimicrobial treatment (linezolid and liposomal amphotericin).

Five and a half weeks after initiation of linezolid therapy the patient developed profound lactic acidosis and severe pancreatitis requiring ICU admission and haemofiltration for the symptomatic lactic acidosis. Following discontinuation of linezolid, the pancreatitis and lactic acidosis resolved.

She is now four months after the vascular reconstruction and is well with no evidence of recurrence of the aneurysm (Image 2) and no recurrent VRE.

She has developed CMV disease from the third-party tissue. This is an important consideration when considering matching for third party tissues and prophylaxis must be reviewed.