a 64-year - old male with past medical history of hypertension , hyperlipidemia , and peripheral artery disease with left carotid endarterectomy that was done 8 years ago , who was treated for salmonella enteritis 4 months ago with ciprofloxacin 500 mg tablet twice daily for 10 days , presented with complains of nausea , vomiting , and abdominal pain .
he had experienced these symptoms on and off since he was treated for enteritis , but worsened prior to admission . on examination
, he had a temperature of 103.5f ; heart rate , 87 beats / min ; blood pressure , 133/85 mm hg ; and oxygen saturation 97% on room air .
laboratory workup was normal except for a white cell count of 14,600/mcl and hemoglobin of 11.2 g / dl .
( iv ) contrast that was done to evaluate for abscess showed a fusiform 3.4-cm infrarenal , abdominal , aortic aneurysm along with an adjacent 2.12.12.7-cm mycotic aneurysm ( figs . 1 and 2 ) .
after a discussion with vascular surgery team regarding the risk benefits of evar versus open surgery , the patient opted for an interval endoluminal graft placement after completion of antibiotic therapy . after a week of iv antibiotics , repeat ct angiogram of the abdomen was done .
he was discharged home with 6 weeks of ceftriaxone and advised to follow - up with infectious disease and vascular surgery for endoluminal graft placement .
he successfully underwent interval evar and was doing well until 18 months after evar without any postoperative infectious complications ( figs . 3 and 4 ) .
the patient had a passion for hunting turtles and reported eating them cooked almost once every 23 months for the past 15 years .
ct angiogram of abdomen and pelvis  transverse section showing the mycotic aneurysm . ct angiogram of abdomen and pelvis  sagittal section showing the mycotic aneurysm . ct angiogram of abdomen and pelvis  status post - evar with successful exclusion of the mycotic aneurysm . ct angiogram of abdomen and pelvis ( coronal view )  status post - evar with aorto - bi - femoral graft .
the salmonellae are a heterogeneous group of bacteria in the genus salmonella of the family enterobacteriaceae .
the centers for disease control and prevention ( cdc ) currently recognizes two species : salmonella enterica ( 6 subspecies ) and salmonella bongori ( 1 subspecies ) .
salmonella are usually known to cause gastroenteritis , which rarely requires antibiotic therapy . immunocompromised and elderly population
are prone to develop extra - intestinal complications , the most feared being infected aneurysms of the abdominal aorta ( 1219 ) .
salmonella typhimurium ( serogroup b ) , salmonella enteritidis ( serogroup d ) , and salmonella choleraesuis ( serogroup c ) are the common serotypes associated with mycotic abdominal aneurysm ( 20 , 21 ) , s. enteritidis is more common in europe compared to east asia where non - typhoidal salmonella is more common ( 10 , 2226 ) . 

salmonella has a predisposition to attach to vascular endothelium , more so in atherosclerotic blood vessels ( 1 ) .
however , the exact mechanism and pathogenesis of salmonella causing the mycotic abdominal aneurysm is still unclear ( 6 ) .
recurrent and latent infections are possible from salmonella due to mechanisms that promote intracellular survival ( 27 ) . mode of transmission of salmonella is fecal  oral and vehicle - borne .
infection may result from ingesting water or food that has been contaminated with animal or human feces , or from direct exposure to the same ( 28 ) .
. however , some of the common presenting symptoms are fever , pain , shock , and leukocytosis ( 6 ) .
widespread use of ct scan to evaluate for unexplained abdominal symptoms and sepsis has led to the early identification of mycotic abdominal aneurysm ( 6 ) .
the food and drug administration ( fda ) prohibits the selling of turtles with a shell under 4 inches in length in an effort to prevent contact with turtles carrying the salmonella bacteria .
the cdc recommends that children , pregnant women , and persons with compromised immune systems avoid contact with reptiles to prevent contact with the salmonella bacteria ( 29 ) .
small pet turtles are of particular concern because children are more prone to handling them without washing their hands after , and even put the turtles in their mouths ( 29 ) .
infectious disease specialists estimate that banning small turtles as pets prevents 100,000 salmonella infections in children each year in the united states ( 29 ) .
it is a popular option to treat with at least 6 weeks of oral or parenteral antibiotics ( 1 , 30 ) .
however , recent studies have shown that most recurrent infections occurred in the first 612 months after the procedure and the majority of the fatal infections and sepsis - related complications developed after discontinuing the antibiotics ( 1 ) .
these finding are suggestive of a potential benefit from long - term antibiotic therapy for 6 months to 1 year , or lifelong based on a case - by - case basis .
positive blood cultures for salmonella during the initial postoperative period have a favorable outcome compared to non - salmonella - positive blood cultures .
the same antibiotics would be less beneficial in patients who have a non - salmonella infection ( 1 , 10 , 3133 ) .
open surgery ( debridement and surgical resection of the infected aorta and the surrounding tissues , the use of body tissue to cover the infected field , and either an extra - anatomic bypass or in situ interposition graft ) followed by long - term antibiotic therapy has been the gold standard treatment but is associated with increased mortality and morbidity ( 1 , 9 , 10 , 23 , 32 , 3438 ) .
it has a short - term mortality of 2040% although there is not sufficient data to comment on long - term outcomes ( 10 , 23 , 3438 ) .
anatomical position of the aneurysm sometimes makes open conventional surgery a less preferred option ( 1 , 9 ) .
it has the potential to become a popular alternative to open conventional surgical management , either as a permanent management option , or as a temporary bridge to stabilize the patient prior to open surgery .
insertion of a graft in acute infection prior to completing a course of antibiotics is controversial .
hence , interval evar ( after a full course of antibiotic therapy ) might help prevent late infection complications .
however , in evar , there is a potential nidus for a late infection of the graft and sepsis . a recent retrospective study done by sorelius et al .
( 1 ) analyzed that evar is a feasible and durable treatment option for patients with mycotic aneurysms .
post - evar , their study showed a 1-month survival of 91% and a120-month survival of 41% ; however , only 19% deaths were due to infection .
non - salmonella - positive blood cultures were associated with increased mortality from late infection ( 1 ) .
in mycotic abdominal aneurysm patients who do not pursue either surgical or endovascular treatment , studies have shown up to a 75% mortality rate from complications related to mycotic aortic aneurysm(6 ) .
there is a possibility of selection bias in the study done by huang et al .
however , details of the indications leading up to an open surgery versus evar were not mentioned . based on this case report
, it might be appropriate to mention that patients with vascular disease should be discouraged from hunting and handling turtles , for the fear of contracting salmonella and then the risk of mycotic aortic aneurysm .
based on the review of literature , in a patient with salmonellosis having abdominal pain , especially in patients with risk factors such as elderly age , atherosclerosis , and immunosuppressed status , a ct scan of the abdomen should be done to detect a possible mycotic aneurysm ( 12 ) .
ct is excellent in preoperative and postoperative evaluation of aneurysms and their potential complications ( 39 ) .
clinical significance : have a low threshold to get a ct scan of the abdomen in salmonellosis patients with risk factors and abdominal symptoms.in salmonella mycotic abdominal aneurysm , there could be potential benefit from long - term antibiotic therapy for 6 months to 1 year or lifelong . 

evar has the potential to become a popular alternative to open conventional surgical management of mycotic abdominal aneurysm as late infections are a major complication of the latter
. 
  have a low threshold to get a ct scan of the abdomen in salmonellosis patients with risk factors and abdominal symptoms . in salmonella
mycotic abdominal aneurysm , there could be potential benefit from long - term antibiotic therapy for 6 months to 1 year or lifelong . 

evar has the potential to become a popular alternative to open conventional surgical management of mycotic abdominal aneurysm as late infections are a major complication of the latter .
 
 salmonella - associated mycotic aneurysm is a rare , but dreaded , complication of salmonellosis . 
 immunocompromised and elderly populations are more susceptible to develop this extra - intestinal complication . 
 salmonella is spread via fecal  oral and vehicle - borne routes . 
 reptiles , especially small pet turtles , have been linked with an increased risk of salmonella infection . 
 diagnosis of mycotic aneurysm is a challenge due to atypical presentations . 
 recently , widespread use of ct scan imaging to evaluate for unexplained abdominal pain and sepsis has led to early identification of mycotic aneurysms . 
 antibiotic therapy and surgical intervention are the cornerstones of management . 
 open surgery has been the gold standard of treatment but is associated with increased morbidity and mortality . 
 a relatively new alternative to open surgery is endovascular aneurysm repair ( evar ) . 
 it is comparatively less invasive and is associated with reduced early morbidity and mortality in the setting of mycotic aneurysm . 
 however , there is a risk of late infection . here 
 , we present a patient with salmonella mycotic aneurysm initially treated conservatively with antibiotic therapy who later underwent successful interval evar with no complications to date . 
 also included is a brief review of salmonella - associated mycotic aneurysms . 