MYCOTIC ANEURYSM of the coronary artery in the absence of underlying endocarditis is rare. Most diagnoses are made at necropsy, and the condition is usually associated with infective endocarditis. 1 We report the case of a patient with fatal ruptured right coronary artery mycotic aneurysm without infective endo- carditis. CASE REPORT A 61-year-old man was admitted to the hospital because of fever and chest pain. He had been well until 4 weeks before admission, when fever and chills developed, fol- lowed by continuous chest pain for 2 days. Chest pain recurred 2 weeks before admission, associated with epigas- tric pain, nausea, and sore throat. All symptoms subsided spontaneously. One week before admission, the patient had pain in the shoulders. He was seen at another hospi- tal, where the diagnosis of pericarditis was made. Oral cor- ticosteroid and aspirin were prescribed, and he was trans- ferred to our hospital. His medical history revealed mild hypertension. On physical examination, the heart rate was 72/ min, blood pressure was 130/ 80 mm Hg, and the heart, lungs, abdomen, and extremities appeared normal. An electrocardiogram revealed sinus rhythm, heart rate of 75/ min, and nonspecific alterations of the ST segment and T waves. Laboratory screening tests were unrevealing, except for the finding of leukocytosis (20,400/ mm 3 with 84% neutrophils and 2% band forms). Transthoracic echocardiography showed a mild pericardial effusion and no abnormalities of the cardiac valves or of contractile function. Soon after admission, the patient had hypotension and cardiogenic shock, which initially responded to saline infu- sion and oxygen. Next morning, the patient had bradycar- dia and died. Blood cultures drawn on admission were negative. At complete necropsy, the pericardium was found to be turgid and filled with clot, consistent with cardiac tampon- ade. Anatomic dissection of the heart revealed left ventric- ular hypertrophy and a large hematoma within the wall of the right ventricle. The hematoma was located on the atri- oventricular groove, along the right coronary artery (Figure, a). Consecutive sections in that region disclosed a disruption in the wall of the right coronary artery, along with some degree of atrophy in the vessel wall. Histologic examination revealed acute inflammation and polymor- phonuclear infiltration within the artery wall, near the point of disruption. Several fragments of the artery, along with colonies of gram-positive cocci and purulent exudate, were found inside the hematoma (Figure, b). Atheroscle- rotic lesions were present in all coronary arteries. Exami- nation of cardiac valves was completely normal, without any signs of endocarditis. There was no evidence of infec- tion or abnormality in the kidneys, spleen, liver, and other organs. Ruptured right coronary artery aneurysm and car- diac tamponade were the cause of death in this patient. DISCUSSION Coronary artery aneurysms have been re- ported in 0.3% to 4.9% of angiograms, 2,3 and they may be congenital or acquired. Con- genital aneurysms more frequently affect the right coronary artery in men. 4 During child- hood, most of the acquired aneurysms are due to Kawasaki disease, 5 whereas in the adult, ath- erosclerosis is the leading cause, followed by dissection, trauma, complications of coronary angioplasty, vasculitis, and syphilis. 4,6 Mycotic aneurysm occurs in 3% to 15% of the cases of endocarditis and accounts for 2.6% of all aneurysms. 7,8 Its occurrence in the coronary arteries is rare. 9 We were able to review 14 pub- lished cases of coronary mycotic aneurysm that were previously summarized. 10 In 11 patients, the diagnosis was made at autopsy. Previous or concomitant endocarditis was Cryptogenic Mycotic Aneurysm of the Right Coronary Artery JORGE SAFI, JR., MD, JUSSARA BIANCHI CASTELLI, MD, ROBERTO KALIL-FILHO, MD, and ALFREDO JOSÉ MANSUR, MD, São Paulo, Brazil ABSTRACT: A 61-year-old man with chest pain and fever was referred to our hospital. The physical examination and electrocardiogram were unrevealing. Laboratory tests showed leukocytosis, and echocardiography showed mild pericardial effusion. The patient died soon after hospital admission. Necropsy revealed ruptured mycotic aneurysm of the right coronary artery in the absence of infective endocarditis. Thus, mycotic aneurysm of the coronary artery may occur without infective endocarditis and may be clinically manifested as pericarditis and leukocytosis. From the Heart Institute (Incor), Hospital das Clínicas, School of Medicine, University of São Paulo, Brazil. Reprint requests to Jorge Safi, Jr., MD, Incor, HC, FMUSP, Av Dr Enéas de Carvalho Aguiar 44, São Paulo, SP 05403-000 Brazil. Safi et al • MYCOTIC ANEURYSM OF CORONARY ARTERY 67