title: A complicated case of vascular Pythium insidiosum infection treated with limb-sparing surgery.
abstract: BACKGROUND
  Pythiosis is a serious life- and limb-threatening infection endemic to Thailand, but rarely seen in the Western hemisphere. Here, we present a unique case of vascular pythiosis initially managed with limb-sparing vascular bypass grafts complicated by a pseudoaneurysm in our repair.
  
  
  METHODS
  The patient is a 17 year-old Jamaican male with severe aplastic anemia. He sustained a minor injury to his left leg while fishing in Jamaica, which evolved to become an exquisitely tender inguinal swelling. His physical exam and imaging were significant for arteriovenous fistula with limb ischemia. Pathology obtained during surgery for an extra-anatomic vascular bypass showed extensive invasion by Pythium insidiosum. He later developed a pseudoaneurysm at the site of proximal anastomosis and required urgent intervention.
  
  
  CONCLUSIONS
  This patient presented with a rare, but classic case of vascular pythiosis, which was unrecognized at the time of presentation. A variety of therapeutic modalities have been used to treat this disease, including antibiotics, antifungals, and immunotherapy, but the ultimate management of vascular pythiosis is surgical source control.
  
  
  CONCLUSIONS
  A high index of suspicion in susceptible patients is needed for timely diagnosis of vascular pythiosis to achieve optimal source control.
authors.affiliation: Surgery Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, MD 20892, USA.
authors.forename: Jenny H
authors.initials: JH
authors.lastname: Pan
authors.affiliation: Center for Cancer Research, National Cancer Institute, National Institutes of Health (NIH), Bethesda, MD 20892, USA.
authors.forename: Sid P
authors.initials: SP
authors.lastname: Kerkar
authors.affiliation: National Institute of Health (NIH), Heart Center at Suburban Hospital, Bethesda, MD 20814, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Siegenthaler
authors.affiliation: Surgery Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, MD 20892, USA.
authors.forename: Marybeth
authors.initials: M
authors.lastname: Hughes
authors.affiliation: Surgery Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, MD 20892, USA. Electronic address: pandalaipk@mail.nih.gov.
authors.forename: Prakash K
authors.initials: PK
authors.lastname: Pandalai
keywords: Pseudoaneurysm; Pythiosis; Pythium insidiosum; Vascular bypass