Medical Image Of The Week: Tricuspid Valve Vegetation with Septic Pulmonary Emboli

Figure 1. Chest radiograph on presentation consistent with septic pulmonary embolic and cavitation.

Figure 2. Echocardiogram demonstrating a highly mobile echo-dense vegetation attached to the atrial side of the tricuspid valve.

A 28-year-old woman with a history of extensive intravenous heroin use presented to the hospital with generalized chest and abdominal pain. Vital signs were remarkable for hypotension, tachypnea, and tachycardia. Laboratory studies revealed leukocytosis, hyponatremia, acute kidney injury, and lactic acidosis. A radiograph of the chest demonstrated multiple airspace opacities throughout the bilateral lungs with associated cavitary lesions and a small right-sided pleural effusion (Figure 1). A transthoracic echocardiogram was obtained, which demonstrated a 3.6 cm x 2.0 cm tricuspid valve vegetation (Figure 2). Blood cultures identified methicillin-sensitive Staphylococcus aureus.

Infective endocarditis, valvular vegetation, and septic pulmonary emboli are common complications of intravenous drug use. Staphylococcus aureus is the most common bacterial cause of infective endocarditis among intravenous drug users (1). Like endocarditis, patients with septic pulmonary emboli often present with non-specific clinical manifestations such as fever (86%), dyspnea (48%), and chest pain (49%) (2). Management may be surgical or medical, and determining the best course is complicated by social and psychiatric factors affecting adherence to treatment. Cardiac valve surgery has been advocated early for large right-sided vegetations but carries high morbidity and expense, as well as risk of compromised recovery, in the setting of ongoing IV drug use. Even for patients with valvular vegetations ≥ 1cm, medical therapy alone may be a safe option under some circumstances in the absence of other surgical indications (3).

Sarah Harris BA¹, Kady Goldlist MD², Maria Tumanik DO², Cameron Hypes MD MPH^3,4

¹ University of Arizona College of Medicine

² Department of Internal Medicine, Banner University Medical Center – South Campus

³ Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

 ⁴Department of Emergency Medicine

University of Arizona

Tucson, AZ USA

References

1. Ortiz-Bautista C, López J, García-Granja PE, et al. Current profile of infective endocarditis in intravenous drug users: The prognostic relevance of the valves involved. Int J Cardiol. 2015;187:472-4. [CrossRef] [PubMed]
2. Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med. 2014 Jan;108(1):1-8. [CrossRef] [PubMed]
3. Otome O, Guy S, Tramontana A, Lane G, Karunajeewa H. A retrospective review: significance of vegetation size in injection drug users with right-sided infective endocarditis. Heart Lung Circ. 2016 May;25(5):466-70. [CrossRef] [PubMed] 

Cite as: Harris S, Goldlist K, Tumanik M, Hypes C. Medical image of the week: tricuspid valve vegetation with septic pulmonary emboli. Southwest J Pulm Crit Care. 2016:12(6):253-4. doi: http://dx.doi.org/10.13175/swjpcc042-16 PDF

April 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

A 38-year old man presented to the Emergency Department with complaints of chest pain, shortness of breath, and fever. A frontal chest radiograph (Figure 1A) was performed; a comparison chest radiograph (Figure 1B) is presented as well.

Figure 1. Panel A: Frontal chest radiography. Panel B: A comparison frontal chest radiograph performed one year earlier.

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph shows bilateral linear and reticular abnormalities
2. The chest radiograph appears normal and unchanged from previous
3. The chest radiograph shows multiple, bilateral poorly defined nodular opacities
4. The chest radiograph shows multifocal pleural abnormalities
5. The chest radiograph shows mediastinal widening

Reference as: Gotway MB. April 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(4):171-7. PDF

Medical Image of the Week: Septic Emboli

Figure 1. Photograph showing septic emboli to distal digits.

A 34 year old woman was admitted for a vasculitis workup after presenting with painful fingers, chest pain, and diffuse joint pain. Her blood cultures grew Staphyloccccus aureus and she was diagnosed with mitral and aortic valve endocarditis.  She had widespread joint involvement as well as a thoracic epidural abscess.

Jarrod Mosier, MD and Nathaniel Reyes, MD

Departments of Medicine and Emergency Medicine

University of Arizona

Tucson, Arizona

Reference as: Mosier J, Reyes N. Medical image of the week: septic emboli. Southwest J Pulm Crit Care. 2013;6(4):170. PDF