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

Medical Image of the Week: Boerhaave Syndrome

Figure 1. Panel A: Coronal CT image with IV contrast showing a massively dilated esophagus with retained food particles.  Panel B: Coronal CT image depicting distal esophageal perforation (red arrow) rupturing into the lung parenchyma with resultant abscess formation (yellow arrow). Panel C: Axial image showing the dilated esophagus, ruptured into the lung (arrow). There is also mass effect on the mediastinum and heart. Panel D. After insertion of a nasogastric tube and chest tube in the lung abscess, computed tomography was performed after administration of oral contrast. There is extravasation of contrast into the lung cavity which now contains a drainage catheter. Arrow shows the rupture site.

A 41-year-old woman with a history of gastroesophageal reflux disease (GERD), asthma and iron deficiency anemia presented with complaints of right sided chest pain, nausea and emesis for several days prior to hospital presentation. She had also been experiencing progressive dysphagia to solids for a month preceding admission. CT chest imaging revealed mega-esophagus (Figure 1A) with rupture into the right lung parenchyma and resultant abscess formation (Figure 1B and 1C). A subsequent echocardiogram also confirmed mitral valve endocarditis. An image-guided chest tube was placed in the abscess for drainage. Endoscopy was attempted but visualization was difficult due to the presence of retained food. Given her low albumin and poor nutritional state, a jejunostomy tube was placed. Follow up CT imaging with contrast through a nasogastric tube confirmed extravasation of esophageal contrast into the right lung parenchyma (Figure 1D).  

Blood and sputum cultures grew Candida glabrata. She was initially started on broad spectrum antibiotics which were later tapered to Liposomal Amphotericin B and ampicillin-sulbactam. Following resolution of her fungemia and optimization of her nutritional status 2 months later, she underwent Ivor Lewis esophagectomy, pyloroplasty and serratus anterior muscle flap buttress to the remnant esophageal staple line. Pathology of the excised esophageal tissue revealed muscular hypertrophy and marked reduction of ganglion cells consistent with achalasia. There was also a segment of esophageal mucosal ulceration, acute inflammation and an area of perforation. Post-operative esophagram revealed no obstructions and contrast flowed without issue through the proximal esophagus into the gastroesophageal anastomosis and into the stomach. The patient did well and on discharge from the hospital was tolerating oral intake.

This case illustrates the multi-faceted approach sometimes required for successful treatment of Boerhaave syndrome, or rupture of the esophagus usually after emesis. Initial management included treating the patient’s sepsis with appropriate antifungal therapy in addition to placing a jejunostomy tube for nutrition—a conservative approach which has proven successful in other reported cases (1). Following resolution of the fungemia, she underwent surgical repair for permanent treatment of her esophageal disease.

While the patient had underlying achalasia predisposing her to spontaneous esophageal rupture, Candida glabrata has also been reported to compromise the esophageal lining through angio-invasive mechanisms (2). Given the pathology findings of mucosal ulceration and inflammation of excised esophageal tissue, it is likely that the patient’s Boerhaave syndrome was due to both a combination of achalasia and Candida glabrata esophageal infection.

Nour Parsa MD¹, Bhupesh Pokhrel MD², Arash Meshksar MD³, Mark Meyer MD⁴, and Samuel Kim MD⁴

Departments of ¹Medicine, ²Gastroenterology, ³Radiology, and ⁴Cardiothoracic Surgery, University of Arizona

Tucson, AZ USA

References

1. Shen G, Chai Y, Zhang GF. Successful surgical strategy in a late case of Boerhaave's syndrome. World J Gastroenterol. 2014 Sep 21;20(35):12696-700. [CrossRef] [PubMed]
2. Tran HA, Vincent JM, Slavin MA, Grigg A. Esophageal perforation secondary to angio-invasive Candida glabrata following hemopoietic stem cell transplantation. Clin Microbiol Infect. 2003 Dec;9(12):1215-8. [CrossRef] [PubMed] 

Cite as: Parsa N, Pokhrel B, Meshksar A, Meyer M, Kim S. Medical image of the week: Boerhaave syndrome. Southwest J Pulm Crit Care. 2016;12(6):233-5. doi: http://dx.doi.org/10.13175/swjpcc039-16 PDF

Medical Image of the Week: Pericardial Effusion in a Setting of Bacterial Endocarditis

Figure 1. Single portable semi-upright chest radiograph with findings of an enlarged cardiomediastinal silhouette, and indistinctness of the perihilar vasculature.

Figure 2. Axial contrast enhanced computed tomography—soft tissue windows. A large concentric rim (fluid density) surrounds all four chambers of the heart, consistent with a pericardial effusion. Notice how the right ventricle is normal, which can be collapsed in cardiac tamponade.

A 25-year-old man with an extensive history of intravenous drug abuse presents to the hospital with worsening shortness of breath and fevers for two weeks. In the emergency department, he was initially provided breathing treatments including ipratropium/albuterol and methylprednisolone. As the patient still required supplemental oxygen, a chest radiograph was performed to evaluate for an underlying infectious etiology.

However, the chest radiograph portrayed an enlarged cardiomediastinal silhouette in a “water-bottle” appearance and obscuration of the hilar vessels (Figure 1). Given these findings, there was a high concern for a pericardial effusion, and the physicians opted for further cross-sectional imaging. The contrast enhanced computed tomography (CT) images confirmed the aforementioned diagnosis (Figure 2). As blood cultures eventually grew Staphylococcus aureus, and given the patient’s extensive history of intravenous drug abuse, there was a high suspicion for bacterial endocarditis. A subsequent echocardiogram verified several valvular vegetations in keeping with endocarditis. The patient’s vitals remained stable throughout the hospital course, and he was continued on long-term antibiotic therapy.

Chest radiographs are often unreliable in depicting pericardial effusions, as they require at least 200 mL of pericardial fluid to portray an enlarged cardiomediastinal silhouette (1).  As fluid continues to accumulate in the pericardial space, the increase in pericardial pressure on the chambers can eventually lead to cardiac tamponade—a form of cardiogenic shock (2). Cardiac tamponade will result in a decrease in stroke volume, decreased blood pressure, and ultimately a diminished cardiac output; all of which require immediate intervention (2). Echocardiography remains the imaging modality of choice given its portability and high sensitivity in diagnosing pericardial fluid (3).

Amrit Hansra, MD

Department of Medical Imaging

University of Arizona

Tucson, AZ

References

1. Restrepo CS, Lemos DF, Lemos JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics. 2007 Nov-Dec;27(6):1595-610. [CrossRef] [PubMed]
2. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003 Aug 14;349(7):684-90. [CrossRef] [PubMed]
3. Chong HH, Plotnick GD. Pericardial effusion and tamponade: evaluation, imaging modalities, and management. Compr Ther. 1995 Jul;21(7):378-85. [PubMed] 

Cite as: Hansra A. Medical image of the week: pericardial effusion in a setting of bacterial endocarditis. Southwest J Pulm Crit Care. 2016 Mar;12(3):110-1. doi: http://dx.doi.org/10.13175/swjpcc009-16 PDF

Medical Image of the Week: Paradoxical Stroke

Figure 1. Vegetation seen on the tricuspid valve on the transthoracic echocardiogram (arrow). RA=right atrium, RV=right ventricle.

Figure 2. Patent foramen ovale (PFO) with right to left shunt of the agitated saline contrast on the trans-esophageal echocardiogram (arrow). RA=right atrium, LA=left atrium.

Figure 3. Acute left cerebellar stroke, hyper-dense lesion on T2 weighted MRI of the brain. (encircled).

A 23-year-old man with a history of intravenous drug abuse (IVDA) was admitted to the intensive care unit (ICU) secondary to sepsis. His blood cultures were positive for methicillin sensitive Staphylococcus aureus. Transthoracic echocardiogram showed vegetation on the tricuspid valve (Figure 1). He had multiple systemic emboli leading to suspicion for right to left shunt, which was confirmed by the agitated saline test during the echocardiogram (Figure 2). Cerebellar strokes likely secondary to posterior circulation embolic phenomenon was also seen (Figure 3). Overall, after a protracted ICU course complicated by multi-organ failure, he improved and is continuing treatment and rehabilitation at this time.

Right-sided infective endocarditis (IE) incidence is low, accounting for 5-10% of all cases of IE (1). IVDA is a well-known cause of tricuspid valve endocarditis. Usual features of tricuspid endocarditis are fever, bacteremia and pulmonary septic emboli. Patent foramen ovale (PFO) is estimated in up to 25% of the general population. Management of PFO for secondary stroke prevention remains controversial. Closure can be achieved surgically or percutaneously. The efficacy of closure of a PFO on the rate of recurrent stroke has not been established.

Laila Abu Zaid MD¹, Evbu Enakpene MD² and Bhupinder Natt MD³

¹Department of Internal Medicine

²Division of Cardiovascular Diseases

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

University of Arizona Medical Center

Tucson, AZ.

Reference

1. Akinosoglou K, Apostolakis E, Marangos M, Pasvol G. Native valve right sided infective endocarditis. Eur J Intern Med. 2013;24(6):510-9. [CrossRef] [PubMed]

Reference as: Zaid LA, Enakpene E, Natt B. Medical image of the week: paradoxical stroke. Southwest J Pulm Crit Care. 2014;9(5):278-80. doi: http://dx.doi.org/10.13175/swjpcc135-14 PDF

Medical Image of the Week: Infective Endocarditis in an IV Drug User

Figure 1. Transthoracic echocardiogram showing a large, irregular, mobile mass attached to the mitral valve annulus (arrows).

A 30 year old man presented with a one week history of fever, chills, body aches, and fatigue, as well as lower extremity and right wrist edema and pain. The patient also had a history of intravenous (IV) drug use. On exam, a previously undocumented 3/6 blowing crescendo murmur was heard at the fifth intercostal space in the midclavicular line. Transthoracic echocardiogram demonstrated a large, irregular, mobile mass, measuring 2.0 x 2.5 cm, attached to the posterior mitral annulus (Figure 1). Cardiothoracic surgery performed a primary repair of the mitral valve.

Abigail S. Hawke, MD

Department of Internal Medicine

University of Arizona

Tucson, Arizona

Arthia Satyanarayan, MS III

University of Arizona College of Medicine

Tucson, Arizona

Reference as: Hawke AS, Satyanarayan A. Medical image of the week: infective endocarditis in an IV drug user. Southwest J Pulm Crit Care. 2013;7(6):348. doi: http://dx.doi.org/10.13175/swjpcc156-13 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