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: Pulmonary Arteriovenous Fistula

Figure 1. Panel A: Micro-bubbles appear in the right atrium (RA) and right ventricle (RV) with delayed appearance in the left atrium (LA) and left ventricle (LV). Panels B and C: The density of the micro-bubbles were same in the left and the right cardiac chambers even after 10 cardiac cycles. Panel D: When the injection was stopped, there were micro-bubbles in the left cardiac chambers, but none in the right cardiac chambers.

A 60 year-old man with hepatic cirrhosis, was referred for chest pain, shortness of breath, and progressive cyanosis and an echocardiographic evaluation. PaO2 was 64 mm Hg on room air, but only 74 mm Hg on 100% oxygen.  Chest X-ray and pulmonary function testing were normal. A contrast echocardiography using agitated saline (bubble study) was performed. A delayed appearance of a substantial amount of micro-bubbles in the left atrium greater than three cardiac cycles after appearance in the right atrium and ventricle was suggestive of pulmonary arteriovenous fistula (Figure 1A). The delayed appearance and a large amount of micro-bubbles in the left atrium preclude the intracardiac shunting result of a patent foramen ovale (PFO) or atrial septal defect (ASD). Interestingly, the density of micro-bubbles were same in the left and the right cardiac chambers even after 10 cardiac cycles (Figure 1B and 1C). When the injection was stopped, there were micro-bubbles in the left cardiac chambers, but none in the right cardiac chambers (Figure 1D). Although pulmonary angiography remains the gold standard method for definitive diagnosis of the pulmonary arteriovenous malformations, contrast echocardiography can suggest arteriovenous fistula in the setting of unexplained hypoxemia before angiography, especially in hospitals without on-site angiography facilities.

Manisha Bajracharya MD, Madhu Gupta MD, Liping Chen MD PhD

Department of Gynecology and the Cardiovascular Disease Center, Norman Bethune College of Medicine, Jilin University, Changchun, China

Reference

Nanthakumar K, Graham AT, Robinson TI, Grande P, Pugash RA, Clarke JA, Hutchison SJ, Mandzia JL, Hyland RH, Faughnan ME. Contrast echocardiography for detection of pulmonary arteriovenous malformations. Am Heart J. 2001;141(2):243-6. [CrossRef] [PubMed]

Reference as: Bajracharya M, Gupta M, Chen L. Medical image of the week: pulmonary arteriovenous fistula. Southwest J Pulm Crit Care. 2014;8(4): . doi: http://dx.doi.org/10.13175/swjpcc035-14 PDF

Medical Image of the Week: Eisenmenger Syndrome and Hemoptysis

A 26 year-old female with Eisenmenger syndrome presented with hemoptysis. An echocardiogram showed an enlarged right ventricle and two large mid-muscular ventricular septal defects (VSD) with right to left shunting (Figures 1 and 2).

Figure 1. Apical four-chamber view of the heart as seen on a transthoracic echocardiogram demonstrating an enlarged right ventricle (RV) and two large mid muscular ventricular septal defects (*).  RA - right atrium, LA - left atrium, LV - left ventricle.

Figure 2.  Apical four-chamber view on a transthoracic echocardiogram.  Color Doppler jets (blue color) demonstrate right-to-left shunt through the two mid-muscular ventricular septal defects seen in Figure 1.

A contrast enhanced CT of the chest showed an enlarged pulmonary artery, no evidence of pulmonary embolism and the VSDs (Figure 3 and 4).

Figure 3. Contrast enhanced CT of chest demonstrating markedly enlarged main pulmonary artery (arrow), approximately twice the size of the ascending aorta (straight arrow).

Figure 4. Contrast enhanced CT of chest showing ventricular septal defects (arrows).

Eisenmenger syndrome is a condition in which increased pulmonary blood flow secondary to a left to right intracardiac shunt leads to irreversible pulmonary vascular obstructive disease.  The resultant high pulmonary vascular resistance causes reversal and right to left intracardiac shunt.  Hemoptysis is a common complication of Eisenmenger syndrome and has been reported as the cause of death in 11-29% of patients. It can be caused by pulmonary artery thrombosis, pulmonary embolism, rupture of aortopulmonary collaterals, pulmonary artery dissection and hemorrhage due to an aneurysm or thin-walled arterioles, infectious sources or a bleeding diathesis.  Treatment of hemoptysis in patients with Eisenmenger syndrome is challenging because they are at increased risk for bleeding and thrombotic complications. Hemoptysis in patients with Eisenmenger syndrome is often self-limited; however, it can be severe and life threatening. It is estimated that nearly 90% of patients with congenital heart disease survive into adulthood therefore adult pulmonologists may encounter this clinical scenario.  Our patient’s hemoptysis resolved spontaneously and she remains clinically stable.

Jamie Nicole Colombo DO*, Linda Snyder MD^¶, and Daniela Lax MD^§

Department of Pediatrics*, Division of Pediatric Cardiology^§

Division of Pulmonary, Critical Care, Allergy and Sleep Medicine^¶

University of Arizona

Reference as: Colombo JN, Snyder L, Lax D. Medical image of the week: Eisenmenger syndrome and hemoptysis. Southwest J Pulm Crit Care. 2013;6(5):231-3. PDF