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: Septic Pulmonary Emboli Misdiagnosed As Metastatic Disease

Figure 1. Representative thoracic CT axial images showing multiple pulmonary nodules (red arrows).

A 54-year-old previously healthy man presented with acute onset of left-sided, sharp pleuritic chest pain and dry cough. He denied having fever, hemoptysis, shortness of breath, or unintentional weight loss. Review of system was positive for bright blood per rectum for the last year. He had a root canal procedure done 3 weeks prior to presentation. His is a 30 pack-year smoker, drinks alcohol occasionally, but denied any IV drug use.

On admission, he was afebrile and hemodynamically stable. Clinical examination was positive for fecal occult blood test. CBC revealed WBC of 12,800/mm³ and his hemoglobin was11.9 g/dL. Thoracic CT scan with contrast was negative for pulmonary embolism, but showed multiple bilateral pulmonary nodules suspicious for malignancy (Figure 1). The left upper lobe showed a subpleural 2.4 x 1.5 cm rounded opacity and emphysematous changes. CT of the abdomen and pelvis showed folds in the stomach but was otherwise unremarkable.

Esophagogastroduodenoscopy was negative. Colonoscopy showed non-bleeding internal hemorrhoids. He underwent percutaneous CT guided lung biopsy. Pathology report showed distended alveoli filled with polymorphonuclear leukocytes mixed with fibrin consistent with septic emboli and no evidence of malignancy.  Special stains for organisms were negative. Blood cultures were negative, Trans-esophageal echocardiograph was normal. Mandibular film done was negative for dental abscess. HIV serology, Quantiferon gold, ß-d glucan, Aspergillus, and mycobacterial culture of sputum were negative. During his hospital stay he developed a fever and his WBC count increased. He was empirically started on broad spectrum antibiotics and he clinically improved significantly.

Septic pulmonary embolus (SPE) is a serious and uncommon condition that poses a diagnostic challenge and carries a high mortality (1,2). Presenting symptoms are often non-specific. Blood cultures may be negative initially. Similarly, chest radiography is not helpful to establish a diagnosis. CT is more useful, usually showing multiple peripheral nodular opacities. SPE can be suspected by the presence of potential source of underlying infection, febrile illness and multiple pulmonary nodules.

Dima Dandachi MD and Sathish Krishnan MD

Department of Internal Medicine

Saint Francis Hospital

Evanston, IL

References

1. Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med 2014;108(1):1-8. [CrossRef] [PubMed]
2. Shiota Y, Taniguchi A, Yuzurio S, Horita N, Hosokawa S, Watanabe Y, Tohmori H, Ono T; Okayama Respiratory Disease Study Group. Septic pulmonary embolism induced by dental infection. Acta Med Okayama. 2013;67(4):253-8. [PubMed] 

Reference as: Dandachi D, Krishnan S. Medical image of the week: septic pulmonary emboli misdiagnosed as metastatic disease. Southwest J Pulm Crit Care. 2014;9(1):38-9. doi: http://dx.doi.org/10.13175/swjpcc083-14 PDF