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LETTER TO EDITOR
Year : 2014  |  Volume : 31  |  Issue : 4  |  Page : 429-430  

Mobile vegetation leading to septic pulmonary embolism


Department of Internal Medicine, Saint Luke's Hospital, Saint Louis, Missouri, USA

Date of Web Publication1-Oct-2014

Correspondence Address:
Imran Haider
Department of Internal Medicine, Saint Luke's Hospital, Saint Louis, Missouri
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.142105

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How to cite this article:
Haider I, Gupta R, Song S. Mobile vegetation leading to septic pulmonary embolism. Lung India 2014;31:429-30

How to cite this URL:
Haider I, Gupta R, Song S. Mobile vegetation leading to septic pulmonary embolism. Lung India [serial online] 2014 [cited 2019 Nov 14];31:429-30. Available from: http://www.lungindia.com/text.asp?2014/31/4/429/142105

Sir,

A 42-year-old Caucasian female with a prolonged history of intravenous (IV) methamphetamine abuse presented with high-grade fever, progressively worsening productive cough, dyspnea, myalgia, arthralgia and intermittent confusion for 1 week. The initial laboratory assessment showed leukocytosis, thrombocytopenia, and acute kidney injury. Chest X-ray showed bilateral lower lobe consolidation with small cavities surrounded by focal infiltrates in the right lung [Figure 1]. Computed tomography of the chest confirmed the presence of multiple cavitary pulmonary nodules suggestive of septic embolization [Figure 2]. Because of a high index of suspicion for infective endocarditis, a transthoracic echocardiogram was obtained, which showed a 3.6 cm × 2.6 cm vegetation on the tricuspid valve and 2.5 cm × 1.6 cm vegetation on the tricuspid annulus, accompanied by severe tricuspid regurgitation. Trans-esophageal echocardiogram demonstrated multiple, large multilobulated, mobile vegetation on the tricuspid valve, with the largest being 3.7 cm × 2.5 cm in size [Figure 3]. Blood cultures were positive for methicillin-resistant Staphylococcus aureus. The patient was initially treated with vancomycin and ceftriaxone. However, the patient failed to improve clinically and, eventually, underwent tricuspid valve excision, right ventricle/tricuspid valve debridement and tricuspid valve replacement. The post-operative course was uneventful and the patient made a satisfactory recovery.
Figure 1: Chest radiography showing bilateral lower lobe consolidation with small cavities within focal infiltrates in the right lung

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Figure 2: Computed tomography of the chest showing numerous cavitary pulmonary nodules located peripherally, representing septic pulmonary emboli in the right lung

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Figure 3: Trans-esophageal echocardiogram with mid position view showing a 3.6 cm × 2.6 cm-sized mobile vegetation in the right atrium attached to the tricuspid valve. RA: Right atrium

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Septic pulmonary embolism (SPE) is a rare and serious disorder that usually presents with non-specific clinical features including fever, pulmonary symptoms and peripheral nodular lung infiltrates with or without cavitation. [1],[2] Major risk factors are IV drug abuse, indwelling catheters, tricuspid valve endocarditis, head and neck infections and immunocompromised state. Early diagnosis of the infectious source and appropriate use of anti-microbial therapy is critical in the management because untreated SPE can lead to the development of pulmonary abscesses and empyema. [3] This vignette highlights how multiple peripheral nodular opacities, often with cavitation, are suggestive of pulmonary septic emboli in the setting of infective endocarditis.

 
   References Top

1.Rossi SE, Goodman PC, Franquet T. Nonthrombotic pulmonary emboli. AJR Am J Roentgenol 2000;174:1499-508.  Back to cited text no. 1
    
2.Iwasaki Y, Nagata K, Nakanishi M, Natuhara A, Harada H, Kubota Y, et al. Spiral CT findings in septic pulmonary emboli. Eur J Radiol 2001;37:190-4.  Back to cited text no. 2
    
3.Cook RJ, Ashton RW, Aughenbaugh GL, Ryu JH. Septic pulmonary embolism: Presenting features and clinical course of 14 patients. Chest 2005;128:162-6.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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