Coronary artery fistula presented as infective endocarditis with pulmonary septic emboli

Abstract

Coronary artery fistula is uncommon, and rarely complicated with infective endocarditis. Only one case of septic pulmonary emboli due to coronary artery fistula has been reported and the definite diagnosis depended on coronary angiography. We report a case of which the diagnosis is established on transesophgeal echocardiography and ultrafast computed tomography. A 16-year-old Chinese girl was admitted due to high fever and bilateral chest pain for 2 days. The pain attacked intermittently and radiated to upper back. On examination, she had a temperature of 40.2 jC and a tachycardia of 120/ min. Her blood pressure was 150/80 mm Hg and her respiratory rate was 38/min. Neither lymph node enlargement nor jugular vein enlargement was noted on the neck. Her breathing sound was clear. A grade II/VI systolic murmur was noted over left upper sternal border. The total white cell count was 4560/Al and biochemical tests were normal. The chest roentgenogram showed multiple patches over bilateral lung fields. Empirical antibiotics with ceftazidime and amikacin were started under the consideration of septic pulmonary emboli. Later, blood culture yielded methicillin-sensitive Staphylococcus aureus and antibiotics was shifted to oxacillin. Transthoracic echocardiogram showed normal size of cardiac chambers but a vegetation over tricuspid valve. Transesophageal echocardiogram revealed the vegetation and dilatation of right coronary artery with a fistula draining into right atrium (Fig. 1). Ultrafast computed tomography (Imatron, South