Endocarditis with pulmonary and systemic embolization

Abstract

A 45-year-old woman with a history of intravenous drug use and tricuspidal endocarditis was admitted to our medical center with a 1-week history of fever and dyspnea. She reported recent intravenous cocaine use. On admission she was normotensive, febrile (temperature 38 C), mildly tachycardic (heart rate 105 beats/min) and tachypneic (respiratory rate 20 breaths/min) with an oxygen saturation of 92%. Examination revealed nonlabored breathing with equal breath sounds. No lymphadenopathy, splenomegaly, or rash was identified. Laboratory tests showed a leukocytosis and increased levels of C-reactive protein. Chest radiography revealed a peripheral right infiltrate. Electrocardiography was unremarkable. Transthoracic echocardiogram detected the presence of a mobile mass (10 mm) attached to the posterior leaflet of the tricuspid valve. A diagnose of right-sided endocarditis was made. Blood cultures demonstrated methicillin-sensitive Staphylococcus aureus. An HIV test was negative. Treatment with oxacillin, gentamicin, and ampicillin was started. During hospitalization, the fever resolved, but the patient complained of worsening dyspnea and left flank pain. Physical examination was unchanged except for the appearance of splinter hemorrhages and tender, subcutaneous nodules on the second finger of the right hand (Fig. 1). A CT scan of the chest and abdomen was performed, and revealed multiple peripheral pulmonary infiltrates consistent with septic pulmonary emboli (Fig. 2) and a splenic hypoperfusion area (Fig. 3). In consideration of pulmonary and systemic embolization, in order to make a differential diagnosis between paradoxical embolism and bilateral endocarditis, a transesophageal echocardiogram study was proposed, but the patient refused. Transthoracic echocardiogram was repeated. The examination confirmed the tricuspid valve vegetation, and revealed the presence of another vegetation attached to the posterior leaflet of the mitral valve (5 mm). Septal defects and cardiac complications were not observed. Based on these findings, pulmonary and systemic embolization was interpreted as a consequence of bilateral endocarditis. The patient was transferred to the Infectious Disease Unit. Antibiotic treatment was continued. The general condition improved, and no further complications occurred.