Septic pulmonary emboli causing recurrent bilateral pneumothoraces in a patient with right sided endocarditis: A case report and review of literature

Intrapleural minocycline pleurodesis for bilateral pneumothorax due to septic pulmonary embolism: a case report

Background

Pneumothorax is a rare but serious complication of septic pulmonary embolism (SPE). SPE is a life-threatening disorder wherein infected thrombi bring infarction of the terminal and small caliber parts of the pulmonary vasculature and develop multiple nodular and cavitary lesions. Interventions other than conservative chest tube drainage for pneumothorax due to SPE have rarely been reported. Here, we present a case of bilateral pneumothorax due to SPE treated with intrapleural minocycline pleurodesis.

Case Description

A 72-year-old male patient previously diagnosed as esophageal carcinoma developed metachronous bilateral pneumothorax while treated for brain metastases. Based on blood cultures and chest computed tomography images, he was diagnosed with pneumothorax secondary to SPE due to methicillin-susceptible Staphylococcus aureus bacteremia. Bilateral chest tube drainage was instituted. Continuous air leakage was found bilaterally after chest tube placement. He was treated with broad-spectrum antibiotics based on the susceptibility profile and supportive treatment for sepsis. Approximately 3 weeks later, air leakage significantly reduced. We performed intrapleural minocycline pleurodesis bilaterally to prevent the recurrence of pneumothorax; the left side was firstly treated and the right side was treated 2 weeks later. Both chest tubes were successfully removed two days after procedures. Although the patient finally died of brain metastases 1 month after pleurodesis, he never recurred pneumothorax.

Conclusions

Intrapleural minocycline pleurodesis may be one of the useful and efficacious options in terms of treating intractable pneumothorax associated with SPE. Intrapleural minocycline pleurodesis could be a consideration for intractable pneumothorax related to SPE.

Bilateral Spontaneous Pneumothoraces in a Case of Tricuspid Valve Endocarditis and Septic Emboli: A Rare Complication

Acute hypoxemic respiratory failure from infective endocarditis with septic emboli has been attributed to the vicious cycle of tissue damage and inflammatory cytokine response. Spontaneous pneumothorax is a rare complication and can be a late-onset presentation despite appropriate antibiotic therapy. We present a rare case of bilateral spontaneous pneumothoraces in a patient with tricuspid valve endocarditis and septic pulmonary emboli. We suspect that the profound inflammatory response from two different bacterial pathogens and the peripheral location of the septic thrombosis are the basis of the development of bilateral pneumothorax development in our patient.

A Case Report of Recurrent Pneumothorax: A Rare Complication of Tricuspid Valve Endocarditis

Intravenous drug use (IVDU) is a recognized risk factor for infective endocarditis (IE), with potential mechanisms involving direct bacterial introduction through the needle puncture. Bilateral pneumothorax, an under-reported yet significant complication of IE, was first documented in 1990. Only eleven cases of spontaneous pneumothorax (PTX) associated with septic pulmonary embolism from IE have been reported. We present a 26-year-old female with a history of IE and a prior pneumothorax. She was transferred to our facility for recurrent IE, confirmed by echocardiography and blood cultures. After an initial stable clinical course, on the fifth morning, she developed new-onset dyspnea, later diagnosed with bilateral PTX that required bilateral chest tube placement. Left-sided PTX resolved quickly, while the right-sided PTX persisted for 11 more days. Following clinical improvement, the patient was discharged on the 18th day. Promptly identifying this rare complication was crucial for the patient's survival.

Septic Pulmonary Embolism Causing Recurrent Pneumothorax in an Intravenous Drug User without Right-Sided Valvular Vegetation in Infective Endocarditis

The following report illustrates a case of a 36-year-old Caucasian male with intravenous drug use (IVDU) induced septic thrombophlebitis presenting with recurrent unilateral pneumothoraces from septic pulmonary embolism (SPE) without the presence of obvious right-sided valvular vegetation in infective endocarditis (IE), defined as tricuspid or pulmonary valve lesions. Pneumothorax (PTX) has been observed as a rare complication of SPE and is commonly associated with infective right-sided IE, IVDU, and intravascular indwelling catheters. However, this case is novel as it is the very rare documented case of recurrent, unilateral, spontaneous right PTX refractory to multiple chest tube placements in such a setting. Therefore, the absence of detectable right-sided valvular vegetation in IE does not obviate the risk of SPE-induced PTX in IVDU and further expands the realm of infectious and pulmonary consequences of SPE and IVDU.