Septic pulmonary arteriovenous fistula. An unusual conduit for systemic embolization in right-sided valvular endocarditis

Case report: right-sided native endocarditis presenting with multiple abscess formations [care compliant]

INTRODUCTION

Right-sided native endocarditis is a difficult case with fewer cardiac symptoms and fewer classic signs of cutaneous vascular lesions compared with left-sided endocarditis.

PATIENT CONCERNS

A 68-year-old Taiwanese man with a history of gouty arthritis, hyperlipidemia, and adrenal insufficiency presented to our ED and complained dyspnea and low back pain for 1 month.

DIAGNOSIS ASSESSMENT

The PE showed bilateral crackles on chest auscultation and a palpable fluctuant mass over the anterior chest wall. The chest and abdominal CT scan showed multiple abscess formations involving pulmonary, sternal, and paraspinal areas. The TEE being performed and an oscillating mass over the anterior and septal leaflets of the tricuspid valve and moderate tricuspid regurgitation.

INTERVENTIONS

Only pharmacologic treatment without surgical interventions.

OUTCOMES

Deceased, patient expired on day 4 after ED visit.

CONCLUSION

This case arose as a sequela of staphylococcal endocarditis associated with persistent bacteremia and immunological dysregulation. The diagnosis of right-sided endocarditis is easily missing, multidisciplinary approach should be triggered as soon as possible, which might lead to a better outcome. Right-sided IE is still an important public health issue in southern Taiwan.

Multidetector CT evaluation of congenital lung anomalies

Congenital lung anomalies vary widely in their clinical manifestation and imaging appearance. Although radiographs play a role in the incidental detection and initial imaging evaluation in patients with clinical suspicion of congenital lung anomalies, cross-sectional imaging such as computer tomography (CT) is frequently required for confirmation of diagnosis, further characterization, and preoperative evaluation in the case of surgical lesions. Recently, with the development and widespread availability of multidetector CT scanners, CT has assumed a greater role in the noninvasive evaluation of congenital lung anomalies. The combination of fast speed, high spatial resolution, and enhanced quality of multiplanar reformation and three-dimensional reconstructions makes multidetector CT an ideal noninvasive method for evaluating congenital lung anomalies. In this article, the authors review the multidetector CT technique for evaluation of congenital lung anomalies. Important clinical aspects, characteristic imaging features, and key points that allow differentiation among various anomalies are highlighted for a variety of common and uncommon conditions.

Central nervous system infections in injection drug users

Central nervous system infections in injection drug users are often devastating in terms of excess morbidity and mortality. In injection drug users with infective endocarditis, embolization from infected valvular vegetations may cause cerebral infarction, intracranial hemorrhage, and the formation of brain abscess. Focal intracranial infections (i.e., brain abscess and spinal epidural abscess) may occur in the absence of infective endocarditis, resulting from bacteremia that seeds the brain or epidural space. Antimicrobial therapy, combined with surgical intervention, may be essential to improve outcome from these neurologic complications. Toxin-mediated diseases (especially tetanus and wound botulism) are also seen in injection drug users. Inoculation of Clostridium spp at injection sites may lead to toxin generation and disease. Clinicians must maintain a high level of suspicion for these diagnoses in injection drug users.

Persistent hypoxemia occurring as a complication of tricuspid valve endocarditis

A 33-year-old woman had intravenous drug-associated tricuspid valve infective endocarditis. Despite resolution of septic pulmonary emboli, hypoxemia persisted. We report a case of right-to-left shunting across a previously insignificant patent foramen ovale documented by contrast transesophageal echocardiography. Although a rare complication of tricuspid endocarditis, clinicians should be aware of this potential correctable complication.