SESSION TYPE: Critical Care Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Hemoptysis is a rare symptom for endocarditis. We describe a case of marantic endocarditis presenting as massive hemoptysis in a patient with ruptured aneurysm of the sinus of Valsalva and bilateral peripheral pulmonary artery aneurysms (PAA).
CASE PRESENTATION: A 27-year-old man presented with acute hypoxemic respiratory failure secondary to massive hemoptysis. He had pleuritic pain, dyspnea, and cough for two months; treatment for pneumonia was noncurative. He denied chronic illness except for a heart murmur. Coughing produced large blood clots. Bilateral rhonchi were present. Hemoglobin was 10.6 g/dL on admission. Chest CT revealed aneurysmal dilatation of pulmonary artery, partial thrombosis, and areas of consolidation in both lower lobes. Bronchoscopy revealed evidence of fresh, but not active, bleeding in right lower lobe. Hemoptysis subsided spontaneously. Echocardiogram showed a ruptured aneurysm of the sinus of Valsalva extending into the right atrium with high flow left-to-right shunt and 1.2 cm vegetation on the tricuspid valve (TV). Infectious etiologies were ruled out; blood cultures remained negative. After surgical repair of the aneurysm and TV, recovery was uneventful.
DISCUSSION: Structural heart disease is a risk factor for endocarditis (1). Our patient had an aneurysm of the sinus of Valsalva, predisposing him to endocarditis. While 90-95% of these aneurysms originate in the non-coronary sinus and project into the right ventricle. In our case it originated from the non-coronary cusp of the aortic valve. It created the left to right shunt towards the septal leaflet of TV, leading to marantic involvement of the TV. We also discovered bilateral PAA. Most PAA with CHD are centrally located and involve infection however, reports of PAA without infection exist. Because our patient’s PAA were multifocal and peripheral we hypothesize that it developed due to weakening of the pulmonary artery wall from embolization to vasa vasorum, which is one postulated mechanism for development of PAA in endocarditis. Self-limiting rupture and subsequent thrombosis within the PAA might be an explanation for hemoptysis (2).
CONCLUSIONS: Marantic endocarditis can occasionally present as massive but self-limited hemoptysis as a result of weakening of the pulmonary artery wall from embolization to vasa vasorum.
1) Bartter T, Irwin RS, Nash G. Aneurysms of the pulmonary arteries. Chest. 1988 Nov;94(5):1065-75.
2) Fields CL, Roy TM, Ossorio MA. Thrombosed pulmonary artery aneurysm. A rare cause of a high-probability lung scan. Chest. 1992 Oct;102(4):1292-4.
DISCLOSURE: The following authors have nothing to disclose: Larisa Buyantseva, Andrew Lutzkanin, Eduardo Villarreal, Mubashir Mumtaz, Richard Evans, Hiren Shingala
No Product/Research Disclosure InformationPinnacle Health System, Harrisburg Hospital, Harrisburg, PA