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Septic Pulmonary Embolism With Pulmonary Infarction From a Pulmonic Valve Endocarditis- A Case Report FREE TO VIEW

Bernadette Magnaye, MD
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Philippine Heart Center, Quezon City, Philippines

Chest. 2015;148(4_MeetingAbstracts):148A. doi:10.1378/chest.2279416
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SESSION TITLE: Infections Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: To our knowledge, there is not well-documented evidence regarding the incidence or occurence of the development of septic pulmonary embolism from vegetations of the pulmonic valve of the right side of the heart, since most of our literatures would mention those arising from the left side of the heart. Early identification of pulmonic valve endocarditis and treatment with appropriate antibiotics with or without surgical management can provide better outcomes.

CASE PRESENTATION: This is a case of 23 year-old, Filipino, female, known case of Tetralogy of Fallot with surgical correction of the defect last 2012. Patient is non-hypertensive, non-diabetic, non-asthmatic, no history of pulmonary tuberculosis or knwon allergies. Patient is apparently well since discharged until, one month prior to admission, patient developed on and off fever, productive cough with greenish sputum and dyspnea. No associated chest pain, hemoptysis, edema, changes in urinary or bowel habits. On examination, patient is weak looking, now with episodes of hemoptysis. Chest and lung findings revealed symmetrical chest expansion, no retractions, vesicular breath sounds, the heart revealedapex beat at the 6th left intercostal space mid-clavicular line, right ventricular heave, loud P2, grade 3/6 holosystolic murmurs heard best at left sternal border. Chest xray showed fibrotic changes both upper lobes, confluent hazy infiltrates in the right mid to lower lung and mild cardiomegaly with pleural effusion and or thickening bilateral. Complete blood count revealed leukocytosis with neutrophilic predominance and thrombocytopenia. Sputum culture revealed heavy growth of Klebsiella pneumoniae and blood culture revealed positive for staphylococcus coagulase negative, sputum AFB smear was negative. Two dimensional echocardiography revealed ejection fraction of 57%, pulmonic valve infective endocarditis, concentric right ventricula hypertrophy with evidence of pressure overload and narrowed right ventricular outflow tract, post correction of tetralogy of fallot. CT pulmonary angiogram showed a lobulated filling defect of the distal segment of the right pulmanary artery just before iots bifurcation, patchy consolidations both lower lobes and lateral segment of the right middle lobe, mossaic pattern in both lower lungs, although non-specific maybe consistent to findings of septic embolism. Based on the history, physical examination and laboratories done, patient was treated for septic pulmonary embolism from pulmonic valve endocarditis and pneumonia. She was admitted for 55 days, given intravenous antibiotics and anticoagulation with repeat blood and sputum cultures negative for microorganism. With the resolution of signs and symptoms and a clear lungs on repeat chest xray, the patient was discharged, improved.

DISCUSSION: Infectious endocarditis of the pulmonic valve is seen in less than 1.5% to 2 % of all cases of endocarditis and is usually associated with tricuspid valve. this occurs infrequently but can present with significant respiratory complications which occur commonly in 58% of cases and pleural complications have occasionally in 6% of cases. The embolic blood clot that leads to an infarction in 10% of cases occurs when a potential sources of lung oxygenation was compromised such as the pulmonary arteries, bronchial arteries and airways. Radiologically, infarction typically appears as peripheral wedge-shaped parenchymal opacities however this may vary depending on the underlying cause and temporal evolution of the lesion. CT scan may yield helpful clues in the diagnosis of pulmonary embolism such as a feeding vessel sign or a vessel leading to a peripheral lesion as a charcteristic feature of septic pulmonary embolism. Echocardiography is is helpful in detecting valvular infections, paravalvular abscesses or congestive heart failure.

CONCLUSIONS: Clinicians should take complete history and physical examination which are crucial to the proper and appropriate managemenet of septic pulmonary embolism without delays to prevent further complications like death. Anticoagulation and empiric or targeted antibiotics is the mainstay of treatment. Blood culture, chest imaging and echocardiography are invaluable in the evaluation of a patient suspected septic pulmonary embolism.

Reference #1: Cassling RS, Rogler WC, McMAnus BM. Isolated pulmonic valve infective endocarditis. A diagnostically elusive entitiy. AMm Heart J, 1985.

Reference #2: Corzo F, De leon et. al., septic emboli in infective endocarditis; Thorax 1993: 47

DISCLOSURE: The following authors have nothing to disclose: Bernadette Magnaye

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