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Right- and Left-Sided Embolic Phenomena in a Patient With Febrile Neutropenia FREE TO VIEW

Badar Al-Hamrashdi, MD; Sabira Valiani, MD; Noman Khan, MD; Marlene Mansour, MD; Scott J. Millington, MD
Author and Funding Information

Drs Al-Hamrashdi and Valiani contributed equally to this manuscript.

CORRESPONDENCE TO: Scott J. Millington, MD, Critical Care, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(6):e173-e175. doi:10.1016/j.chest.2015.12.044
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Published online

A 33-year-old woman presents with febrile neutropenia after initiating treatment with deferiprone, an iron chelating agent. She has a history of beta-thalassemia requiring monthly blood transfusions, complicated by iron overload and significant myocardial iron deposition. Before her hospitalization, she was asymptomatic from a cardiac perspective and had normal left and right ventricular systolic function. On admission, the patient was treated for a retropharyngeal abscess with piperacillin-tazobactam.

On postadmission day 7, she developed a new fever, cough, and pleuritic chest pain, with radiologic evidence of a right upper lobe and left lower lobe consolidation. At this time, her antibiotic coverage was broadened to azithromycin, meropenem, and vancomycin. Her chronic indwelling peripherally inserted central catheter (PICC) was removed and the tip was sent for culture, which grew coagulase-negative staphylococcus. Doppler ultrasonography revealed a nonocclusive thrombus of the right brachiocephalic vein (at the former PICC line site) and a CT scan of the chest showed multifocal consolidations but no large proximal pulmonary embolism.

On postadmission day 14, she had a trans-thoracic echocardiogram (TTE), which was essentially normal, apart from an aneurysmal interatrial septum (IAS) not noted on previous cardiac imaging. A bubble study was not performed at that time. Later that same day, she suffered a complex partial seizure and thereafter had a progressive decrease in her level of consciousness. Voriconazole was added at this time for empiric antifungal coverage.

She was admitted to the ICU on postadmission day 16 for hypoxemic respiratory failure and required intubation. An MRI of the brain revealed bilateral frontal and left occipital acute infarctions as well as radiologic evidence of meningitis.

Point-of-care echocardiography was performed on postadmission day 17 to assess for potential sources of an embolic phenomenon (Videos 1-4).

Question: What is the source of the patient’s likely embolic phenomenon?

Question: Do the views subsequently obtained by TTE and transesophageal echocardiogram (TEE) provide an explanation for the systemic embolic phenomena seen on brain MRI?

Answer: The visualized mobile mass in the right atrium is a potential cause of septic pulmonary emboli, but does not in and of itself explain the cerebral infarctions.

Answer: The now-visible mobile mass in the left and right atria are a potential explanation for both the pulmonary and systemic embolic phenomena. The TEE images demonstrate that the mass is bridging a defect in the IAS.

This case illustrates the use of point-of-care echocardiography in the workup of medically complex cases; here, the discovery of a structure within the bilateral atria dramatically altered the management of an already difficult case. The initial TTE examination demonstrates the importance of a systemic approach to goal-directed echocardiography. Working progressively through the four major cardiac views (Videos 1-4) revealed the first sign of the atrial mass in the subcostal four-chamber view, which then led to a series of more directed views (Videos 5-7). In the clinical context of embolic phenomena, the structures of particular interest are the bilateral atria, the four cardiac valves, and the apices of both ventricles. The left atrial appendage is also of great importance, but is typically not visible via transthoracic examination.

A moderate-sized circumferential pericardial effusion is immediately seen on the initial TTE examination, here an incidental finding as the patient was hemodynamically stable with no clinical signs of tamponade physiology. Also of interest is the appearance of the IAS in the apical four-chamber view (Video 3); there does appear to be a defect in the structure, raising the possibility of a large patent foramen ovale (PFO) or atrial septal defect. Here the defect is artefactual, a “drop-out” phenomenon caused by the parallel alignment of the IAS and the ultrasound beam plane. Looking at the subcostal four-chamber view (Video 4), the IAS is seen to be grossly intact.

The differential diagnosis for an intra-atrial mass includes tumor, thrombus, vegetation, artefact, or normal anatomic variant. This patient’s presentation of both right- and left-sided embolic phenomena in the context of a known PICC-associated thrombus was highly suspicious for paradoxical embolus via a patent foramen ovale, a common mechanism for stroke in younger patients. Visualization of a thrombus-in-transit between the left and right atria, as seen in this case, is rare.,

The incidence of a PFO is approximately 27%. Physiologically, the passage of a thrombus through a PFO requires a higher right than left atrial pressure,; therefore, numerous case reports have described this phenomenon in the context of pulmonary embolism due to increased right-sided pressures.,,, Hypoxemic respiratory failure and positive pressure ventilation can also increase pulmonary pressures and aggravate this phenomenon.

Interestingly, the material embolized on both the pulmonary and systemic sides appeared to be a septic clot, rather than sterile emboli. In hindsight, the most likely explanation is a sterile thrombus originating at the site of the PICC line subsequently becoming infected because of the patient’s immunosuppressed state. The patent’s pneumonia was likely caused by septic pulmonary emboli, explaining the simultaneous right upper lobe and left lower lobe consolidations. Septic cerebral emboli explain the ischemic stroke as well as the MRI appearance of meningitis.

This case illustrates the use of point-of-care echocardiography in the workup of a patient presenting with left- and right-sided embolic phenomena. Although TTE is less sensitive than TEE, the visualization of an intra-atrial mass on point-of-care ultrasound facilitated rapid appropriate investigations as well as multidisciplinary team involvement. Focused point-of-care ultrasound has become an integral part of the assessment of critically ill patients, and as noncardiologist operators become increasingly skilled, its application can go beyond basic functional and structural assessment.

With the TTE finding confirmed by TEE, an urgent cardiac surgery consult was obtained. Given the size of the right and especially the left atrial masses, the patient was taken to the cardiac operating room for urgent open removal (Videos 8-10). Intraoperative findings included evidence of active pericarditis, a large mass of infected thrombus in the right and left atria and an abscess involving the interatrial septum. The infected thrombus was removed and the interatrial defect was closed using a bovine pericardial patch.

Postoperative TEE showed mildly reduced biventricular function, with no signs of intra-atrial shunting. There was no evidence of residual mass or valvular pathology. The patient tolerated the procedure well.

  • 1.

    Point-of-care echocardiography can be used to triage and focus investigations in medically complex cases.

  • 2.

    Cardiac ultrasound, both TTE and TEE, is an essential early step in the workup of embolic phenomena for both the pulmonary and systemic circulation.

  • 3.

    Thrombus-in-transit through a PFO can account for clinical findings of left- and right-sided embolic phenomena.

Financial/nonfinancial disclosures: None declared.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Dhutia H. . A differential diagnosis for left atrial mass on transthoracic echocardiography: Hiatus hernia. Case Rep Gastroenterol. 2014;8:115-118 [PubMed]journal. [CrossRef] [PubMed]
 
Baydoun H. .Barakat I. .Hatem E. .Chalhoub M. .Mroueh A. . Thrombus in transit through patent foramen ovale. Case Rep Cardiol. 2013;2013:395879- [PubMed]journal. [PubMed]
 
Raaphorst J. .Wouda E.J. . Thrombus in transit through a patent foramen ovale: paradoxical embolism. J Neurol Neurosurg Psychiatry. 2005;76:1199- [PubMed]journal. [CrossRef] [PubMed]
 
Myers P.O. .Bounameaux H. .Panos A. .Lerch R. .Kalangos A. . Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010;137:164-170 [PubMed]journal. [CrossRef] [PubMed]
 
Nellesen U. .Daniel W.G. .Matheis G. .Oelert H. .Depping K. .Lichtlen P.R. . Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. JACC. 1985;5:1002-1004 [PubMed]journal. [CrossRef] [PubMed]
 
Kim J.H. .Kim Y.J. . Thrombus in transit within a patent foramen ovale: gone with the cough! J Cardiovasc Ultrasound. 2011;19:196-198 [PubMed]journal. [CrossRef] [PubMed]
 
Sen T. .Cagli K. .Golbasi Z. .Cagli K. . Thrombus-in-transit entrapped in a patent foramen ovale: a complication of brucellosis. Arch Turk Soc Cardiol. 2011;39:487-490 [PubMed]journal. [CrossRef]
 
Arntfield R. .Millington S.J. . Point of care cardiac ultrasound applications in the emergency department and intensive care unit - a review. Curr Cardiol Rev. 2012;8:98-108 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Dhutia H. . A differential diagnosis for left atrial mass on transthoracic echocardiography: Hiatus hernia. Case Rep Gastroenterol. 2014;8:115-118 [PubMed]journal. [CrossRef] [PubMed]
 
Baydoun H. .Barakat I. .Hatem E. .Chalhoub M. .Mroueh A. . Thrombus in transit through patent foramen ovale. Case Rep Cardiol. 2013;2013:395879- [PubMed]journal. [PubMed]
 
Raaphorst J. .Wouda E.J. . Thrombus in transit through a patent foramen ovale: paradoxical embolism. J Neurol Neurosurg Psychiatry. 2005;76:1199- [PubMed]journal. [CrossRef] [PubMed]
 
Myers P.O. .Bounameaux H. .Panos A. .Lerch R. .Kalangos A. . Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010;137:164-170 [PubMed]journal. [CrossRef] [PubMed]
 
Nellesen U. .Daniel W.G. .Matheis G. .Oelert H. .Depping K. .Lichtlen P.R. . Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. JACC. 1985;5:1002-1004 [PubMed]journal. [CrossRef] [PubMed]
 
Kim J.H. .Kim Y.J. . Thrombus in transit within a patent foramen ovale: gone with the cough! J Cardiovasc Ultrasound. 2011;19:196-198 [PubMed]journal. [CrossRef] [PubMed]
 
Sen T. .Cagli K. .Golbasi Z. .Cagli K. . Thrombus-in-transit entrapped in a patent foramen ovale: a complication of brucellosis. Arch Turk Soc Cardiol. 2011;39:487-490 [PubMed]journal. [CrossRef]
 
Arntfield R. .Millington S.J. . Point of care cardiac ultrasound applications in the emergency department and intensive care unit - a review. Curr Cardiol Rev. 2012;8:98-108 [PubMed]journal. [CrossRef] [PubMed]
 
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