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Pneumothorax as a Complication of Septic Pulmonary Emboli with Tricuspid Valve Endocarditis
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A3202 - Pneumothorax as a Complication of Septic Pulmonary Emboli with Tricuspid Valve Endocarditis
Author Block: D. Chen; Internal Medicine, University of Louisville School of Medicine, Louisville, KY, United States.
Introduction: Tricuspid valve endocarditis is a major cause of morbidity and mortality among intravenous drug users (IVDUs). While septic pulmonary emboli are common in the setting of right sided endocarditis, pneumothorax remains a rare complication of septic pulmonary emboli. Here, we present a case of pneumothorax from ruptured septic pulmonary emboli.
Case Presentation: A 22-years-old female with a history of intravenous drug use was found unresponsive in her apartment. She was obtunded at the time of admission and she was intubated for airway protection. Empiric broad spectrum antibiotics were started. Despite fluid resuscitation, the patient continued to be hypotensive and she was started on vasopressors. Her blood cultures came back positive for methicillin sensitive staphylococcus aureus. A transesophageal echocardiogram showed multipronged masses attached at the commissures of the septal and anterior tricuspid leaflet and the sub-valvular apparatus with moderate tricuspid regurgitation. The patient remained dependent on vasopressors with persistent bacteremia. On the third hospital day, her oxygen requirement increased abruptly together with increased tachycardia and worsening of hypotension. Chest x-ray showed a right basilar pneumothorax. Of note, the patient had not undergone any invasive procedure prior to the occurrence of pneumothorax. A right basilar Thal-Quick chest tube was emergently placed with improvement in saturation and hemodynamics. Subsequently, a right apical pneumothorax developed and an apical surgical chest tube was placed. The patient was deemed high risk for surgical intervention by the cardiothoracic surgery team due to refractory septic shock with persistent bacteremia. The patient passed away after family agreed to comfort measures only for palliation.
Discussion: Pneumothorax remains a very rare complication of septic pulmonary emboli secondary to tricuspid endocarditis in IVDUs with only few cases reported in literature. The spontaneity of the pneumothorax seen in our patient and the atypical subpulmonic location were likely related to progression of basal septic pulmonary emboli with subsequent rupture of subpleural lesions. Pneumothorax in these cases can be lethal and prompt drainage via tube thoracostomy is indicated to prevent further expansion. In patients with septic pulmonary emboli whose respiratory status changes abruptly, pneumothorax should be considered.
Author Block: D. Chen; Internal Medicine, University of Louisville School of Medicine, Louisville, KY, United States.
Introduction: Tricuspid valve endocarditis is a major cause of morbidity and mortality among intravenous drug users (IVDUs). While septic pulmonary emboli are common in the setting of right sided endocarditis, pneumothorax remains a rare complication of septic pulmonary emboli. Here, we present a case of pneumothorax from ruptured septic pulmonary emboli.
Case Presentation: A 22-years-old female with a history of intravenous drug use was found unresponsive in her apartment. She was obtunded at the time of admission and she was intubated for airway protection. Empiric broad spectrum antibiotics were started. Despite fluid resuscitation, the patient continued to be hypotensive and she was started on vasopressors. Her blood cultures came back positive for methicillin sensitive staphylococcus aureus. A transesophageal echocardiogram showed multipronged masses attached at the commissures of the septal and anterior tricuspid leaflet and the sub-valvular apparatus with moderate tricuspid regurgitation. The patient remained dependent on vasopressors with persistent bacteremia. On the third hospital day, her oxygen requirement increased abruptly together with increased tachycardia and worsening of hypotension. Chest x-ray showed a right basilar pneumothorax. Of note, the patient had not undergone any invasive procedure prior to the occurrence of pneumothorax. A right basilar Thal-Quick chest tube was emergently placed with improvement in saturation and hemodynamics. Subsequently, a right apical pneumothorax developed and an apical surgical chest tube was placed. The patient was deemed high risk for surgical intervention by the cardiothoracic surgery team due to refractory septic shock with persistent bacteremia. The patient passed away after family agreed to comfort measures only for palliation.
Discussion: Pneumothorax remains a very rare complication of septic pulmonary emboli secondary to tricuspid endocarditis in IVDUs with only few cases reported in literature. The spontaneity of the pneumothorax seen in our patient and the atypical subpulmonic location were likely related to progression of basal septic pulmonary emboli with subsequent rupture of subpleural lesions. Pneumothorax in these cases can be lethal and prompt drainage via tube thoracostomy is indicated to prevent further expansion. In patients with septic pulmonary emboli whose respiratory status changes abruptly, pneumothorax should be considered.
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