Case presentation

A 37-year-old female with a history of mild intermittent asthma, hepatitis C, and opioid abuse disorder (in remission for the past year being maintained on buprenorphine) presents to the emergency department after being called due to positive blood cultures. She was seen at urgent care the day prior for a worsening progressive cough, shortness of breath, and pleuritic right anterolateral chest pain.

Review of her records show she was diagnosed with multifocal pneumonia in July, 2021 and treated with dual therapy of Augmentin and Azithromycin. Subsequently, she was diagnosed with a left upper lob pneumonia in September and treated with the same regimen.

Her laboratory workup at urgent care was reviewed included the following labs (pertinent positives in parenthesis):

CBC (WBC 12.6)

CMP (NA 129)

HIV – pending

Blood cultures x2 (rapid identification was positive for enterococcus faecalis)

Her CT chest w/o contrast is shown below:

CT chest w/o contrast impression: Worsening multifocal infectious process primarily involving the right lower lobe with extension into the right midle lobe and additional involvement of the left lower lobe

Upon her presentation to the emergency department her vitals are as follows:

BP 93/61, HR 103, T 35.9 C, RR 17, O2 sat 96% on RA

In addition to having the standard sepsis workup with three blood cultures ordered upon primary evaluation, she was started on Ampicillin-Sulbactam and a bedside echo was performed. The images are as follows:

Parasternal long view - left atrium (LA), left ventricle (LV), right ventricle (RV). Arrow denotes a large tricuspid valve vegetation coming in and out of view

Parasternal short axis view - Right ventricle (RV). Similar to last month’s images this view is showing a “D-sign” which is an indication of increased right sided pressures pushing the interventricular septum over to create the D-shaped cross-sectional appearence of the left ventricle. The red arrow is highlighting a small pericardial effusion. Also note that on the unannotated image you can see the tricuspid vegetation coming in and out of view in the location of the ‘RV’ on the annotated version.

Subxiphoid view - Right atrium (RA), right ventricle (RV), left atrium (LA), left ventricle (LV). Arrow highlighting the small pericardial effusion.

Ultrasound pearls

Assessing for a valvular vegetation is not one of the main assessments while performing point-of-care echocardiograms in the emergency department. However, if you happen to see one it definitely helps guide your workup in the ED and future conversation with the hospitalist.

In review, the three core echo assessments are:

What is the global function of their ejection fraction: normal, reduced, severely reduced?
Is there a pericardial effusion: yes/no?
Is the RV dilated: yes/no?

If you have a strong clinical suspician for endocarditis and are curious about looking for a vegetation, you typically will have the best chance of seeing it on on the apical 4-chamber view (notably this view was absent in this case as she had difficult apical windows). This is due to the fact that in the correct plane, your apical view should show you both valves concurrently. This patient’s vegetation was large enough that Dr. Bunting was able to pick it up on beautiful parasternal views. Additionally you will note that she performed a subxiphoid exam, which helps evaluate the tricuspid valve better (a useful tip if you do not have a good view of it on your apical 4-chamber exam).

Case resolution

The patient’s blood cultures resulted with alpha strep in addition to the enterococcus faecalis from the rapid identification. During admission she had a TEE performed confirming a large amount of vegetation on all three leaflets of the tricuspid valve with perforation of the posterior leaflet. Gentamycin was added to her Ampicillin-Sulbactam and her blood cultures cleared after 4 days of antibiotics. Gentamycin was then switched to Ceftriaxone and she will continue with a 42-day course of antibiotics. She is currently undergoing a multidisciplinary evaluation for tricuspid valve repair for definitive management of her endocarditis.

Want to learn more about infectious endocarditis? check out our previous post by clicking here