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(Circulation. 2006;114:e523-e524.)
© 2006 American Heart Association, Inc.

Images in Cardiovascular Medicine

Rapid Resolution of Massive Lung Abscesses Complicating Tricuspid-Valve Endocarditis

Yok-Ai Que, MD, PhD; Olivier Muller, MD, PhD; Lucas Liaudet, MD

From the Department of Intensive Care Medicine (Y.-A.Q., L.L.) and the Service of Cardiology (O.M.), University Hospital, Lausanne, Switzerland.

Corresponding to Professor Lucas Liaudet, MD, Department of Intensive Care Medicine, BH 10-982, University Hospital, 1011 Lausanne, Switzerland. E-mail Lucas.Liaudet{at}chuv.ch

A 33-year-old female intravenous drug abuser presented with fever and acute respiratory failure requiring mechanical ventilation. Chest x-ray and a thoracic computed tomographic scan revealed multiple nodular lesions with cavitation (Figure 1). A transesophageal echocardiogram disclosed a tricuspid-valve vegetation (Figure 2), and blood cultures were positive for Staphylococcus aureus. A diagnosis of tricuspid-valve endocarditis with septic pulmonary emboli (SPE) was made. Antibiotherapy with intravenous flucloxacillin and gentamicin induced a spectacular regression of the lung abscesses, allowing weaning from mechanical ventilation after 8 days and discharge from the hospital after 4 weeks (Figure 1).

View larger version (120K): [in this window] [in a new window]   Figure 1. Repeated computed tomographic scans of the chest from apex to base showing massive, bilateral, nodular lesions with cavitation on admission (A, B, and C). Spectacular improvement of the lesions under appropriate antibiotic therapy was noted after 14 days (D, E, and F), and almost complete resolution was noted after 4 weeks (G, H, and I).

View larger version (31K): [in this window] [in a new window]   Figure 2. Transesophageal echocardiography (4-chamber view) showing a large mobile mass attached to the atrial surface of the anterior leaflet of the tricuspid valve.

Infective endocarditis is a serious complication of intravenous drug abuse, with a reported mortality of 5% to 10%.¹ In a recent retrospective series of 493 cases of infective endocarditis, 220 (44.6%) occurred in intravenous drug users. The tricuspid valve was most frequently affected (88% of cases), and S aureus was the most frequently encountered pathogen.² SPE are relatively common in this setting. Intravenous drug users comprised 78% of a cohort of 60 patients with SPE reported in 1978,³ and tricuspid endocarditis was the embolic source in 53% of the cases. Although SPE may be particularly severe and life-threatening, appropriate antibiotherapy may result in rapid resolution of the lung abscesses, as indicated here, and thus such a complication should not be considered an indication for valve surgery in the setting of tricuspid endocarditis.

	Disclosure

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Dr Liaudet is supported by the Swiss National Fund for Scientific Research (Grant Nr PP00B-68882/1). The other authors have no potential conflicts of interest to disclose.

	References

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1. Moreillon P, Que YA. Infective endocarditis. Lancet. 2004; 363: 139–149.[CrossRef][Medline] [Order article via Infotrieve]

2. Martin-Davila P, Navas E, Fortun J, Moya JL, Cobo J, Pintado V, Quereda C, Jimenez-Mena M, Moreno S. Analysis of mortality and risk factors associated with native valve endocarditis in drug users: the importance of vegetation size. Am Heart J. 2005; 150: 1099–1106.[CrossRef][Medline] [Order article via Infotrieve]

3. MacMillan JC, Milstein SH, Samson PC. Clinical spectrum of septic pulmonary embolism and infarction. J Thorac Cardiovasc Surg. 1978; 75: 670–679.[Abstract]

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