A 24yr old IV drug user with no past medical history presents with dyspnea and pleuritic chest pain. Patient reports being ill for the past 2 weeks. He initially developed diffuse abdominal pain with non-bilious emesis, non-productive cough and intermittent fevers. Over the past week he began having pleuritic chest pain over the right anterior chest wall and progressive dyspnea.
On initial evaluation, patient was tachypneic, tachycardic to 140bpm with a Tmax 103F. On exam patient had a diffusely tender abdomen without signs of peritonitis. EKG revealed sinus tachycardia without ischemic changes. Troponin and lactate were unremarkable. CT abdomen/pelvis demonstrated multiple cavitary lesions in the bilateral lung fields consistent with septic emboli. Bedside ultrasound was performed and a large 16 x16mm vegetation on the tricuspid valve with severe tricuspid regurgitation was identified. Blood cultures were positive for staph aureus and gram positive aerobic bacilli. Patient was admitted and treated for septic shock secondary to endocarditis with a discharge plan to follow up as an outpatient with Cardiothoracic Surgery to determine future need for tricuspid valve repair/replacement.
Infective endocarditis can be identified on bedside ultrasound most commonly by the presence of vegetations. These appear as hyperechoic mobile masses either on a valvular leaflet or along the valve annulus. A perivalvular abscess might also be identified as a hypoechoic lesion, typically alongside the aortic valve annulus. Valvular regurgitation and subsequent enlargement of atrial chambers can also be assessed in order to guide management and possible interventions.
Habib G, Badano L, Triboouilloy C, et al. Recommendations for the practice of echocardiography in infective endocarditis. European Journal of Echocardiography. 2010: 11;202-219.
Sarah Holgren PGY1 Emergency Medicine