A 30 yo female with a hx of IVDA presents with 2 weeks of progressively worsening right sided pleuritic chest pain, productive cough and shortness of breath.  She reports five days of nausea, vomiting and diarrhea as well.  A chest x-ray is shown.  What's the diagnosis?   Scroll down for answer.

Answer:  Cavitary lesion with air-fluid level consistent with abscess from septic emboli secondary to infective endocarditis

Or viewed on CT

Etiology

• bacteria laden clots from right sided bacterial endocarditis, septic thrombophlebitis, periodontal, and central venous catheter infections
• in IVDA tricuspid is most commonly involved in endocarditis, most common pathogen Staph aureus
• primary insult of ischemia due to vascular occlusion and secondary insult of infection

Presentation

• pleuritic chest pain, cough, fever, hemoptysis

Differential

• pulmonary abscess, septic emboli, tuberculosis, Aspergillosis, granulomatosis with polyangitis, scarcoid, malignancy

Diagnosis

• chest x-ray, CT, blood cultures
• +/- new heart murmur, presence of indwelling venous catheter, echo to identify valvular vegetation

Treatment

• 2-8 weeks of IV antibiotics
• possible abscess drainage, heart valve replacement

References

Stawicki SP, Firstenberg MS, Lyaker MR, et al. Septic embolism in the intensive care unit.Int JCrit Illn Inj Sci. 2013;3(1):58-63. doi:10.4103/2229-5151.109423

Parkar AP, Kandiah P. Differential Diagnosis of Cavitary Lung Lesions.J Belg Soc Radiol.2016;100(1):100. Published 2016 Nov 19. doi:10.5334/jbr-btr.1202

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