COTW 3/29: 25 year old male presents with fever and shortness of breath...

A 25 year old male with hx of IVDA presents with fever and shortness of breath. He has been coughing and having night sweats. He is hypotensive, febrile, and tachycardic. He has R sided crackles on physical exam.

His lung ultrasound shows:

This is his right anterior lung field. Note the confluent B-lines. There were no B-lines in the posterior or Left sided lung fields, making these findings focal.

His echo shows:

This parasternal long axis shows a fast heart rate. Notice that there is a somewhat paradoxical motion of the septum.

And here we see a large vegetation on the tricuspid valve as well as the paradoxical bowing of the septum.

There is a significant amount of tricuspid regurgitation.

His overall presentation is consistent with endocarditis with septic emboli to the lungs.

His tricuspid vegetation is likely due to bacteremia secondary to IV drug abuse. In most cases of endocarditis secondary to IVDA, the vegetation will be on the atrial side of the valve given the direction of flow.

The paradoxical bowing of the septum is a sign of increased right sided heart pressures from the incompetent tricuspid valve.

The patient’s focal b-lines are more consistent with a focal pneumonia or in his case septic emboli from his endocarditis.

This is a great case where echo can help guide treatment decisions for antibiotics (CAP vs endocarditis) and evaluate the patient’s current physiology (R-heart pressures and regurgitation).