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EMGuideWire's Radiology Reading Room: Septic Pulmonary Emboli

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Septic Pulmonary Emboli and is brought to you by Victoria Serven, MD, Travis Barlock, MD, and Katherine Sillman, NP.

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EMGuideWire's Radiology Reading Room: Septic Pulmonary Emboli

  1. 1. Septic Pulmonary Emboli And Infective Endocarditis Victoria Serven, MD, Katherine Sillman, NP & Travis Barlock, MD Carolinas Medical Center & Levine Children’s Hospital Charlotte, North Carolina Michael Gibbs, MD, Faculty Editor The Chest X-Ray Mastery Project™
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.
  3. 3. Process • Many are providing clinical cases and presentations are then shared with all contributors on our departmental educational website. • Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. • We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: SEPTIC PULMONARY EMBOLI.
  4. 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. 26-Year-Old Intravenous Drug User Presents With Back Pain And Fever.
  8. 8. 26-Year-Old Intravenous Drug User Presents With Back Pain And Fever. Bilateral Rounded Densities
  9. 9. 26-Year-Old IV Drug User Presents With Back Pain And Fever. Septic Pulmonary Emboli
  10. 10. 30-Year-Old With A History Of Intravenous Drug Abuse Presents With Weakness and Shortness of Breath.
  11. 11. 30-Year-Old With A History Of Intravenous Drug Abuse Presents With Weakness and Shortness of Breath. Bilateral Rounded Densities
  12. 12. 30-Year-Old With A History Of Intravenous Drug Abuse Presents With Weakness and Shortness of Breath. Septic Pulmonary Emboli
  13. 13. 22-Year-Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough.
  14. 14. 22-Year-Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough. Bilateral Rounded Densities
  15. 15. 22-Year-Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough. Septic Pulmonary Emboli
  16. 16. 22-Year-Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough. Point Of Care ED Echo: Tricuspid Valve Vegetation
  17. 17. 22-Year-Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough. Here Is Her CXR Three Months Ago.
  18. 18. In One Week We Received Three Cases Of Septic Pulmonary Emboli In Young, IV Drug-Dependent Adults With Endocarditis. That Seems Like A Lot!
  19. 19. In One Week We Received Three Cases Of Septic Pulmonary Emboli In Young, IV Drug-Dependent Adults With Endocarditis. That Seems Like A Lot! Let’s Look At Some North Carolina-Specific CDC Data.
  20. 20.  12-fold increase in the incidence of hospitalization between 2010 and 2015  Incidence increasing most rapidly amongst drug users who are younger, white (87%), non-Hispanic (92%), and from rural areas  18-fold increase in the total cost of hospitalization  Median hospital charges $54,281  In 2015 42% of patients were either uninsured or receiving Medicaid
  21. 21. Another More Recent Case 39-Year-Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough. Bilateral Rounded Densities
  22. 22. 39-Year-Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough. Septic Pulmonary Emboli
  23. 23. 55-Year-Old Intravenous Drug User A New Pacemaker Successfully Placed.
  24. 24. 55-Year-Old Intravenous Drug User Presents Two Weeks Later with AMS and Signs of Sepsis. What do you notice?
  25. 25. 55-Year-Old Intravenous Drug User Presents Two Weeks Later with AMS and Signs of Sepsis. Bilateral Nodular Opacities Consistent with Septic Emboli.
  26. 26. 55-Year-Old Intravenous Drug User With Septic Pulmonary Emboli on CT Chest.
  27. 27. Infective Endocarditis [IE] represents an infection of the cardiac endothelium that can present as either acute or subacute disease. Acute Advances rapidly, presenting with a sudden onset of high fever, rigors, and systemic complications. Subacute Symptoms develop over a period of weeks to months, can be non-specific and therefore difficult to diagnose. Fever may or may not be present.
  28. 28. Epidemiology • In the U.S. there are 40,000 – 50,000 new case each year. • The one-year mortality of IE has not improved in two decades. • Risk factors: IV drug use, prosthetic valve replacement, implantable cardiac devices, hemodialysis, venous catheters, and immunosuppression. • There has been an increase in incidence, reflecting a growing number of healthcare-acquired case, that now make up 25% of total cases.
  29. 29. Diagnosis [+] Blood cultures + diagnostic imaging. Imaging Strategies • TTE generally recommended as the initial modality of imaging. • TEE when TTE is positive with high risk features, or negative but high suspicion. • Cardiac CT scanning is the key adjunctive modality when the anatomy is not clearly delineated by echocardiography.
  30. 30. Cardiac CT Scan Of A Patient With Aortic Valve Endocarditis. Vegetations See As Filling Defects Contrast-Filled Perivalvular Abscess Image Courtesy Of Dr. Markus Scherer, MD. March 2020.
  31. 31. The Microbiology Of Infective Endocarditis S. aureus 30-40% Viridans group streptococcus (VGS): • Oral pathogens • S. mutans, S. sanguinis, S. oralis, S. salivarius 20% Enterococci 10% HACEK organisms: • Haemophilus species, Aggregati bacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella species <5% Culture negative 10-20%
  32. 32. Management • AHA and IDSA recommends Infectious Disease consultation. • Mainstay of therapy is antimicrobial therapy, and surgery in selected cases. • Choice of antimicrobial therapy based on several factors: • Patient presentation • Native vs. prosthetic valve • For prosthetic valves, length of time since valve replacement
  33. 33. Empiric Therapy: Native Valve Endocarditis Acute Clinical Presentation: • Recommend coverage for S. aureus, beta-hemolytic streptococci, and aerobic gram-negative bacilli. • Vancomycin and Cefepime (Aztreonam if penicillin allergic). Subacute Clinical Presentation: • Recommend coverage for S. aureus, VGS, HACEK, and enterococci • Vancomycin and Ampicillin-Sulbactam.
  34. 34. Empiric Therapy: Prosthetic Valve Endocarditis Onset Of Symptoms Within 1 Year Of Prosthetic Valve Placement: • Recommend coverage for staphylococci, enterococci, and aerobic gram- negative bacilli. • Regimen could include Vancomycin, Gentamicin, Cefepime, Rifampin. Onset Of Symptoms >1 Year After Prosthetic Valve Placement: • Recommend coverage for staphylococci, VGS, and enterococci. • Vancomycin and Ceftriaxone.
  35. 35. Surgery The IDSA recommends early surgery for patients with: • Endocarditis caused by fungi or highly resistant organisms • Valve dysfunction resulting in symptoms of heart failure • Endocarditis causing complete heart block • Annular or aortic abscesses or destructive penetrating lesions • Recurrent emboli or persistent/enlarging vegetations • Mobile vegetations >10 mm • Relapsing prosthetic valve endocarditis
  36. 36. If You Have Interesting Cases Of Septic Pulmonary Emboli, We Invite You To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To: michael.gibbs@atriumhealth.org Your De-Identified Case(s) Will Be Posted On Our Education Website And You And Your Institution Will Be Recognized!

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