Case Report: Infective Endocarditis With Pulmonary Emboli, Effusion, and Pneumonia (Last Methamphetamine Abuse 15 Years Ago)




Patel, Salman
Charolia, Samita
Ahmed, Affan
Kasim, Chaitanya


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Background: Infective endocarditis of the right-sided native valve involves the tricuspid or pulmonic valve; isolated right-sided IE accounts for approximately 10 percent of all IE cases. Methamphetamine use is known to cause cardiac complications including vasospasms and damage to the myocardial surface. Case Presentation: Patient is a 51-year-old Caucasian male presented to the ED with cough, fever, shortness of breath and wheezing for the last 2 weeks. Past medical history significant of COPD, hypertension (not on home medications), history of skin cancer of unknown type 10 years ago status postresection, methamphetamine use 15 years ago, current tobacco use disorder, and marijuana use disorder. Patient reported that his symptoms started with fever and a cough that is productive with yellow-colored sputum. He also lost about 15 to 20 pounds in the last 2 to 3 weeks. Patient also noticed hemoptysis and had a couple episodes of bloody sputum. He also reported worsening shortness of breath associated with wheezing and has been using albuterol nebulizer up to 4 times a day without much relief in symptoms. He denies sick contacts. He has been experiencing left upper quadrant abdominal pain worse with breathing/deep inspiration. Patient denies family history of blood clots. Work-up in the ED showed elevated leukocytosis with hyponatremia and mild hyperkalemia. Initial troponin was 0.06 and elevated BNP at 460. Urine analysis was only positive for marijuana. Patient's chest x-ray showed left sided pleural effusion. CTA chest with PE protocol was done and showed numerous cavitary consolidate to masses suspicious for septic emboli and left lower lobe pulmonary embolus with left lower lobe pneumonia and moderate pleural effusion. Day 1 he had a left thoracentesis showing exudative effusion. Day 3-5 PPD skin test, quant gold and AFB sputum cultures x3 are negative. BCX show initially MSSA and then repeat BCX show corynebacterium and staph capitis likely skin contaminant. Patience was placed on oxacillin for MRSA coverage. Day 5 TEE shows 1 cm vegetation in tricuspid valve confirming infective endocarditis. CT surgery is following outpatient for improvement of vegetation in 4 weeks with OP cardiology f/u. Heparin drip switched to Argatroban for heparin resistance and possible HIT. Argatroban bridged to warfarin. PT is now therapeutic. ANA is elevated 1:640, but further work up is negative. Patient will need continued IV antibiotic with oxacillin for at least 6 weeks. Will follow up echo with Cardiology in 4 weeks then revaluate with ID and CT surgery. Order heparin resistance antithrombin III evaluate OP after acute treatment. Conclusion: This case illustrates a unique presentation of infective endocarditis with pulmonary effusion, embolus, and pneumonia. Not certain what caused this patient case if it was his current use of marijuana or is methamphetamine use 15 years ago that just started presenting now.