University of New MexicoUNM Digital Repository

Hospital Medicine Internal Medicine

1-14-2014

Clinical vignette: Tension pneumothoraxcomplicating septic pulmonary emboliA Clemens

J Rush Pierce Jr

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Recommended CitationClemens, A and J Rush Pierce Jr. "Clinical vignette: Tension pneumothorax complicating septic pulmonary emboli." (2014).https://digitalrepository.unm.edu/hostpitalmed_pubs/10

1. Pnemothorax is an uncommon complication of pneumonia; it may be seen

with Pneumocystis jiroveci, tuberculosis, or necrotizing bacterial pneumonia.

2. Pneumothorax associated with septic pulmonary emboli is a very rare

complication of Staphyloccus aureus bacteremia.

3. The pathophysiology of pneumothorax in the setting of septic pulmonary

emboli is presumed to be erosion of a embolic bacterial cavitary lesion into a

bronchus with creation of a bronchopulmonary fistula.

4. Septic pulmonary embolus is a severe complication of staphylococcal

bacteremia and right-sided endocarditis that may be seen in IV drug users.

On rare occasion, it may be associated with pneumothorax. This infection is

often associated with prolonged morbidity and increased mortality.

CASE PRESENTATION

TEACHING POINTS

CONCLUSIONS

INFECTIVE ENDOCARDITIS IN IVDU

A 40 year old female was referred from the local jail with a tension

pneumothorax. She had a long history of intravenous (IV) heroin and cocaine

use followed by a 2-year history of sobriety. She had resumed intravenous

heroin use 3 weeks before admission and soon thereafter developed fever and

chills. She was incarcerated 7 days before admission. Five days before

admission she developed progressive dyspnea and left-sided pleuritic chest

pain. On arrival in the emergency department, she was found to be febrile (39.0

deg C), tachycardic (121 beats/min), tachypneic (34 breaths/min), and

hypoxemic. Leukocyte count was 12,100 cells/mcL. A chest x-ray showed a

large left tension pneumothorax with mediastinal shift and a moderate left sided

pleural effusion. After placement of a left-sided chest tube, computerized

tomography revealed multifocal peripheral cavitary nodules suggestive of septic

emboli. Per the radiology report, the etiology of the pneumothorax was

compatible with bronchopleural fistula, suspected to be due to a peripheral

cavitary nodule in the anteromedial left lower lobe. A transthoracic

echocardiogram revealed a large tricuspid valve vegetation measuring 0.95 x

1.47cm. Blood cultures grew methicillin-sensitive Staphylococcus aureus. She

was treated with nafcillin. Her initial hospital course included respiratory failure

requiring mechanical ventilation and development of a right-sided

pneumothorax requiring placement of an additional chest tube. Serial chest x-

rays showed improvement of the cavitary lesions and resolution of the bilateral

pneumothoraces. She was eventually transferred to a skilled nursing facility to

complete a six week course of nafcillin. At the time of discharge, she was

without leukocytosis and no longer required supplemental oxygen.

Septic pulmonary embolus is a severe complication of staphylococcal

bacteremia and right-sided endocarditis that may be seen in IV drug users. On

rare occasion, it may be associated with pneumothorax. This infection is often

associated with prolonged morbidity and increased mortality.

1. 1. Sheu CC, Hwang JJ, Tsai JR, Wang TH, Chong IW, Huang MS.

Spontaneous pneumothorax as a complication of septic pulmonary

embolism in an intravenous drug user: a case report. Kaohsiung J Med Sci.

2006 Feb;22(2):89-93.

2. Alafify AA, Al-Khuwaitir TS, Wani BA, Taifur SM. Staphylococcus aureus

endocarditis complicated by bilateral pneumothorax. Saudi Med J. 2006

May;27(5):707-10.

3. 3. Corzo JE, Lozano de León F, Gómez-Mateos J, López-Cortes L, Vázquez

R, García-Bragado F. Pneumothorax secondary to septic pulmonary emboli

in tricuspid endocarditis. Thorax. 1992 Dec;47(12):1080-1.

4. Aguado JM, Arjona R, Ugarte P. Septic pulmonary emboli. A rare cause of

bilateral pneumothorax in drug abusers. Chest. 1990 Nov;98(5):1302-4.

REFERENCES

Background. Intravenous drug users (IVDU) are at risk for developing infective

endocarditis, especially of the tricuspid valve. Estimated incidence is 2 – 4

cases/1,000 years of intravenous drug use. Damage to the tricuspid valve

occurs in IVDU due to injection of particulate matter, direct toxicity of injected

drugs for the tricuspid valve, and injected microorganisms. IVDU also have

higher rates of skin colonization with Staph aureus, which is the most common

organism to cause infective endocarditis in IVDU. Other common causes of

infective endocarditis in IVDU include streptococci and enterococci. Gram

negative bacilli and fungi uncommonly cause infective endocarditis in IVDU.

Clinical manifestations include fever, heart murmurs, septic pulmonary

emboli, metastatic abscesses (brain, kidney, spine) and heart failure.

Pulmonary complications. Septic pulmonary emboli ,often manifest by

cavitary pneumonia, occur in about 75% of IVDU with tricuspid valve

endocarditis. Less common pulmonary complications include pulmonary

infarction, empyema, and pulmonary hemorrhage due to rupture of a

pulmonary artery mycotic aneurysm. Pneumothorax is very uncommon.

Diagnosis. Blood cultures and echocardiography are the most useful diagnostic

procedures. Evidence of septic emboli may be suggested by CXR.

Treatment and prognosis. Prolonged parenteral antibiotic therapy is

recommended for all patients. Most experts treat endocarditis caused by Staph

aureus for 4 – 6 weeks. Vegetation size is associated with mortality in patients

with tricuspid valve endocarditis. Vegetations <1 cm have been associated with

very high cure rates, whereas vegetations > 2 cm have been associated with

mortalities rates of > 30%. The role of surgery remains controversial.

CXR showing tension pneumothorax and peripheral

cavitary nodules

IMAGING