Septic Pulmonary Embolism: A Rare and Cataclysmic Complication of Infective Endocarditis

Background: Septic pulmonary embolism (SPE) is an uncommonly reported complication of IE requiring a high index of suspicion. Case: We report a 21-year-old male, former methamphetamine user, complaining of intermittent fever, cough and dyspnea for 6 months. He had a Graham-Steell murmur, grade 3/6 pansystolic murmur at the left lower sternal border, bipedal edema and petechiae on the trunk and extremities. Ceftriaxone and Gentamicin were given empirically for possible infective endocarditis. 2D echocardiography revealed heavy echogenic densities attached to the pulmonic valve cusps (2.0 × 0.79 cm), fluttering echogenic densities at the tricuspid valve leaflet tips and spontaneous echo contrast. Anticoagulation with Enoxaparin was started. Streptococcus agalactiae grew on blood culture (3 sites). On the 10th hospital day, he had an episode of hemoptysis (~600 ml) requiring endotracheal intubation. CT angiogram of the pulmonary arteries revealed several filling defects adherent to the pulmonary valve (endocarditic lesion), pulmonary embolism/septic emboli involving the left lateral wall of the main pulmonary artery, anterior segmental arteries of both upper lobes, and bilateral lower lung pulmonary arteries. Multiple small nodules, some exhibiting cavitation and the feeding vessel sign, were seen in both mid to lower lungs. Antibiotics were continued. Repeat blood cultures after 2 weeks no longer showed any growth. He was successfully extubated. Valve surgery was advised but no consent was given. Medical management was maximized. He was discharged improved after 2 months. Conclusion: Patients with RSIE are at risk to develop SPE which is an uncommon and potentially fatal complication of IE which may go unrecognized without a high index of suspicion. Early recognition is therefore important.