A 61-year-old African-American male came to the emergency department with a history of back and hip pain, night sweats, and decreased appetite coupled with an unintentional weight loss of 40 lbs. He also reported feeling fatigued and had generalized malaise. His history was also significant for hemoptysis and pleuritic chest pain.
Five months ago, before the current admission, he had presented to our hospital for similar symptoms. During that time, he underwent a Computed Tomography scan (CT) of the chest that reportedly showed right lower lobe pleural thickening with hilar lymphadenopathy. The patient was then prescribed oral antibiotics for possible community acquired pneumonia and was subsequently discharged. Unfortunately, the patient did not feel better and came to the hospital again for the current admission.
Past medical history was significant for a period of incarceration during which time he had a PPD placed, which was negative. He also endorsed an eight pack-year history of smoking tobacco and a history of remote IV drug use for two years.
On admission, the patient's vitals were remarkable for tachycardia at 106 beats per minute and an oxygen saturation of 98% on 2 liters. On physical exam, a grade IV/VI holosystolic murmur was heard in all cardiac foci. Lungs were clear to auscultation bilaterally. The abdomen was tender to palpation diffusely with normoactive bowel sounds. There was significant tenderness to palpation in the lumbar spine with a positive straight leg test. Digital clubbing of the fingernails was noted bilaterally. Pertinent labs showed an elevation of white blood cell counts at 14.5 thousand cells per milliliter and sodium of 128. Radiological imaging included a CT scan of the chest that showed multiple opacities bilaterally, more prominent on the right (Figure 1). Patient was then admitted with a diagnosis of right upper lung community acquired pneumonia, with a high suspicion for tuberculosis. Eventually, tuberculosis was ruled out with three negative acid-fast bacillus sputum samples, negative quantiferon screen, and negative nucleic acid amplification test. Blood cultures came back positive for streptococcus sanguinus. Following positive blood cultures, the patient underwent transthoracic echocardiography (TTE) which confirmed the presence of a large and mobile pulmonic valve vegetation, as well as moderate to severe tricuspid regurgitation (Figure 2). Infectious disease consult was obtained and he was started on ceftriaxone 2 grams intravenously per day. The treatment was continued for a total of four weeks. Due to the large size of the vegetation and severe pulmonary valve insufficiency, the patient underwent valve replacement (Figure 3).