A 31-year-old man with a past medical history of intravenous drug use (IVDU), specifically heroin and cocaine, and untreated hepatitis C virus infection presented to the emergency department for the evaluation of chest pain. The patient's chest pain began approximately 5 days prior to presentation as a sharp, non-radiating, persistent pain, which was worse with inspiration and on movement. The pain progressed to 10/10 in intensity below the nipples bilaterally. Our patient endorsed exertional dyspnea mostly because of the inability to inspire without significant pain and subjective fever. He also reported worsening cough productive of light green sputum and, at times, a scant amount of blood. Moreover, approximately a week prior, the patient missed a vein while injecting the drug in the right side of his neck which led to swelling and redness of the area. The remainder of the review of systems was noncontributory. As for his past medical history, our patient reported being informed he was positive for hepatitis C 10 years prior, but he did not seek treatment nor did he follow up with medical providers for the same. The patient has a smoking history of 15 pack years and has been injecting "speedball", a mixture of cocaine and heroin, almost daily for the last 10 years. Our patient reported using "a bundle and a half" of heroin together with "few grams" of cocaine in powder form with water daily. When the patient was not able to acquire cocaine, he used crack which comes in solid "rock" form. He reported crushing the rock form and diluting it with vinegar. He heated the mixture after filtering through cotton-wool before injecting himself using a syringe. The patient generally uses his neck and left arm veins to inject drugs. Our patient used the same syringe for up to a month. He reported that, at times, the needle tip would break off in tiny fragments and it would become difficult to acquire access through it. The patient's last use of these drugs was the day of admission. Our patient admitted to being homeless and has been living on the streets for the last 3 years.
Initial vital signs demonstrated a temperature of 98.7  F, pulse of 135/min, respiratory rate of 19/min and blood pressure of 108/72 mmHg. He appeared to be in mild distress, with poor inspiratory effort due to pain. Physical examination was significant for poor dentition including a few chipped and missing teeth but no oral lesions or thrush. There was an area of erythema, induration and tenderness on the right side of the neck, about 4 x 10cm in size. Lungs were clear to auscultation bilaterally. Cardiac auscultation revealed normal S1 and S2, with no murmurs, rubs or gallops. Examination of the extremities revealed track marks on left antecubital fossa and onychomycosis of the nail beds. Stigmata of bacterial endocarditis were not seen.
Initial laboratory data was significant for a normal white blood cell (WBC) count of 8.5 K/muL, hemoglobin of 10.2 gm/dL and platelet count of 106 K/muL. The patient's mean corpuscular volume (MCV) was 73.6 fL, with red cell distribution width of 15.3%. Serum sodium was 129 mEq/L, with otherwise unremarkable basic metabolic panel. Serum lactic acid was 1.2 mmol/L (normal 0.5-2.2 mmol/L) and D-dimer was 1197 ng/mL (normal 0-230 ng/mL). Erythrocyte sedimentation rate (ESR) was 95 mm/hr (normal 0-15 mm/hr) and C-reactive protein (CRP) was 15.2 ng/dL (normal <1.0 ng/dL). Urine drug screen was positive for cocaine and opiates but negative for amphetamines. Chest X-ray indicated a patchy increased density in the left lower lobe, lingula, and right middle and lower lobes (Fig. 1). Given a significantly elevated d-dimer in the setting of tachycardia, CT angiography of the chest was performed which excluded pulmonary embolism. However, multiple, fluffy, nodules of varying size and ill-defined margins were seen throughout both lungs (Fig. 2). Some of these nodules were cavitary. Larger coalescent areas were seen in the left lower lobe and the lingula. These findings were concerning for septic emboli or metastatic disease. As a result, CT abdomen and pelvis with contrast was performed which did not show any masses. The only finding was splenomegaly, measuring 18cm in length. Furthermore, given the findings of tenderness on the right side of the neck, CT of the neck with contrast performed to exclude septic jugular vein phlebitis or Lemierre's syndrome was unremarkable.
Meanwhile, blood cultures were drawn and our patient was empirically administered intravenous (IV) Vancomycin 1 g and Piperacillin-Tazobactam 3.375 g. Emergent transthoracic echocardiogram (TTE) was performed which did not show valvular vegetation or abscess. Given a high suspicion of bacterial endocarditis (BE), trans-esophageal echocardiogram (TEE) was performed which also did not show any vegetations or abscess. Piperacillin-tazobactam was changed to IV Cefepime 2 g every 12 hours. IV Vancomycin was continued to achieve a therapeutic vancomycin trough level. Pulmonology was consulted and, based on the findings on high resolution CT scan of the chest (Fig. 3), the decision was made to perform navigational bronchoscopy to obtain endobronchial and transbronchial lung biopsies. Specimens were obtained from the right lower lobe using a needle biopsy, and near the pleura using the forceps. A few specimens were also obtained using triple needle brush. In addition, specimens from bronchial washings were sent for cytologic analysis, routine cultures, acid-fast bacilli (AFB) culture and fungal culture.
Additional diagnostic evaluation included HIV testing, QuantiFeron TB, hepatitis panel, rapid plasma reagin (RPR), antinuclear antibody (ANA), anti-double stranded DNA (DsDNA) antibody, anti-glomerular basement membrane (GBM) antibody, anti-neutrophil cytoplasmic antibody (ANCA) and complement levels. Results were unremarkable.
Histopathology report of right lower lobe biopsy specimen was normal with no mononuclear infiltration. A brush tip specimen was also obtained from right lower lobe. Moreover, approximately 55 cc of thick pale orange fluid was obtained via bronchial wash of right lower lobe which showed scattered refractile material surrounded by dense neutrophilic and mononuclear infiltration (Fig. 4, Fig. 5). Gomori methenamine silver (GMS) stain for Pneumocystis jirovecii was negative.
The patient's maximum temperature was 100.1  F five days after the admission on antibiotics. The patient's heart rate normalized to 70-90/min and WBC count remained in between 6 and 8 K/muL throughout admission. The patient's chest pain improved over the course of days but mild discomfort with breathing persisted. Blood, respiratory and bronchial wash cultures for bacteria, AFB and fungi remained negative. Because of ongoing concern for bacterial septic emboli, the patient was continued on IV Vancomycin and IV Cefepime for a total of 6 weeks. The patient completed the final 3 weeks of antibiotics at a sub-acute facility.