Presentation
Fever, tachycardia and right-sided chest pain. History of intravenous drug use.
Patient Data
There is a rounded are of opacification laterally in the right mid-zone measuring up to 50mm in diameter. This is difficult to localize on the lateral image but may lie laterally within the right middle lobe. Faint opacification is also noted overlying the anterior end of the left 5th rib which is less specific in nature. Heart size is not increased and no mediastinal or hilar abnormalities are detected. There is a trace of pleural fluid on the right. No sub-diaphragmatic abnormalities are detected.
Conclusion:
Rounded opacity in the right mid-zone is suspicious for pneumonia. Peripheral infarct is possible.
Right hilar and subcarinal lymphadenopathy. Large area of pulmonary opacity in the lateral aspect right lower lobe, further large area anterior segment of right upper lobe but multiple further areas of abnormal pulmonary opacity bilaterally with several stellate appearing densities in left apex. No central endobronchial lesion. No definite superior mediastinal lymphadenopathy. Small bilateral pleural effusions, a little larger on the right.
Case Discussion
This is a case of an active intravenous drug user (IVDU) who presented with a left elbow abscess and MRSA bloodstream infection. He complained of right-sided chest pain and was found to be febrile and tachycardic. Trans-thoracic echocardiography showed no overt valvular vegetations, however, there was a concern for infective endocarditis (IE) given the presence of septic pulmonary emboli on CT. He was treated empirically with IV vancomycin as if right-sided IE given the presence of pulmonary embolic phenomenon.