The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Septic Pulmonary Emboli and is brought to you by Victoria Serven, MD, Travis Barlock, MD, and Katherine Sillman, NP.

1. Septic Pulmonary Emboli
And Infective Endocarditis
Victoria Serven, MD, Katherine Sillman, NP
& Travis Barlock, MD
Carolinas Medical Center & Levine Children’s Hospital
Charlotte, North Carolina
Michael Gibbs, MD, Faculty Editor
The Chest X-Ray Mastery Project™

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: SEPTIC PULMONARY EMBOLI.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 26-Year-Old
Intravenous
Drug User
Presents
With Back
Pain And
Fever.

8. 26-Year-Old
Intravenous
Drug User
Presents
With Back
Pain And
Fever.
Bilateral Rounded Densities

9. 26-Year-Old IV Drug User Presents With Back Pain And Fever.
Septic Pulmonary Emboli

10. 30-Year-Old With
A History Of
Intravenous Drug
Abuse Presents
With Weakness
and Shortness of
Breath.

11. 30-Year-Old With
A History Of
Intravenous Drug
Abuse Presents
With Weakness
and Shortness of
Breath.
Bilateral Rounded Densities

12. 30-Year-Old With A History Of Intravenous Drug Abuse
Presents With Weakness and Shortness of Breath.
Septic Pulmonary Emboli

13. 22-Year-Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough.

14. 22-Year-Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough.
Bilateral Rounded Densities

15. 22-Year-Old With A History Of Intravenous Drug Abuse
Presents With Fever, Chest Pain & Cough.
Septic Pulmonary Emboli

16. 22-Year-Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough.
Point Of Care
ED Echo:
Tricuspid Valve
Vegetation

17. 22-Year-Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough.
Here Is Her CXR
Three Months
Ago.

18. In One Week We Received Three Cases Of Septic Pulmonary
Emboli In Young, IV Drug-Dependent Adults With Endocarditis.
That Seems Like A Lot!

19. In One Week We Received Three Cases Of Septic Pulmonary
Emboli In Young, IV Drug-Dependent Adults With Endocarditis.
That Seems Like A Lot!
Let’s Look At Some North Carolina-Specific CDC Data.

20.  12-fold increase in the incidence of hospitalization between 2010 and 2015
 Incidence increasing most rapidly amongst drug users who are younger,
white (87%), non-Hispanic (92%), and from rural areas
 18-fold increase in the total cost of hospitalization
 Median hospital charges $54,281
 In 2015 42% of patients were either uninsured or receiving Medicaid

21. Another More
Recent Case
39-Year-Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough.
Bilateral Rounded Densities

22. 39-Year-Old With A History Of Intravenous Drug Abuse
Presents With Fever, Chest Pain & Cough.
Septic Pulmonary Emboli

23. 55-Year-Old
Intravenous
Drug User A
New
Pacemaker
Successfully
Placed.

24. 55-Year-Old Intravenous Drug User Presents Two
Weeks Later with AMS and Signs of Sepsis.
What do you notice?

25. 55-Year-Old Intravenous Drug User Presents Two
Weeks Later with AMS and Signs of Sepsis.
Bilateral Nodular Opacities
Consistent with Septic
Emboli.

26. 55-Year-Old Intravenous Drug User With Septic
Pulmonary Emboli on CT Chest.

28. Infective Endocarditis [IE] represents an infection of the cardiac
endothelium that can present as either acute or subacute disease.
Acute Advances rapidly, presenting with a sudden onset of high fever,
rigors, and systemic complications.
Subacute Symptoms develop over a period of weeks to months, can be
non-specific and therefore difficult to diagnose. Fever may or
may not be present.

29. Epidemiology
• In the U.S. there are 40,000 – 50,000 new case each year.
• The one-year mortality of IE has not improved in two decades.
• Risk factors: IV drug use, prosthetic valve replacement, implantable
cardiac devices, hemodialysis, venous catheters, and immunosuppression.
• There has been an increase in incidence, reflecting a growing number of
healthcare-acquired case, that now make up 25% of total cases.

30. Diagnosis
[+] Blood cultures + diagnostic imaging.
Imaging Strategies
• TTE generally recommended as the initial modality of imaging.
• TEE when TTE is positive with high risk features, or negative but high suspicion.
• Cardiac CT scanning is the key adjunctive modality when the anatomy is not
clearly delineated by echocardiography.

31. Cardiac CT Scan Of A Patient With Aortic Valve Endocarditis.
Vegetations See
As Filling Defects
Contrast-Filled
Perivalvular Abscess
Image Courtesy Of Dr. Markus Scherer, MD. March 2020.

32. The Microbiology Of Infective Endocarditis
S. aureus 30-40%
Viridans group streptococcus (VGS):
• Oral pathogens
• S. mutans, S. sanguinis, S. oralis, S. salivarius
20%
Enterococci 10%
HACEK organisms:
• Haemophilus species, Aggregati bacter actinomycetemcomitans,
Cardiobacterium hominis, Eikenella corrodens, Kingella species
<5%
Culture negative 10-20%

42. Management
• AHA and IDSA recommends Infectious Disease consultation.
• Mainstay of therapy is antimicrobial therapy, and surgery in selected
cases.
• Choice of antimicrobial therapy based on several factors:
• Patient presentation
• Native vs. prosthetic valve
• For prosthetic valves, length of time since valve replacement

43. Empiric Therapy: Native Valve Endocarditis
Acute Clinical Presentation:
• Recommend coverage for S. aureus, beta-hemolytic streptococci, and
aerobic gram-negative bacilli.
• Vancomycin and Cefepime (Aztreonam if penicillin allergic).
Subacute Clinical Presentation:
• Recommend coverage for S. aureus, VGS, HACEK, and enterococci
• Vancomycin and Ampicillin-Sulbactam.

44. Empiric Therapy: Prosthetic Valve Endocarditis
Onset Of Symptoms Within 1 Year Of Prosthetic Valve Placement:
• Recommend coverage for staphylococci, enterococci, and aerobic gram-
negative bacilli.
• Regimen could include Vancomycin, Gentamicin, Cefepime, Rifampin.
Onset Of Symptoms >1 Year After Prosthetic Valve Placement:
• Recommend coverage for staphylococci, VGS, and enterococci.
• Vancomycin and Ceftriaxone.

45. Surgery
The IDSA recommends early surgery for patients with:
• Endocarditis caused by fungi or highly resistant organisms
• Valve dysfunction resulting in symptoms of heart failure
• Endocarditis causing complete heart block
• Annular or aortic abscesses or destructive penetrating lesions
• Recurrent emboli or persistent/enlarging vegetations
• Mobile vegetations >10 mm
• Relapsing prosthetic valve endocarditis

46. If You Have Interesting Cases Of Septic Pulmonary Emboli, We Invite You
To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!