A 51 y.o. woman comes in from a drug rehab facility with altered mental status

The pt has a hx of tricuspid valve replacement and untreated hep C. She is clinically dehydrated.

What do you notice on her cxr?

Our patient had a cavitary lesion caused by Staph aureus.  She had a tricuspid valve vegetation. Right sided endocarditis accounts for only 5-10 percent of infective endocarditis.  In addition to intravenous drug users, patients with hemodialysis catheters, defibrillators and pacemakers are also at risk for right sided endocarditis. The most common valve to develop endocarditis is the mitral valve, then aortic.

Septic pulmonary emboli are common in right sided endocarditis and can be seen on CXR as peripheral cavitary lesions or nodules. On CT they can appear as infected thrombi in the pulmonary arteries,  A vegetation size greater than 10 mm presents a significantly higher risk of embolization and a higher risk of death.

WHAT THINGS SHOULD YOU CONSIDER IF YOU SEE CAVITARY LESIONS ON CXR?

Although we live in the era of advanced imaging and CT is often the first imaging considered, the simple CXR can provide useful information. The differential for cavitary lesions is broad including:

INFECTION- bacterial infections include: Streptococcus, Staph aureus, Klebsiella and H flu as well as tuberculosis and fungal infections like aspergillus

If a fungal ball is observed on radiographic imaging, then a diagnosis of aspergilloma can be confirmed with a positive serum Aspergillus IgG test.

A growth of fungus  can occur in a pre-formed cavity with any cavitary lung disease: Tbc, sarcoid or bronchiectasis. A Rasmussen’s aneursym can occur in a tuberculous cavity where a branch of the pulmonary artery forms a pseudoaneurym and ruptures causing massive hemoptysis.

MALIGNANCY- Squamous cell mets to the lung frequently cavitate as well as breast, adenocarcinomas and sarcomas.

COLLAGEN VASCULAR DISEASE- Granulomatosis with polyangiitis (GPA)  is an autoimmune disease that causes vasculitis in small vessels  and nodules.  25% of these cavitate.  Rheumatoid arthritis also forms cavitary lesions. The picture below shows cavitary lesions from Wegener’s on the L and a cavity infected with Aspergillus on the R.

Our patient grew out Staph aureus from the blood and developed fulminant sepsis with persistent shock. She developed renal failure and persistent lactic acidosis in spite of maximal pressor therapy and suffered a cardiac arrest.  She could not be resuscitated.

 Mohananey D, Mohadjer A, Pettersson G, et al. Association of vegetation size with embolic risk in patients with enfective endocarditis. JAMA Intern Med. 2018;178(4):502-510.

Parkear A, Kandiah P. Differentila diagnosis of cavitary lung lesions. J Gelg Soc Radiol 2016;100(1):100.

Gaillard F, Kogan J, Campos A, et al. Aspergilloma Radiopaedia.org https://doi.org/10.53347/rID-8680

Lang M, Lang A, Chauhan N. Non-surgical treatment options for pulmonary aspergilloma Respiratory Medicine PRIL 2020, 105903

http://www.nejm.org/doi/full/10.1056/NEJMicm980601#t=article 

Ananthakrishnan L, Sharma N, Kanne J. Wegener’s granulomatosis in the chest: high-resolution CT findings. AJR 2009. Vol 192(3).