==== Front
Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2356301310.5144/0256-4947.2013.200asm-2-200What's Your Diagnosis?A male with a one week history of fever, cough and breathlessness Kumar K.V.S Hari Baruah M.M From the Department of Endocrinology, Command Hospital, Lucknow Cantt, IndiaCorrespondence: Dr. K.V.S Hari Kumar, Department of Endocrinology, Command Hospital, Lucknow Cantt, AP 226002 India, T: 919454674679, hariendo@rediffmail.comMar-Apr 2013 33 2 200 200 Copyright © 2013, Annals of Saudi Medicine2013This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
==== Body
A 39-year-old male presented with one week history of fever, cough and breathlessness. The patient reported using oral antibiotics and mucolytics with no significant relief. He reported having used illicit drugs intravenously in the past and gave a history of high-risk sexual behaviour. The patient denied a history of tuberculosis or diabetes. Physical examination revealed a poor general condition with tachycardia, tachypnea and hypotension. Chest examination revealed the presence of grade 3/6 systolic murmur over mitral and tricuspid area and polyphonic rhonchi in all areas. Rest of the systemic examination was normal. An urgent chest radiograph is shown in Figure 1. What is the diagnosis and possible etiology?

For the answer, visit: http://annsaudimed.net

Figure 1 Chest x-ray.

Ann Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre asm-2-200aWhat's Your Diagnosis?Diagnosis: Multiple lung abscesses Kumar K.V.S Hari Baruah M.M From the Department of Endocrinology, Command Hospital, Lucknow Cantt, IndiaCorrespondence: Dr. K.V.S Hari Kumar, Department of Endocrinology, Command Hospital, Lucknow Cantt, AP 226002 India, T: 919454674679, hariendo@rediffmail.comMar-Apr 2013 33 2 Copyright © 2013, Annals of Saudi Medicine2013This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Computed tomography confirmed the presence of multiple rounded lesions with thin borders and air fluid levels. Echocardiography revealed vegetation on the tricuspid valve with moderate tricuspid regurgitation. Blood culture examination grew Staphylococcus aureus and the patient was diagnosed as having infective endocarditis with septic emboli into lungs leading to multiple lung abscesses. Other investigations revealed polymorphonuclear leucocytosis, negative screen for viral infections and normal biochemistry. He was treated with parenteral antibiotics (cloxacillin and gentamicin) for 6 weeks. He had a marked recovery in clinical status and the lung lesions healed without any residual disability.

Infective endocarditis can present with myriad manifestations and is rare to present with multiple lung abscesses. The involvement of tricuspid valve is seen in only 5% to 10% of all cases of infective endocarditis.1 Majority of tricuspid valve involvement is secondary to intravenous drug abuse. Right-sided endocarditis occasionally presents a diagnostic challenge with obscure presentation. Our patient presented with the classical “tricuspid syndrome” consisting of recurrent episodes of fever, chest symptoms and feeling of impending doom.2 The presentation suggests primary lung pathology but his investigations and parenteral drug abuse lead us to the diagnosis of infective endocarditis.

The prognosis of tricuspid valve endocarditis is favorable and most patients respond to antibiotic therapy. The American Heart Association recommends antibiotic therapy for 6 weeks in staphylococcal endocarditis for complicated right sided and all left sided endocarditis. In uncomplicated right sided endocarditis two weeks of antibiotic therapy is adequate.3 Surgical treatment is indicated with persisting failure, sepsis and abscess formation.

Lung abscess is necrosis of the pulmonary tissue leading to pus filled cavity formation and occurs as a complication of aspiration. Lung abscess is mostly single and formation of multiple small abscesses is referred to as necrotizing pneumonia or lung gangrene.4 Multiple lung abscesses are very unusual and are due to septic thrombophlebitis or right sided endocarditis. 4 The common pathogens include Staphylococcus, Streptococcus, Hemophilus, Peptostreptococcus and Bacteroides species. The cure rate of lung abscess is over 90% with appropriate antibiotic therapy.

Figure 1 Chest x-ray showing multiple lung abscesses.