Intravenous Drug Abuse Resulting in Infected Retained Cardiac Needle Embolization and Septic Pulmonary Emboli

Intravenous drug abuse remains a significant health concern worldwide. Complications of intravenous drug use include transmission of infectious diseases, infective endocarditis, and localized infection. Central needle embolization of needle fragments from intravenous drug use is extremely rare and can result in life threatening complications. However, management of these patients poses a clinical dilemma for physicians when considering conservative versus surgical treatment. We present a case of a young male with a history of intravenous drug abuse who presented with fevers and shortness of breath and was found to have infective CASE REPORT Intravenous Drug Abuse Resulting in Infected Retained Cardiac Needle Embolization and Septic Pulmonary Emboli Keith Brown, DO, MBA; Valentina Del Signore, DO; Zainab Shahid, DO; Stephen Daly, DO, FACC 959 Journal of Cardiol Ther 2021 January; 8(1): 959-962 ISSN 2309-6861(print), ISSN 2312-122X(online) Online Submissions: http: //www.ghrnet.org/index./jct/ DOI: 10.17554/j.issn.2309-6861.2021.08.189 Journal of Cardiology and Therapy cocaine. Due to his level of intoxication, he was unable to provide additional history or an adequate review of systems. On physical examination, his vital signs were the following: Temperature of 100.7 degrees fahrenheit, blood pressure 102/59 mmHg, and heart rate of 140 beats per minute. The remainder of his examination was significant for mild respiratory distress with rhonchi present in bilateral lung fields. There were also multiple areas of ecchymosis on his upper and lower extremities with associated track marks. His admission labs were significant for a white blood cell (WBC) count of 27,000/uL with a differential revealing 90% neutrophils, hemoglobin of 8.9 g/dL, and creatinine of 1.41 mg/dL. Blood cultures were positive for gram positive cocci, further speciating as staphylococcus aureus. He was then started on empiric antibiotics of vancomycin and ampicillin-sulbactam. Urine drug screen was positive for opiates and cocaine. EKG revealed sinus tachycardia at 140 beats per minute with incomplete right bundle branch block. A portable chest x-ray revealed findings consistent with bilateral lower lung infiltrates, a small right pleural effusion, and cystic changes noted at the right lung base. A computerized tomography (CT) scan of the chest without contrast was done due to acute renal dysfunction, Brown K et al . Cardiac needle embolization 960 which revealed bilateral lungs with cavitary lesions concerning for septic emboli. The left lower lobe demonstrated a large 8.4cm cavity and a large right sided multiseptated cavitary lesion with air fluid levels and associated hydropneumothorax. In addition, a linear lesion was apparent towards the apex of the heart (Figure 1). A transthoracic echocardiogram (TTE) was performed due to concern for endocarditis and revealed no gross evidence of vegetation, mild mitral regurgitation, and hyperdynamic left ventricular ejection fraction estimated to be 75%. The Interventional Radiology team placed a right sided pigtail catheter in the left lung and injected tPA dornase for treatment of the loculated cavity. A fluid analysis of the cavitation revealed WBC of 644, RBC of 23,496, glucose of 73, LDH of 497, and protein of 3.5, meeting Light’s criteria for an exudative effusion. Cytology was negative for malignancy and cardiothoracic surgery was consulted. A right sided video-assisted thoracoscopic surgery (VATS) with empyectomy and right middle and lower lobe wedge resection was performed. A review of the specimen by pathology revealed a right middle and lower lobe resection with focally organizing acute pneumonia with abscess formation and focal necrosis with foreign body giant cell reaction present. Figure 1 (A) Sagittal view of CT of the chest with metallic fragment in at apex of heart. (B) Coronal view of CT of the chest with metallic fragment seen in right ventricle. Figure 2 (A) Transesophageal echocardiogram transgastric view of metallic fragment in the right ventricle at the end of diastole. (B) Transesophageal echocardiogram transgastric view of metallic fragment in the right ventricle projecting towards the interventricular septum during systole. Brown K et al . Cardiac needle embolization 961 Despite infectious disease management with broad spectrum antibiotics, the patient continued to have persistent fevers and there was ongoing concern for infective endocarditis given the patient’s clinical history. A transesophageal echocardiogram (TEE) was performed and revealed a linear metallic echodensity in the inferior aspect of the right ventricle near the apex and extending into the septum and lateral free wall (Figure 2). There were no valvular vegetations identified. Given these significant findings, a cardiothoracic surgery consultation from a tertiary care center was obtained. Due to the location of the retained needle fragment and the risk of migration, a consensus for conservative management was decided. The patient was ultimately discharged from the hospital to an acute rehabilitation facility in stable condition and remained on intravenous antibiotic therapy of cefepime for 6 weeks. He was lost to follow-up after his stay at the rehabilitation facility.