(P33) Thromboembolism vs Vegetation: A Case of a Curious Clot

Chief Complaint : Patient states that she was in a normal state of health prior to experiencing the lightheadedness.

History of Present Illness : 41-year-old female with a past medical history of hypertension, type 2 diabetes, peripheral vascular disease complicated by osteomyelitis and right foot total metatarsal amputation, end-stage renal disease on dialysis via permacath presents to the emergency department for 2 days of worsening lightheadedness.

Pertinent Physical Exam: Upon arrival to the emergency department patient vitals were remarkable for a blood pressure of 89/53. Remainder of vitals were unremarkable: Heart rate 86 bpm, respiratory rate 16 bpm, oxygen saturation 99% on room air, temperature of 98.7 °F. Upon reassessment, blood pressure decreased to 71/43.

Pertinent Laboratory Data:

Case Discussion: 41-year-old female with a past medical history of hypertension, type 2 diabetes, peripheral vascular disease complicated by osteomyelitis and right foot total metatarsal amputation, end-stage renal disease on dialysis via permacath presents to the emergency department for 2 days of worsening lightheadedness. Transthoracic echocardiogram (TTE) revealed a hyperechoic structure noted in the right atrium periodically extending into the right ventricle, suggestive of an acute pulmonary embolism in transit versus vegetation secondary to infective endocarditis. A pulmonary CT angio demonstrated a segmental pulmonary embolism in the right lower lobe. A comprehensive TTE demonstrated a dilated right atrium with a 3.8 x 0.6 cm mass originating in the right atrium which prolapses into the right ventricle suggestive of a thrombus in transit or vegetation. Considering the uncertainty of the hyperechoic structure, the patient was started on vancomycin and piperacillin/tazobactam, later transitioned to vancomycin and cefepime, as well as a heparin drip. A right cardiac catheterization was performed with serial thrombectomies room moving extensive thrombus from the tricuspid valve and from the hemodialysis catheter. It was noted that a small fibrotic clot remained attached to the hemodialysis port which was later removed and exchanged by interventional radiology. Overall, this case represents another example of the essential role of POCUS in diagnosing and treating life-threatening causes of hypotension and shock in the ED. This unique case also demonstrates that prompt identification can help prompt early diagnostic and treatment modalities that may not have been pursued in a timely manner in the past.

References and Acknowledgements (Optional): Keikha M, Salehi-Marzijarani M, Soldoozi Nejat R, Sheikh Motahar Vahedi H, Mirrezaie SM. Diagnostic Accuracy of Rapid Ultrasound in Shock (RUSH) Exam; A Systematic Review and Meta-analysis. Bull Emerg Trauma. 2018 Oct;6(4):271-278. doi: 10.29252/beat-060402. PMID: 30402514; PMCID: PMC6215077.

Bagheri-Hariri S, Yekesadat M, Farahmand S, Arbab M, Sedaghat M, Shahlafar N, Takzare A, Seyedhossieni-Davarani S, Nejati A. The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. Emerg Radiol. 2015 Oct;22(5):517-20. doi: 10.1007/s10140-015-1311-z. Epub 2015 Mar 21. PMID: 25794785.

Hu W, Wang X, Su G. Infective endocarditis complicated by embolic events: Pathogenesis and predictors. Clin Cardiol. 2021 Mar;44(3):307-315. doi: 10.1002/clc.23554. Epub 2021 Feb 1. PMID: 33527443; PMCID: PMC7943911.