A 32-year-old man comes to the emergency department with a 3-day history of fever, cough, and weakness. Blood pressure is 120/80 mm Hg and pulse is 110/min. Physical examination shows multiple needle tracks on the patient's arms. ECG shows sinus tachycardia but is otherwise normal. Chest x-ray reveals scattered round lesions in the peripheral lung fields bilaterally. Which of the following accompanying findings is most likely present in this patient?

Question

A 32-year-old man comes to the emergency department with a 3-day history of fever, cough, and weakness.  Blood pressure is 120/80 mm Hg and pulse is 110/min.  Physical examination shows multiple needle tracks on the patient's arms.  ECG shows sinus tachycardia but is otherwise normal.  Chest x-ray reveals scattered round lesions in the peripheral lung fields bilaterally.  Which of the following accompanying findings is most likely present in this patient?

Quizplus · Accepted Answer

11ec25c8_d34c_1c44_bc81_d55065775cd1_MD0003_00 This patient's clinical presentation is consistent with infective endocarditis (IE) of the tricuspid valve with septic emboli to the lungs. Septic pulmonary emboli typically cause cough, chest pain, and hemoptysis and on chest imaging appear as multiple round, nodular opacities with or without cavitation. chest imaging Patients who use intravenous drugs are at increased risk for IE involving the right-sided heart valves; this may be because particulate matter (eg, dirt) is often injected intravenously with the drugs and causes microinjury to the right-sided heart valves before being filtered out by the lungs (never reaching the left-sided heart valves). The microinjury may act as a bacterial attachment point and nidus for infection. Tricuspid regurgitation is a common complication of IE and typically causes a holosystolic murmur that increases in intensity with inspiration when additional blood is pulled into the right side of the heart. Augmentation of intensity with inspiration has been shown to have 100% sensitivity and 88% specificity in differentiating right-sided systolic murmurs from all others. (Choice A) A diastolic murmur best heard when the patient is sitting up is typical of aortic regurgitation. IE involving the aortic valve commonly causes aortic regurgitation, but left-sided IE does not cause septic pulmonary emboli. (Choice B) The pulmonic component (P2) of S2 typically slightly follows the aortic component (A2); this physiologic split is enhanced during inspiration. Paradoxical splitting of S2 is when A2 is delayed to the point that it is heard after P2, which can occur with aortic stenosis, systemic hypertension, or a left bundle-branch block. Paradoxical splitting (Choice C) An S4 is caused by blood striking a stiff left ventricular (LV) wall. It may be a normal finding in the elderly but in younger patients typically indicates pathologic concentric LV hypertrophy (eg, due to chronic hypertension or aortic stenosis). (Choice E) Most murmurs increase in intensity when more blood is in the heart. A systolic murmur that increases in intensity upon standing (when less blood is in the heart) is characteristic of hypertrophic cardiomyopathy, as the decrease in LV blood volume worsens LV outflow tract obstruction. Educational objective: Patients who use intravenous drugs are at increased risk for infective endocarditis involving the right-sided heart valves, which is commonly complicated by septic pulmonary emboli. Tricuspid regurgitation is common in patients with tricuspid valve endocarditis and can be distinguished from other murmurs by increased intensity with inspiration.

A 32-Year-Old Man Comes to the Emergency Department with a 3-Day