Open Access

A patient with fever, chest pain and a rapidly changing chest X-ray

  • Bas de Groot1Email author,
  • Daan Brand1,
  • Tessel N. E. Vossenberg2 and
  • Andrea Warnemunde1
International Journal of Emergency Medicine20103:247

https://doi.org/10.1007/s12245-010-0247-z

Received: 9 September 2010

Accepted: 13 September 2010

Published: 26 October 2010

A 58-year-old male presented to the emergency department with fever, malaise and right-sided chest pain, aggravating during inspiration. Two days prior to presentation, he had been discharged home from another hospital with antibiotics for a suspected urinary tract infection. Chest X-ray and CT scan, trans-thoracic echocardiography and blood cultures had not revealed any abnormalities during that hospital admission. The patient had a Bentall procedure with aortic valve replacement, complicated by cardiac tamponade 2 years earlier. Since then his body weight had gradually decreased by 20 kg, and there had been intermittent low-grade fever.

The diagnosis was prosthetic valve endocarditis (PVE) with partial dehiscence of the prosthesis resulting in a contained mediastinal hematoma. The chest radiograph showed a circular paracardial structure (Fig. 1) that was not present on the chest X-ray 2 days prior to presentation. The dramatic change in the plain chest film over 2 days is suggestive of a rapidly developing false aneurysm or haemorrhage. CT scan of the chest revealed extravasation of contrast cranial to the aortic valve (Fig. 2: white arrow) with a contained hematoma in the anterior and middle mediastinum. PVE occurs with a 3–6% accumulative frequency 5 years after surgery, with the highest incidence in the first year [1]. The ~11 year probability of bleeding is 19 to 42%, occurring more frequently in mechanical valves because of the lifelong anti-coagulation [2, 3]. PVE can be treated with antibiotics alone unless there is evidence of bleeding [4], as was the case for our patient, who was admitted to the intensive care unit after replacement of the prosthesis, where he gradually recovered.
Fig. 1

Chest X-ray made during current presentation

Fig. 2

Contrast-enhanced CT scan of the chest

Authors’ Affiliations

(1)
Department of Emergency Medicine, Leiden University Medical Center
(2)
Department of Cardiology, Leiden University Medical Center

References

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Copyright

© The Author(s) 2010

This article is published under license to BioMed Central Ltd. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

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