Letters to Editor

4. 5. 6.

flow volume loop examination in assessment and management. J R Soc Med 1982;75:425‑34. Gittoes  NJ, Miller  MR, Daykin  J, Sheppard  MC, Franklyn  JA. Upper airways obstruction in 153 consecutive patients presenting with thyroid enlargement. BMJ 1996;312:484. Chapman  S, Robinson  G, Stradling  J, West  S. Oxford Handbook of Respiratory Medicine. (2nd Ed.) : Oxford University Press New York,;2009. p. 828‑9. Cooper JC, Nakielny R, Talbot CH. The use of computed tomography in the evaluation of large multinodular goitres. Ann R Coll Surg Engl 1991;73:32‑5.

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Website: www.lungindia.com DOI: 10.4103/0970-2113.142104

Mobile vegetation leading to septic pulmonary embolism Sir, A 42‑year‑old Caucasian female with a prolonged history of intravenous (IV) methamphetamine abuse presented with high‑grade fever, progressively worsening productive cough, dyspnea, myalgia, arthralgia and intermittent confusion for 1 week. The initial laboratory assessment showed leukocytosis, thrombocytopenia, and acute kidney injury. Chest X‑ray showed bilateral lower lobe consolidation with small cavities surrounded by focal infiltrates in the right lung [Figure 1]. Computed tomography of the chest confirmed the presence of multiple cavitary pulmonary nodules suggestive of septic embolization [Figure 2]. Because of a high index of suspicion for infective endocarditis, a transthoracic echocardiogram was obtained, which showed a 3.6 cm × 2.6 cm vegetation on the tricuspid valve and 2.5 cm × 1.6 cm vegetation on the tricuspid annulus, accompanied by severe tricuspid regurgitation. Trans‑esophageal echocardiogram demonstrated multiple, large multilobulated, mobile vegetation on the tricuspid valve, with the largest being

Figure 1: Chest radiography showing bilateral lower lobe consolidation with small cavities within focal infiltrates in the right lung

3.7 cm × 2.5 cm in size [Figure 3]. Blood cultures were positive for methicillin‑resistant Staphylococcus aureus. The patient was initially treated with vancomycin and ceftriaxone. However, the patient failed to improve clinically and, eventually, underwent tricuspid valve excision, right ventricle/tricuspid valve debridement and tricuspid valve replacement. The post‑operative course was uneventful and the patient made a satisfactory recovery. Septic pulmonary embolism (SPE) is a rare and serious disorder that usually presents with non‑specific clinical features including fever, pulmonary symptoms and peripheral nodular lung infiltrates with or without cavitation. [1,2] Major risk factors are IV drug abuse, indwelling catheters, tricuspid valve endocarditis, head and neck infections and immunocompromised state. Early diagnosis of the infectious source and appropriate use of anti‑microbial therapy is critical in the management because untreated SPE can lead

Figure 2: Computed tomography of the chest showing numerous cavitary pulmonary nodules located peripherally, representing septic pulmonary emboli in the right lung

Lung India • Vol 31 • Issue 4 • Oct - Dec 2014 429

Letters to Editor

Imran Haider, Raghav Gupta, Shuang Song Department of Internal Medicine, Saint Luke’s Hospital, Saint Louis, Missouri, United States of America E‑mail: [email protected]


Figure 3: Trans-esophageal echocardiogram with mid position view showing a 3.6 cm × 2.6 cm-sized mobile vegetation in the right atrium attached to the tricuspid valve. RA: Right atrium

Rossi SE, Goodman PC, Franquet T. Nonthrombotic pulmonary emboli. AJR Am J Roentgenol 2000;174:1499‑508. Iwasaki Y, Nagata K, Nakanishi M, Natuhara A, Harada H, Kubota Y, et al. Spiral CT findings in septic pulmonary emboli. Eur J Radiol 2001;37:190‑4. Cook  RJ, Ashton  RW, Aughenbaugh  GL, Ryu  JH. Septic pulmonary embolism: Presenting features and clinical course of 14 patients. Chest 2005;128:162‑6.

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to the development of pulmonary abscesses and empyema. [3] This vignette highlights how multiple peripheral nodular opacities, often with cavitation, are suggestive of pulmonary septic emboli in the setting of infective endocarditis.

DOI: 10.4103/0970-2113.142105

Relationship between lung function and indoor air pollution Sir, The recent report on the, ‘Relationship between lung function and indoor air pollution’ among rural women in the fishing community is very interesting.[1] Umoh and Peters noted that ‘chronic exposure to biomass smoke is associated with chronic bronchitis and reduced lung function in women engaged in fish smoking’.[1] Of interest, there is another publication by Umoh et al., focusing on the problem of chronic bronchitis in the same community and same period, in the Niger delta.[2] Umoh et al. have further mentioned a relationship between exposure to smoke and anxiety.[2] Overall, the number of subjects investigated in both reports (342 VS 342)[1,2] is equal, however, the number of the cases with chronic bronchitis is not equal (68 VS 63). This leads to the query on the reliability of the present report. In addition, there is no report on the environment of the community. The main query is whether there is any other pollution in this area, in addition to fish smoking.


Sora Yasri, Viroj Wiwanitkit1 Primary Care Unit, KMT Center, Bangkok, Thailand, 1 Hainan Medical University, Haikou, Hainan, China E-mail: [email protected]


Umoh VA, Peters E. The relationship between lung function and indoor air pollution among rural women in the Niger Delta region of Nigeria. Lung India 2014;31:110‑5. Umoh VA, Ibok A, Edet B, Essien E, Abasiubong F. Psychological distress in women with chronic bronchitis in a fishing community in the Niger Delta region of Nigeria.Int J Family Med 2013;2013:526463.

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Website: www.lungindia.com DOI: 10.4103/0970-2113.142106

Lung India • Vol 31 • Issue 4 • Oct - Dec 2014

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