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Case Presentation: A 40 year old female was referred from the local jail with a tension pneumothorax. She had a long history of intravenous (IV) heroin and cocaine use followed by a 2-year history of sobriety. She had resumed intravenous heroin use 3 weeks before admission and soon thereafter developed fever and chills. She was incarcerated 7 days before admission. Five days before admission she developed progressive dyspnea and left-sided pleuritic chest pain. On arrival in the emergency department, she was found to be febrile (39.0 deg C), tachycardic (121 beats/min), tachypneic (34 breaths/min), and hypoxemic. Leukocyte count was 12,100 cells/mcL. A chest x-ray showed a large left tension pneumothorax with mediastinal shift and a moderate left sided pleural effusion. After placement of a left-sided chest tube, computerized tomography revealed multifocal peripheral cavitary nodules suggestive of septic emboli. Per the radiology report, the etiology of the pneumothorax was compatible with bronchopleural fistula, suspected to be due to a peripheral cavitary nodule in the anteromedial left lower lobe. A transthoracic echocardiogram revealed a large tricuspid valve vegetation measuring 0.95 x 1.47cm. Blood cultures grew methicillin-sensitive Staphylococcus aureus. She was treated with nafcillin. Her initial hospital course included respiratory failure requiring mechanical ventilation and development of a right-sided pneumothorax requiring placement of an additional chest tube. Serial chest x-rays showed improvement of the cavitary lesions and resolution of the bilateral pneumothoraces. She was eventually transferred to a skilled nursing facility to complete a six week course of nafcillin. At the time of discharge, she was without leukocytosis and no longer required supplemental oxygen. Discussion: Pnemothorax is an uncommon complication of pneumonia; it may be seen with Pneumocystis jiroveci, tuberculosis, or necrotizing bacterial pneumonia. Pneumothorax associated with septic pulmonary emboli is a very rare complication of Staphyloccus aureus bacteremia. The pathophysiology is presumed to be erosion of a embolic bacterial cavitary lesion into a bronchus with creation of a bronchopulmonary fistula. Conclusions: Septic pulmonary embolus is a severe complication of staphylococcal bacteremia and right-sided endocarditis that may be seen in IV drug users. On rare occasion, it may be associated with pneumothorax. This infection is often associated with prolonged morbidity and increased mortality


Presented at the Society of Hospital Medicine, 05/18/2013, National Harbor, MD.