Multimodality Imaging for the Diagnosis of Infective Endocarditis Associated With Inferior Vena Cava Vegetations

A 7-year-old child presented with recurrent fever on the 4th day after vehicle accident trauma and it persisted for more than 3 months. He had a history of previous liver rupture with injury to the inferior vena cava. Laboratory test results revealed neutrophilic leukocytosis and elevated C-reactive protein levels. Blood culture was positive for Pseudomonas aeruginosa, so the clinical diagnosis of infective endocarditis was made based on modified Duke criteria. Transthoracic echocardiography revealed a moderate echo mass arising from the right atrial wall near the inferior vena cava (Figure A), and computed tomography angiography showed a hypodense mass located at the junction of the right atrium and the inferior vena cava (Figure B). Surgical removal was undertaken. Intraoperative transesophageal echocardiography showed the mass located in the ostium of the inferior vena draining into the right atrium (Figure C,D; Supplementary Movies 1,2) and postoperative pathology confirmed an infectious inflammatory vegetation (Figure E,F). The patient’s postoperative recovery was uneventful and he was discharged 7 days later, on antibiotic treatment for 6 weeks.

Figure.

(A) Transthoracic echocardiography showing a moderate echo mass (yellow arrow) arising from the RA wall near the IVC. (B) Computed tomography angiography showing a mass (yellow arrow) located at the junction of the RA and IVC. (C,D) Transesophageal echocardiography showing the mass located in the ostium of the IVC and draining into the RA. Gross specimen (E) and histopathology (F) confirming diagnosis of infectious inflammatory vegetation. IVC, inferior vena cava; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Inferior vena cava vegetation caused by trauma-induced infective endocarditis is a rare entity. To our knowledge, this is the first reported case. It is easily misdiagnosed as thrombus or tumor. Delayed diagnosis and treatment may lead to severe complications and a poor prognosis. Once the clinical diagnosis is established, surgical treatment is recommended, and multimodality imaging plays an important role in both the diagnosis and clinical treatment of inferior vena cava vegetation.

Supplementary Files

Supplementary Movie 1,2. Transesophageal echocardiography of the mass located in the ostium of the inferior vena and draining into the right atrium.

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https://doi.org/10.1253/circj.CJ-22-0504