We have previously discussed about the echocardiographic features of valvular vegetations. Now let us see an illustrative case. A middle-aged dialysis patient presented with shortness of breath and fever. No history of missed dialysis sessions. Chest X-ray report read, “Bilateral interstitial opacities with peripheral and basilar predominance. Findings suspicious for pneumonia”. COVID-19 testing was negative.

That’s it? Just start antibiotics and continue dialysis? Don’t forget to perform physical examination (= POCUS). Focused cardiac ultrasound demonstrated a mobile, irregular, echogenic structure adherent to tricuspid valve. There was some tricuspid regurgitation and heart function was overall hyperdynamic. In the setting of fever and absence of underlying cardiac disease, the lesion is more suggestive of a vegetation than thrombus (clots usually form in hearts with decreased systolic function, atrial fibrillation etc.). Lung ultrasound demonstrated bilateral B-lines with non-homogeneous distribution and irregular pleural line, more in favor of lung pathology (non-cardiogenic). Subpleural consolidations were noted. In the given clinical context, they likely represent pulmonary infarctions from septic emboli. Findings were confirmed on a CT scan.

Above images were obtained by a handheld ultrasound machine. Here are more images from cart machine, demonstrating the lesion in different cardiac views.

Note that gentle transducer rotation/rocking might be necessary to open up the chambers and optimally visualize the lesion. In poor quality images and hurry-burry examinations, you can easily miss the diagnosis. For example, see these two images obtained from the same patient. Its almost impossible to appreciate the vegetation.