<div>Diagnostic Assessment &amp; Therapeutic Intervention</div><div>Due to fever, dyspnea, and an SPO2 below 90%, a Computed Tomography
(CT) was performed. The chest CT showed moderate pleural effusion and
bilateral emphysema in the apex of the lungs and cardiomegaly. Pelvic
and abdominal ultrasounds were normal. Because of dyspnea, tachycardia
elevated D-dimer, and SpO2 of less than 90%, we decided to take CT
angiography for pulmonary thromboembolism (PTE). CT angiography showed
PTE, moderate pleural effusion in the right lung compatible with
empyema, and a blurred wedge in the left upper lobe (LUL). We put the
patient under anticoagulation therapy with warfarin, after PTE was
diagnosed, and based on the loculated pleural fluid in the CT scan,
empyema pattern, and the patient’s fever, the effusion was tapped, and a
chest tube was placed. The patient’s pleural fluid was analyzed, which
was exudative with Alb=900, Pro=2400, LDH=1184, RBC=50, WBC=3400,
Glucose=80, and negative culture.</div><div>The lung field was found to have a septic embolism pattern, which led to
an echocardiogram. Upon echocardiography, small vegetation was detected;
therefore, a transthoracic echocardiogram (TTE) was conducted to
confirm. TTE showed severe tricuspid valve damage, 8 millimeter
vegetation in place, increased pulmonary artery pressure (PAP= 40), and
ejection fraction(EF)=45%, confirming the vegetation on the atrial side
of the tricuspid valve.</div><div>According to the findings, the first diagnosis was right-side
endocarditis, which led to septic embolism, so we started empiric
antibiotic therapy with vancomycin plus ceftriaxone. After two weeks of
constant fever despite broad-spectrum antibiotic therapy and pleural
effusion drainage, we changed the antibiotic regimen to vancomycin plus
meropenem, and, re-evaluated our diagnosis by taking a detailed history,
re-sending blood cultures, which were negative 3 times, performing
abdominal ultrasound and investigating the possible causes of
culture-negative endocarditis including Q fever, bartonella, and
brucellosis, according to the history of staying in the camp. The
serology and blood PCRs were sent to the laboratory of the Pasteur
Institute of Iran. The PCR and serology for Q-fever were negative.
serology wright and 2-ME test for brucellosis were negative, but a
serology test confirmed for Bartonella henselae with a 1: 2048
titer.11the kit used was Bartonella IFA IgG.</div><div>In the meantime, we changed the patient’s drug regimen to doxycycline
(100 mg twice daily), instead of aminoglycosides, plus rifampin (300mg
twice daily), due to the high level of creatinine (3-3.3 mg/dL), and
warfarin was switched to enoxaparin due to rifampin and warfarin drug
interactions and patient noncompliance.</div><div>After 72 hours he responded to this drug combination significantly;
fever, tachycardia, and dyspnea improved, creatinine levels decreased
and the pleural fluid test result was negative for Bartonella. After two
weeks, rifampin was discontinued, but he received an extended course of
doxycycline monotherapy. Also, due to severe tricuspid valve
insufficiency, he underwent medical treatment, but because of his
addiction, the cardiac surgery service did not recommend him for
valvoplasty. A summary of the clinical practice of the patient is shown
in Figure 1.</div>