Aquarium sign in sepsis
Serviço de Cardiologia, Centro Hospitalar de Coimbra, Hospital Geral, Quinta dos Vales, 3041-801 S. Martinho do Bispo, Coimbre, Portugal
Received 24 September 2007; received in revised form 30 October 2007; accepted after revision 7 November 2007.
* Corresponding author. Tel: +35 1961023760; fax: +35 1239814779. E-mail address: rui_providencia{at}yahoo.com
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Abstract |
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A 91-year-old man appeared in our lab with fever for a transthoracic echocardiography assessment. Highly unusual echo images were found, with a size and movement resembling ‘bubbles in an aquarium’ in every cardiac chamber, both left and right. The patient died 8 days later, due to a methicillin-resistant Staphylococcus aureus sepsis. These are highly unusual images that should not be confused with microbubbles from contrast agents or radiofrequency ablation, and were previously reported once in association with atrioesophageal fistula.
Keywords: Microbubbles; Aquarium sign; Sepsis
A 91-year-old man (J.G.) is referred to the Emergency Department (ED) with a traumatic fracture of the right femur's neck. He was sent to the Traumatology ward, after orthopaedic surgery with no immediate complications. His electrocardiogram was normal. Four years before, he had been diagnosed a B cell small lymphocytic lymphoma being regularly followed in the haematology clinic. The last chemotherapy cycle had occurred 12 months earlier. His medication included weekly erythropoietin.
He had to have frequent packed blood cell transfusions (12 units in 6 weeks) due to blood loss during surgery and to melaena. No thrombocytopaenia or coagulation abnormalities were detected. Endoscopic evaluation and biopsies of the intestinal tract evidenced an invasive adenocarcinoma, 18 cm away from the anal margin, at the rectosigmoid transition. Pathology and staging showed a Dukes B pT3 N0 Mx moderately differentiated invasive adenocarcinoma.
Hartmann's surgery was performed and the patient was stable until post-operative day 10, when he developed intermittent fever (38–39°C), with no evident signs of infection at the surgical wound or any other signs or symptoms suggesting an infectious focus. There were no signs of respiratory distress, with a 97% O2 saturation on oximetry and 1500–2000 mL daily urine output. A systolic aortic ejection murmur II/VI was detected at cardiac auscultation. This condition was already known for 2 years when a previous transthoracic echocardiography (TTE) showed a mild aortic stenosis with a maximum transvalvular aortic gradient of 16 mmHg, and normal systolic function. He had a complete denture prosthesis and a right subclavian central venous catheter with no signs of infection. Lab tests showed: Haemoglobin 79 g/L, WBC 11.70 x 103/µL (with 49.9% lymphocytes), CRP of 16.7 mg/dL, 14 g/L serum albumin and 40.6 g/L protein. No changes in renal or hepatic function were found.
In addition to supportive measures, the patient started on endovenous 500 mg meropenem three times a day although showing no improvement after 10 days.
An echocardiogram was performed. At the time the patient attended the ECHO Lab, he was calm and cooperative, with no signs of respiratory distress. His vital signs were: 38.4°C, 82 bpm, 98/56 mmHg, and a 97% O2 saturation on oximetry while on 4 L/min O2 by mask. In order to avoid any artifact, and as a regular practice in our lab, endovenous medication was interrupted during examination.
TTE revealed normal left ventricle wall and cavity dimensions, with no wall motion anomalies, and a preserved systolic function (Figure 1). A slight dilatation of the left atrium was detected (52 mm). The right atrium and ventricle had normal dimensions, with no signs of overload. The aortic valve showed mild degenerative changes. No other valve changes or intracardiac masses were found. The pericardium had a normal thickness, with no effusion. A Doppler assessment evidenced a 22 mmHg maximum LV/Ao gradient.
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Inside the heart chambers, there were some bubble-like echoes, with 3 mm diameter approximately, in circular motion like ‘bubbles in an aquarium’. They were present throughout the whole exam (15 min). They were initially confined to the right cavities but 5 min later, these bubbles were also found in the left ventricle and atrium. We confirmed once again that the patient was under no endovenous therapy during the examination. The patient showed no clinical change during the examination or the following hours.
Three days later, the patient maintained fever and a lower respiratory tract infection was evident. The central line was removed. The clinical situation deteriorated. Meropenem was suspended on day 13 and ev vancomicine (1 g bid) started. The therapy proved ineffective and the patient died 8 days after TTE, with a sepsis diagnosis. A methicillin-resistant Staphylococcus aureus was isolated from blood culture collected 2 days before his death.
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Discussion |
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These are highly unusual echocardiographic images. We have found only one report in the literature of similar findings but in a patient with an atrioesophageal fistula.1
Our findings differ from the more common ‘microbubbles’ (below 1 mm) since they were larger, showed circular movements and lasted much longer than the usual. If these were ev infusion artifacts they would have disappeared after a few cardiac cycles. We seldom find reports of this in association with thromboemboli2 or in patients with heart failure and pulmonary hypertension.3 Microbubbles can usually be found when using agitated serum or echocardiographic contrast agents4,5 in radiofrequency ablations6,7 or near prosthetic mechanical valves.8,9
Although we cannot be sure about the nature of these bubbles, we presume they can be agglomerates of circulating bacteria and blood cell rouleaux. Their presence in both right and left chambers and the slow circulating time is very unusual and we are inclined to think they are correlated with the septic condition of the patient.
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Supplementary material |
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Supplementary material associated with this article can be found in the online version.
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References |
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[Abstract/Free Full Text] - Orsinelli DA, Pasierski TJ, Pearson AC. Spontaneous appearing microbubbles associated with prosthetic cardiac valves detected by transesophageal echocardiography. Am Heart J (1994) 128:990–6.[CrossRef][Web of Science][Medline]
- Gencbay M, Degertekein M, Basaran Y, Yaym, aci B, Izgi A, Dindar I, Turan F. Microbubbles associated with mechanical heart valves: their relation with serum lactic dehydrogenase levels. Am Heart J (1999) 137:463–8.[CrossRef][Web of Science][Medline]
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