Fever and haemoptysis in an injecting drug user

A 46-yr-old injecting drug user was admitted with a history of repeated haemoptysis, pleuritic chest pain and fevers. He had a neutrophilia and elevated C-reactive protein. A pulmonary embolus was diagnosed by computed tomography (CT) pulmonary angiography and he was treated with low molecular weight heparin. He received i.v. antibiotics (flucloxacillin, amoxicillin, gentamicin and metronidazole) for polymicrobial bacteraemia (methicillin-sensitive S taphylococcus aureus , Enterococcus , viridans type Streptococcus) caused by a right groin abscess, which was subsequently incised and drained, and was associated with iliofemoral thrombosis. No valvular vegetation was seen on transthoracic or subsequent transoesophageal echocardiogram. The patient had a fluctuating clinical course, requiring respiratory support with supplemental oxygen and noninvasive ventilation. He had a persistent neutrophil leukocytosis and greatly elevated C-reactive protein at >100 mg·L−1. Clinically, there was evidence of bilateral pleural effusions, which cultured Enterococcus on aspiration. Attempted thoracocentesis was unsuccessful with minimal fluid drained. An ultrasound scan of the chest revealed loculated pleural effusions. He continued to cough blood and 17 days after admission had an episode of massive haemoptysis requiring a blood transfusion. At this point the anticoagulation was discontinued given the risk of further massive haemoptysis. A repeat CT of the chest was performed to clarify the cause of the continuing haemoptysis (fig. 1⇓). Despite halting the anticoagulation, further fresh haemoptysis occurred a few days later and he was referred to a cardiothoracic surgeon with a view to surgical intervention. Due to …