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Images in neonatal medicine
Infective atrial thrombus
  1. Barah Hassan1,
  2. Stefan Zalewski1,
  3. Antony Hermuzi2
  1. 1 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
  2. 2 Paediatric Cardiology, Freeman Hospital Cardiothoracic Centre, Newcastle upon Tyne, Newcastle upon Tyne, UK
  1. Correspondence to Dr Barah Hassan; barah.hassan1{at}nhs.net

https://doi.org/10.1136/archdischild-2024-327552

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    An infant was born at 27 weeks’ gestation weighing 930 g. The umbilical venous catheter (UVC) initially projected over T5 (cardiac silhouette) on X-ray requiring adjustment to T10 (inferior vena cava). Benzylpenicillin and gentamicin were administered for 5 days to cover early-onset infection. Initial FBC was normal.

    Lethargy and hyperglycaemia prompted a sepsis screen, the removal of UVC and the initiation of ceftazidime with vancomycin (day 9). Blood tests demonstrated a raised C-reactive-protein (67 mg/dL) and thrombocytopenia (6×109/L). Blood cultures isolated Staphylococcus epidermis at screening and on repeat after 48 hours.

    Thrombocytopenia persisted despite multiple platelet transfusions and therapeutic vancomycin. By week 3, the patient received nine platelet transfusions. Blood films, urine and cerebrospinal fluid culture/virology and cranial and abdominal ultrasonography yielded no diagnosis or identified complications. Microbiology advice prompted escalation to meropenem and later piperacillin/tazobactam.

    Echocardiography (ECHO) on day 34 identified a large atrial thrombus prolapsing through the tricuspid valve (figures 1 and 2). Given the risk of cardiac outflow obstruction and mobilisation, a multidisciplinary team decision was to remove the mass. Excision of the right atrial mass was performed on day 38. Histopathology reported a vegetation 16S positive for Staphylococcus epidermis. Two weeks postoperatively, the patient developed a significant pericardial effusion, likely reactive, requiring drainage (figure 3). Vancomycin continued for 6 weeks postoperatively. The patient made a good recovery and was discharged.

    Figure 1
    Figure 1

    ECHO demonstrating vegetation with extension into right ventricle.

    Figure 2
    Figure 2

    ECHO demonstrating vegetation within right atrium.

    Figure 3
    Figure 3

    Post-operative imaging showing large pericardial effusion.

    Learning points include considering thrombus/vegetation in persistent thrombocytopenia or repeated blood culture growth particularly with a history of indwelling vascular access and for close surveillance for effusion as a complication following cardiac surgery.

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    Footnotes

    • Contributors BH, AH and SZ contributed to the write up of this case summary. BH is guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; internally peer reviewed.