Gusano de la muerte

A young adult presented to the emergency department with chest pain and shortness of breath.

They had had an ICD placed years ago, but this had been removed a month ago after they had been developed bacteremia. A large vegetation had been found on the right ventricular ICD lead, and the post-removal echo had been normal. A PICC in the right arm was delivering antibiotics.

The chest discomfort was modestly pleuritic, and they endorsed recent development of a cough and chills. A chest X-ray was interpreted as showing an infiltrate, so antibiotics for health-care associated pneumonia were started.

A bedside echo was performed, and the following clips were obtained from the RV inflow view (N.B. the probe orientation here is "flipped" from the cardiologists' convention):

What two findings suggest further imaging?

First, the dramatic, circus-like tricuspid regurgitation suggests either a new problem with the valve, or new pulmonary hypertension. Comprehensive echocardiography is indicated to investigate the valve and assess for pulmonary hypertension.  

But why is there TR? 

Probably because of the little gusano in the RA that the red arrows are pointing at. Although RA masses have a broad differential, the history (a recent normal echo, PICC, recent hospitalization) obligated consideration of a pulmonary embolism. Which the the patient had: A CT scan revealed that the "infiltrate" was hiding a PE.

Venous emboli in transit through the heart are often described as "worm-like" or serpiginous in appearance, although other morphologies are described. Other signs of venous thrombolic embolic disease are typically present, and a PE is diagnosed through complementary imaging, as was the case with this patient. 

It is crucial to highlight, however, that a point-of-care ultrasound may be the sole test that suggests VTE. A recent case report by Minardi et al. described a patient with a history strongly suggestive of PE, and a right atrial mass but a negative CTA for PE.

UPDATE
Although the RA clot seemed obvious on the screen of my US machine, it has been pointed out that my clips above are not unambiguous.

Well, it doesn't help to simply sputter "It was there, I tell you!" Instead, let me offer a clip from the formal echo that was obtained soon after my focused ED echo. 

WARNING: While it  demonstrates more clearly the mass in the RA, the quality of the clip here is, quite frankly, horrid.

References:
Free-Floating Thrombi in the Right Heart 

Focused Cardiac Ultrasound: Uncommon but Critical Diagnoses Made at the Point of Care