**8.2. Septic embolism to the liver**

**Figure 6.** Septic pulmonary emboli associated with tricuspid valve endocarditis due to methicillin-resistant Staphylococcus aureus. Source: Stawicki et al. [2]. Used under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided

Regarding diagnostic modalities used in the setting of suspected SPE, chest radiography is nonspecific and usually shows poorly marginated peripheral lung nodules, possibly with cavitary features [25]. Computed tomography provides much better image granularity and usually demonstrates bilateral nodules or multifocal infiltrates, often involving peripheral lung zones and associated cavitary lesions [102]. These features, in conjunction with extrapulmonary infection, should raise suspicion of SPE as the underlying cause. The "feeding vessel" sign, or the finding of a vessel which projects into a peripheral lung lesion, is fairly specific for SPE [111, 112]. Patients with SPE and suspected IE should undergo echocardiography to rule out valvular infection and to assess for any associated cardiac complications [113, 114]. TEE is preferred over TTE due to better image resolution and improved diagnostic accuracy for detecting small vegetations, abscesses, and leaflet perforations up to 5 mm in size

A conservative approach is recommended in most patients with right-sided IE because significant majority of the cases will resolve with antimicrobial therapy alone [115, 116]. The role of surgery remains unclear because the presence of SPE and/or recurrent SPE is not an absolute indication for operative intervention. Surgery is usually indicated in cases of persistent sepsis, lack of response to appropriate antimicrobial therapy, right heart failure secondary to severe tricuspid regurgitation, and persistent large vegetation [50, 58, 117, 118]. Thoracoscopy or thoracotomy may be required in complicated cases of SPE (e.g., empyema, pulmonary

Majority of the literature on IE and SE is devoted to the most common and clinically relevant presentations, leading to a degree of "neglect" toward the unusual yet still potentially

the original work is properly cited.

154 Contemporary Challenges in Endocarditis

[113, 114].

abscess) [102, 106].

**8. Additional considerations and special topics**

Liver abscesses due to SE associated with IE are well documented in the medical literature [121]. As outlined above, larger hepatic abscesses may evolve over time from smaller, adjacent microabscesses [120]. Infectious endocarditis should be entertained in the setting of any hepatic abscess of uncertain etiology, with echocardiography undertaken in order to rule out cardiac valvular source [122]. Clinical approach is usually multi-modal, including broad-spectrum antibiotics, endoscopy, percutaneous drainage, and/or surgery [2].
