Right Atrial Vegetation on a Chiari Network Presenting With Multifocal Pulmonary Lesions

The Chiari network is a rare embryological fenestrated web-like structure located in the right atrium, present in approximately 2-3% of the general population. Infective endocarditis of the Chiari network is exceedingly rare and poses significant diagnostic and management challenges. We present a case of a 67-year-old male with hypertension, chronic obstructive pulmonary disease (COPD), and chronic hepatitis C who presented with malaise and dyspnea. Workup revealed multifocal bilateral pulmonary opacities on computed tomography (CT) of the chest, and transthoracic echocardiography (TTE) identified a right atrial echodensity of uncertain significance. The infectious workup was unrevealing. Transesophageal echocardiography (TEE) subsequently demonstrated a new oscillating echodensity on the Chiari network, leading to a diagnosis of Chiari network endocarditis. The patient was treated empirically with a six-week course of intravenous antibiotics. Our case highlights the importance of advanced cardiac imaging in diagnosing Chiari network endocarditis and embolic pulmonary findings.