Spiral CT findings in septic pulmonary emboli

Isolated tricuspid valve Group B Streptococcal endocarditis with septic pulmonary embolism and multiple mycotic aneurysms of the pulmonary arteries

A diabetic woman in her 30s was admitted to our medical centre for persistent fever associated with worsening cough, easy fatigability and pleuritic chest pain noted after childbirth. Investigations revealed an isolated tricuspid valve endocarditis from Group B Streptococcus Despite appropriate antibiotic coverage, her symptoms persisted with worsening dyspnoea; hence, a CT pulmonary angiogram was done which showed septic pulmonary embolism and multiple mycotic aneurysms of the pulmonary arteries. She was treated with antibiotics and underwent tricuspid valve replacement and was discharged well with a return to her baseline functional capacity on subsequent follow-ups.

Tips and Tricks in Thoracic Radiology for Beginners: A Findings-Based Approach

This review has the purpose of illustrating schematically and comprehensively the key concepts for the beginner who approaches chest radiology for the first time. The approach to thoracic imaging may be challenging for the beginner due to the wide spectrum of diseases, their overlap, and the complexity of radiological findings. The first step consists of the proper assessment of the basic imaging findings. This review is divided into three main districts (mediastinum, pleura, focal and diffuse diseases of the lung parenchyma): the main findings will be discussed in a clinical scenario. Radiological tips and tricks, and relative clinical background, will be provided to orient the beginner toward the differential diagnoses of the main thoracic diseases.

Computed tomography findings in septic pulmonary embolism: A case report and literature review

This case report describes the findings of septic pulmonary embolism (SPE) in a young adult male with a history of intravenous drug use who initially presented with signs and symptoms of acute sepsis. The patient underwent evaluation by computed tomography (CT) imaging as well as blood cultures and echocardiography, which confirmed the diagnosis of SPE secondary to Staphylococcus aureus positive bacterial endocarditis. In this case report, we discuss the presentation and characteristic CT imaging findings of SPE as well as highlight the value of this imaging modality in the timely diagnosis and management of this urgent condition.

Home Parenteral Nutrition in Patients with Intestinal Failure: Possible Undetected Complications

Background: Septic pulmonary embolism (SPE) may be a frequently undetected complication of central venous catheter (CVC)-related bloodstream infections (CRBSIs). Materials and Methods: The incidence of SPE was evaluated in a cohort of non-oncological patients on home parenteral nutrition (HPN) who were hospitalized for a CRBSI from January 2013 to December 2017. The main clinical, microbiological, and radiological features and the therapeutic approach were also described. Results: Twenty-three infections over 51,563 days of HPN therapy were observed, corresponding to an infection rate of 0.45/1000. In 10 out of the 23 cases (43.5%), pulmonary lesions compatible with SPE were identified. Conclusion: Our results demonstrated that a CRBSI can produce asymptomatic SPE with lung infiltrates in 43.5% of the cases, suggesting the need to check for secondary lung infections to choose the most appropriate antimicrobial therapy.

Deep neck infection and descending mediastinitis as lethal complications of dentoalveolar infection: two rare case reports

Background

We report two cases of innocuous dentoalveolar infections which rapidly progressed to deep neck abscesses complicated by descending mediastinitis in a resource-constrained rural mission hospital in the Cameroon.

Case presentation

The clinical presentations of a 35-year-old man and a 32-year-old woman both of Fulani origin in the Northern region of Cameroon were similar with submandibular fluctuant and tender swelling and differential warmth to palpation. The patients had tachycardia, high grade pyrexia, and normal blood pressure. Further physical and neurological examinations were unremarkable. An ultrasound scan of the neck swellings showed submandibular turbid collections. Plain chest radiographs confirmed empyema thoraces. Our patients had serial drainage of the neck abscesses as well as closed thoracostomy tube drainage which were connected to pleurovac and suctioning machines, with significant amount of pus drainage. Both patients were admitted to our intensive care unit for close monitoring. The first patient continued to make satisfactory clinical progress and was discharged by the fourth week of admission. The patient who had human immunodeficiency viral infection died on the fifth postoperative day.

Conclusions

The possibility of lethal complications and the associated morbidity and mortality portray this clinical entity as an important public health concern. Clinicians taking care of patients with dentoalveolar and oropharyngeal infections need to be sensitized to these potentially fatal complications. Alternatively, strategies to improve oral health and reduce the incidence of dental caries, the main cause of dental abscess, would maximize use of resources; especially in resources-constrained centers like ours in Banso Baptist Hospital.

Computed Tomography Features of Septic Pulmonary Embolism Caused by Klebsiella pneumoniae Liver Abscess Associated With Extrapulmonary Metastatic Infection

OBJECTIVES

The aims of the study were to investigate the computed tomography (CT) features and clinical course of septic pulmonary embolism (SPE) caused by Klebsiella pneumoniae liver abscess (KPLA) and to explore the possible mechanism underlying the spread of infection.

METHODS

Twenty-one patients with KPLA-induced SPE admitted to our hospital between January 2010 and May 2015 were evaluated. According to the presence or absence of extrapulmonary metastatic infection (EMI), they were divided into EMI and non-EMI groups and clinical and CT features of the 2 groups were compared. Hepatic vein thrombophlebitis was evaluated on liver CT images. Chest CT features included nodules, wedge-shaped lesions, ground-glass opacity, consolidation, cavitation, feeding vessel sign, pleural effusion, and lymphadenopathy.

RESULTS

All the vessels within the so-called feeding vessel sign were confirmed as pulmonary veins by multiplanar reconstruction, so we used an alternative name draining vessel sign (DVS) instead. Peripheral nodules, DVS, and consolidation were the main CT features of KPLA-induced SPE. Peripheral nodules and DVS were more frequently seen in the EMI group than in the non-EMI group (P = 0.019 and 0.008, respectively). Five of 8 patients with hepatic vein thrombophlebitis had lung consolidation, whereas only 3 of 13 patients without hepatic vein thrombophlebitis had lung consolidation, although the difference was not significant (P = 0.09).

CONCLUSIONS

Multiple pulmonary nodules and DVS were associated with EMI. Hepatic and pulmonary vein invasion are possible causes underlying the metastatic spread of infection.

Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes

OBJECTIVES:

Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care.

METHODS:

The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed.

RESULTS:

Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%). The most common computed tomographic findings included a feeding vessel sign (90%), peripheral nodules without cavities (80%) or with cavities (65%), and peripheral wedge-shaped opacities (75%). The most common primary source of infection was liver abscess (40%), followed by pneumonia (25%). The two most frequent causative pathogens were Klebsiella pneumoniae (50%) and Staphylococcus aureus (35%). Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess.

CONCLUSIONS:

Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential.

Cardiac septic pulmonary embolism: A retrospective analysis of 20 cases in a Chinese population

Based on the source of the embolus, septic pulmonary embolism (SPE) can be classified as cardiac, peripheral endogenous, or exogenous. Cardiac SPEs are the most common.We conducted a retrospective analysis of 20 patients with cardiac SPE hospitalized between 1991 and 2013 at a Chinese tertiary referral hospital.The study included 14 males and 6 females with a median age of 38.1 years. Fever (100%), cough (95%), hemoptysis (80%), pleuritic chest pain (80%), heart murmur (80%), and moist rales (75%) were common clinical manifestations. Most patients had a predisposing condition: congenital heart disease (8 patients) and an immunocompromised state (5 patients) were the most common. Staphylococcal (8 patients) and Streptococcal species (4 patients) were the most common causative pathogens. Parenchymal opacities, nodules, cavitations, and pleural effusions were the most common manifestations observed via computed tomography (CT). All patients exhibited significant abnormalities by echocardiography, including 15 patients with right-sided vegetations and 4 with double-sided vegetations. All patients received parenteral antimicrobial therapy as an initial treatment. Fourteen patients received cardiac surgery, and all survived.Among the 6 patients who did not undergo surgery, only 1 survived. Most patients in our cardiac SPE cohort had predisposing conditions. Although most exhibited typical clinical manifestations and radiography, they were nonspecific. For suspected cases of SPE, blood culture, echocardiography, and CT pulmonary angiography (CTPA) are important measures to confirm an early diagnosis. Vigorous early therapy, including appropriate antibiotic treatment and timely cardiac surgery to eradicate the infective source, is critical.

Infection

Community-Acquired Pneumonia (CAP) is the first leading cause of death due to infection worldwide.Many gram-positive, gram-negative bacteria, funguses and viruses can cause the infectious pulmonary disease, and the severity of pneumonia depends on the balance between the microorganism charge, the body immunity defenses and the quality of the underlying pulmonary tissue. The microorganisms may reach the lower respiratory tract from inhaled air or from infected oropharyngeal secretions. The same organism may produce several different patterns that depend on the balance between the microorganism charge and the body immunity defenses.CAP is classified into three main groups: lobar pneumonia, bronchopneumonia and interstitial pneumonia.Lobar pneumonia is characterized by the filling of alveolar spaces by edema full of white and inflammatory cells. Necrotizing pneumonia consists of a fulminant process associated with focal areas of necrosis that results in abscesses. Bronchopneumonia or lobular pneumonia, is characterized by a peribronchiolar inflammation with thickening of peripheral bronchial wall, the diffusion of inflammation to the centrilobular alveolar spaces and development of nodules.The interstitial pneumonia represents with the destruction and esfoliation of the respiratory ciliated and mucous cells. The interstitial septa, the bronchial and bronchiolar walls become thickened for the inflammation process and lymphocytes interstitial infiltrates.Chest radiography represents an important initial examination in all patients suspected of having pulmonary infection and for monitoring response to therapy.Its role is to identify the pulmonary opacities, their internal characteristics and distribution, pleural effusion and presence of other complications as abscesses and pneumothorax.High spatial CT resolution allows accurate assessment of air space inflammation.The CT findings include nodules, interlobular septal thickening, intralobular reticular opacities, ground-glass opacities, tree-in-bud pattern, lobar-segmental consolidation, lobular consolidation, abscesses, pneumatocele, pleural effusion, pericardial effusion, mediastinal and hilar lymphoadenopaties, airway dilatation and emphysema.

A review of complications of odontogenic infections

Life-threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. Complications include airway obstruction, mediastinitis, necrotizing fascitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre's syndrome, cerebral abscess, orbital abscess, and osteomyelitis. The incidence of these "space infections" has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur. This study reviews complications of odontogenic infections. The search done was based on PubMed and Google Scholar, and an extensive published work search was undertaken. Advanced MEDLINE search was performed using the terms "odontogenic infections," "complications," and "risk factors."

Septic pulmonary embolism caused by a Klebsiella pneumoniae liver abscess: clinical characteristics, imaging findings, and clinical courses

OBJECTIVES

Septic pulmonary embolism caused by a Klebsiella (K.) pneumoniae liver abscess is rare but can cause considerable morbidity and mortality. However, clinical information regarding this condition is limited. This study was conducted to elucidate the full disease spectrum to improve its diagnosis and treatment.

METHOD

We reviewed the clinical characteristics, imaging findings, and clinical courses of 14 patients diagnosed with septic pulmonary embolism caused by a K. pneumoniae liver abscess over a period of 9 years.

RESULTS

The two most prevalent symptoms were fever and shortness of breath. Computed tomography findings included a feeding vessel sign (79%), nodules with or without cavities (79%), pleural effusions (71%), peripheral wedge-shaped opacities (64%), patchy ground-glass opacities (50%), air bronchograms within a nodule (36%), consolidations (21%), halo signs (14%), and lung abscesses (14%). Nine (64%) of the patients developed severe complications and required intensive care. According to follow-up chest radiography, the infiltrates and consolidations were resolved within two weeks, and the nodular opacities were resolved within one month. Two (14%) patients died of septic shock; one patient had metastatic meningitis, and the other had metastatic pericarditis.

CONCLUSION

The clinical presentations ranged from insidious illness with fever and respiratory symptoms to respiratory failure and septic shock. A broad spectrum of imaging findings, ranging from nodules to multiple consolidations, was detected. Septic pulmonary embolism caused by a K. pneumoniae liver abscess combined with the metastatic infection of other vital organs confers a poor prognosis.

Associations and outcomes of septic pulmonary embolism

Background:

Septic pulmonary embolism is a serious but uncommon syndrome posing diagnostic challenges because of its broad range of clinical presentation and etiologies.

Objective:

To understand the clinical and radiographic associations of septic pulmonary embolism in patients presenting to an acute care safety net hospital.

Methods:

We conducted a retrospective analysis of imaging and electronic health records of all patients diagnosed with septic pulmonary embolism in our hospital between January 2000 and January 2013.

Results:

41 episodes of septic pulmonary embolism were identified in 40 patients aged 17 to 71 years (median 46); 29 (72%) were men. Presenting symptoms included: febrile illness (85%); pulmonary complaints (66%) including pleuritic chest pain (22%), cough (19%) and dyspnea (15%); and those related to the peripheral foci of infection (24%) and shock (19%). Sources of infection included: skin and soft tissue (44%); infective endocarditis (27%); and infected peripheral deep venous thrombosis (17%). 35/41 (85%) were bacteremic with staphylococcus aureus. All patients had peripheral nodular lesions on chest CT scan. Treatment included intravenous antibiotics in all patients. Twenty six (63%) patients required pleural drainage and/or drainage of peripheral abscesses. Seven (17%) patients received systemic anticoagulants. Eight (20%) patients died due to various complications.

Conclusion:

The epidemiology of septic pulmonary embolism has broadened over the past decade with an increase in identified extrapulmonary, non-cardiac sources. In the context of an extrapulmonary infection, clinical features of persistent fever, bacteremia and pulmonary complaints should raise suspicion for this syndrome, and typical findings on the chest CT scans confirm the diagnosis. Antibiotics, local drainage procedures and increasingly, anticoagulation are keys to successful outcomes.

Intraoperative Life Threatening Acute Lung Injury Due to Multiple Septic Pulmonary Emboli during Transpedicular Biopsy and Kyphoplasty

A 55-year-old gentleman was presented to our clinic two months after a trivial fall with persistent pain, gibbus at the thoraco-lumbar junction and intact neurology. Radiological and laboratory investigations suggested osteoporotic fracture or metastasis. Due to unremitting pain, a plan was made to do transpedicular biopsy and kyphoplasty. Biopsy needles were inserted into both pedicles and an attempt at aspiration was made. Since the aspirate was dry, 5 to 6 mL of saline was injected through one needle and an attempt at aspiration was made through the other. Three-millilitres of sero-sanguineous material mixed with pus came out and kyphoplasty was deferred. After extubation, the patient developed severe bronchospasm and was transferred to the intensive care unit. Investigations confirmed multiple septic pulmonary emboli and the patient recovered completely after treatment. This report highlights that confirmation of the diagnosis is essential before performing any procedure that increases the intravertebral pressure and the place should have appropriate facilities to manage complications.

A case of septic pulmonary embolism associated with renal abscess mimicking pulmonary metastases of renal malignancy

We report the case of a 46-year-old woman with acute febrile symptom who had multiple pulmonary nodules and a renal mass. She underwent (18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to find a hidden malignancy and the cause of her fever. FDG PET/CT images demonstrated a renal mass and multiple lung nodules with intense FDG uptake, which was suspicious of a renal malignancy with multiple pulmonary metastatic lesions. CT-guided biopsies of the pulmonary and renal lesions only showed chronic inflammatory infiltrates without evidence of malignancy. She was diagnosed with septic pulmonary embolism from a renal abscess. One month after antibiotic treatment, the follow-up chest and abdomen CT showed improvement of the lung and renal lesions. This is the first case demonstrating the FDG PET/CT finding of septic pulmonary embolism associated with renal abscess in the published literature.

Septic pulmonary embolism originated from subcutaneous abscess after living donor liver transplantation: a pitfall of postoperative management

The use of immunosuppressants after liver transplantation (LT) is associated with postoperative complications, including infections. A 49-year-old male underwent living-donor (LD) LT because of primary sclerosing cholangitis. He was treated with tacrolimus, mycophenolate mofetil, and steroids as immunosuppressants, discharged on postoperative day (POD) 40, and re-admitted because of severe acute cellular rejection on POD 48. Three courses of steroid pulse therapy were performed, and continuous peripheral intravenous drip infusion therapy via the left forearm was necessary for 20 days because of appetite loss. The patient was discharged on POD 83, but re-admitted on POD 87 with pyrexia. A subcutaneous abscess was present at a puncture wound on the left forearm formed by an intravenous drip during the last hospital stay. Furthermore, computed tomography showed five pieces of cavitary or wedge-shaped nodules in the bilateral lung. Because sputum revealed the presence of Gram-positive coccus, and subcutaneous abscess and blood cultures revealed Staphylococcus aureus, the pathogenesis was septic pulmonary embolism (SPE) secondary to S. aureus septicemia originating from a subcutaneous abscess formed by an intravenous drip. The patient was treated with drainage of the subcutaneous abscess and antibiotic therapy, and recovered immediately. Although there have been few reports of SPE after LDLT, SPE is fatal in up to 13.3 % of patients. Early diagnosis, drainage of the infectious source, and appropriate use of antimicrobial therapy should be necessary to overcome SPE. Furthermore, the identical intravenous catheters should be removed whenever possible to avoid infectious complications including SPE for patients who receive steroid pulse therapy after LDLT.

Pyogenic liver abscess associated with septic pulmonary embolism

BACKGROUND

Septic pulmonary embolism (SPE) is one of the metastatic foci of pyogenic liver abscess. The purpose of this study was to investigate the clinical presentations of, and management options for patients with pyogenic liver abscess complicated with SPE.

METHODS

A retrospective chart review was conducted from January 1, 1999 to December 31, 2005 inclusively, in a medical center in northern Taiwan. We collected and analyzed the clinical presentations, diagnostic modalities, treatment programs and prognoses for all pyogenic liver abscess patients with SPE.

RESULTS

The association between liver abscess affected with the complication of SPE and diabetes mellitus was significant. There were 9 patients who had pyogenic liver abscess with SPE. Abnormal chest radiograph (CXR) findings with multiple ill-defined peripheral round densities were noted in all patients. Seven patients were diabetic, fever occurred in 5 patients, respiratory symptoms were noted in 6 patients, and abdominal pain occurred in 3 patients. Endophthalmitis coexisted in 3 patients, meningitis in 1 patient, and necrotizing fasciitis in 2 patients. Microbiological studies revealed Klebsiella pneumoniae in 9 patients. Computed tomography (CT) demonstrated metastatic nodules in both lung lobes, some of which featured cavitation, in all 9 patients. Three patients soon advanced to acute respiratory failure, and later died due to acute respiratory distress syndrome and/or septic shock. The remaining 6 patients survived without complication during their hospital course.

CONCLUSION

There is diagnostic value in performing a chest CT scan in diabetic patients who have liver abscess plus abnormal CXR findings with multiple ill-defined peripheral round densities, in order to detect SPE, which has a relatively poor outcome in patients with liver abscess.

Cavitary pulmonary disease

A pulmonary cavity is a gas-filled area of the lung in the center of a nodule or area of consolidation and may be clinically observed by use of plain chest radiography or computed tomography. Cavities are present in a wide variety of infectious and noninfectious processes. This review discusses the differential diagnosis of pathological processes associated with lung cavities, focusing on infections associated with lung cavities. The goal is to provide the clinician and clinical microbiologist with an overview of the diseases most commonly associated with lung cavities, with attention to the epidemiology and clinical characteristics of the host.

Computed Tomographic Features of Pulmonary Septic Emboli

OBJECTIVE

To describe and compare the computed tomographic (CT) findings of pulmonary septic emboli in causative microorganisms.

METHODS

The CT findings of 16 patients (8 men and 8 women; age range, 17 to 80 years; mean, 53.1 years) with documented pulmonary septic emboli were retrospectively reviewed by 2 radiologists; their decisions on the findings were reached by consensus. Statistical analysis was performed using the t test and the chi test.

RESULTS

A total of 197 peripheral nodules were seen in 6 gram-positive (n = 88) and 10 gram-negative (n = 109) septic pulmonary emboli patients, respectively. The sizes of the nodules (15.94 mm; range, 3-46 mm) in gram-positive septic emboli were larger than those (12.29 mm; range, 4-44 mm) in gram-negative septic emboli (P = 0.006). Cavitation (n = 30 [34%] vs n = 23 [21%]; P = 0.041) and air bronchogram (n = 12 [14%] vs n = 4 [4%]; P = 0.008) within the nodules were more commonly seen in gram-positive septic emboli. A ground-glass attenuation halo around a nodule (n = 69 [63%] vs n = 32 [36%]; P = 0.000) and feeding vessel signs (n = 56 [51%] vs n = 25 [28%]; P = 0.001) were more commonly seen in gram-negative septic emboli. Wedge-shaped peripheral lesions abutting the pleura were seen in 4 gram-positive (67%) and in 1 gram-negative (10%) septic emboli patients, respectively (P = 0.047).

CONCLUSIONS

The detailed CT characteristics of peripheral nodules in pulmonary septic emboli may be able to differentiate the causative microorganisms and to provide additional information regarding treatment plans in patients with sepsis.

Septic pulmonary embolism in Korea: Microbiology, clinicoradiologic features, and treatment outcome

OBJECTIVES

The aim of this study was to investigate the clinicoradiologic features, microbiologic data, primary sites of infection, and treatment results for patients with septic pulmonary embolism (SPE) in Korea.

METHODS

We retrospectively analyzed 21 SPE patients including "definite" and "probable" cases.

RESULTS

On CT scan, peripheral nodules were the most common lesions (89.0%), followed by non-nodular infiltrates (7.0%) and wedge-shaped peripheral lesions (3.2%). Cavitation and feeding vessel sign, more specific to SPE were identified in 10.4% and 6% of all the lesions, respectively. Transthoracic echocardiography revealed significant abnormalities in three of 13 patients with an additional finding of vegetation in only one of five patients when studied by transesophageal echocardiography. In 15 patients, primary sites of infection were found, and three causative organisms were isolated in 16: K. pneumoniae (8); S. aureus (6); and viridans streptococci (2). All patients received parenteral antimicrobial therapy with or without drainage of the extrapulmonary infection and 18 recovered.

CONCLUSIONS

Although the pathogens of SPE may differ depending on the primary foci of infection, early diagnosis and prompt antimicrobial therapy with radiologic or surgical intervention can lead to a successful treatment outcome.

Unusual Pulmonary Embolism Septic Pulmonary Embolism and Amniotic Fluid Embolism

BACKGROUND

Septic and amniotic fluid emboli are rare sources of pulmonary embolism (PE), so the present study sought to elucidate the background of these cases.

METHODS AND RESULTS

A total of 11,367 PE cases were identified from 396,982 postmortem examinations. The incidence of septic PE was 247 (2.2%) of the total. The origin of infection was found in 85.6% of the cases. Fungal embolus was detected more often than bacterial embolus. The most frequently detected fungus was aspergillus (20.8%). The primary disease associated with fungal embolus was leukemia (43.2%). The incidence of PE cases associated with pregnancy and/or delivery was 89 (0.8%) of the total PE cases. Among them, amniotic fluid embolism was found in 33 (73.3%) of 45 PE cases with vaginal delivery, and in 7 (21.2%) of 33 PE cases with cesarean delivery (p<0.0001).

CONCLUSION

Fungal embolus was more frequent than bacterial embolus, and leukemia was most frequent as the primary disease in cases of fungal embolus. The main cause of PE in cesarean section cases was thrombotic embolism, and the main cause in vaginal delivery cases was amniotic fluid embolism.

High-Resolution MDCT of Pulmonary Septic Embolism: Evaluation of the Feeding Vessel Sign

OBJECTIVE

The objective of this study was to use high-resolution MDCT to assess the relation of the pulmonary vasculature to septic emboli with particular attention to the feeding vessel sign.

MATERIALS AND METHODS

The MDCT scans of nine patients with septic emboli were retrospectively, blindly evaluated by two observers. A control group of 10 patients with documented pulmonary metastasis and pathologically proven carcinoma also were included. Transverse images, multiplanar reconstructions, and maximum intensity projections were used to analyze nodules and the pulmonary vasculature. The CT scans were obtained with 1- to 1.25-mm collimation on a 4-, 8-, or 16-MDCT scanner. The feeding vessel sign was defined as a vessel coursing directly into a nodule.

RESULTS

The patients with septic embolism had a total of 141 nodules and 52 wedge-shaped opacities. Transverse images showed that 52 (37%) of the nodules and 11 (22%) of the wedge-shaped opacities had a vessel that appeared to enter the nodule, but multiplanar reconstructions (without IV contrast enhancement) and maximum intensity projections (with IV contrast enhancement) showed the vessels passed around the nodules. Twenty-one (15%) of the spherical nodules and seven (13%) of the wedge-shaped opacities exhibited a central vessel entering the lesion in all imaging planes. All of these vessels were traced to the left atrium on transverse images, a finding consistent with pulmonary vein branches. Similar findings were seen in pulmonary metastatic lesions.

CONCLUSION

Although pulmonary septic emboli often appear to have a feeding vessel on conventional cross-sectional images, multiplanar reconstructions show that most of these vessels course around the nodule and that the others are pulmonary veins.

A young adult patient with septic pulmonary emboli of undetermined origin

A 25-year-old male who had no significant medical history presented abrupt onset of high-grade fever and chills without noticeable trigger. The patient sought for medical attention for subsequently developed dyspnea and chest pain. Radiological examinations revealed bilateral lung peripheral multiple opacities, some of which were cavitating, suggesting of septic pulmonary emboli (SPE). Isolation of Staphylococcus aureus in blood and sputum culture confirmed the diagnosis. Extensive examinations disclosed neither underlying immunocompromising conditions nor infectious foci, which are usually notable in patients with SPE. The present patient illustrates that there are patients with SPE in whom underlying conditions or infectious foci are difficult to determine, and that suspicion of the disease based on characteristic radiological findings is critical for appropriate management in those patients.

Staphylococcus aureus infective endocarditis and septic pulmonary embolism after septic abortion

We report a case of a 26-year-old female who after septic abortion developed tricuspid valve endocarditis with large vegetations, which subsequently resulted in embolism to right main pulmonary artery. Patient was treated with intravenous antibiotics and had a good recovery.

Septic Pulmonary Embolism

BACKGROUND

Septic pulmonary embolism (SPE) is an uncommon disorder with an insidious onset and is difficult to diagnose.

STUDY OBJECTIVES

To characterize the presenting features and clinical course of patients with SPE.

DESIGN

Retrospective study.

SETTING

Tertiary care, referral medical center.

PATIENTS

Fourteen subjects with SPE diagnosed during a 6-year period between 1996 and 2002.

INTERVENTIONS

None.

RESULTS

The median age of these patients was 37.5 years (range, 14 to 81 years) and included five women. Presenting symptoms included fever (93%), dyspnea (36%), pleuritic chest pain (29%), cough (14%), and hemoptysis (7%). The median duration of symptoms before diagnosis was 18 days (range, 5 to 180 days). A potential source or underlying condition that predisposed to SPE was identified in all 14 patients and included Lemierre syndrome (4 patients), central venous catheter infection (3 patients), prosthetic cardiac valve (2 patients), and pacemaker infection (2 patients). Two patients had a focal extrapulmonary infection, and one patient was an IV drug user. Most common pathogens were staphylococcal species (eight patients) and fusobacterium (four patients). Chest radiographic presentation was usually nonspecific, but CT was more helpful and revealed multiple nodular opacities peripherally, often with cavitation. Transesophageal echocardiography was performed in eight patients and demonstrated infectious vegetations in four cases. Aside from antimicrobial therapy and removal of infected devices, the management of these patients included cardiac surgery (two patients), thoracoscopic surgery with decortication (one patient), and tube thoracostomy (one patient). All 14 patients recovered from their illness.

CONCLUSIONS

We conclude that SPE presents with variable and often nonspecific clinical and radiographic features. The diagnosis is usually suggested by the presence of a predisposing factor, febrile illness, and CT findings of multiple, nodular lung infiltrates peripherally, with or without cavitation.