Coccidioidomycosis and Pulmonary Emboli: A Report of 5 Cases.

BACKGROUND Coccidioidomycosis is endemic to the Sonoran life zone, which extends from Latin America to the western United States. The principle manifestation is pneumonia but disseminated disease also occurs. Venous thromboembolism occurring in association with this disease has not been reported. We encountered 5 cases of coccidioidomycosis, each complicated by pulmonary emboli, during a single year. We report these cases with the intent of making those caring for patients with coccidioidomycosis aware of this association. CASE REPORT A 35-year-old man developed fever and respiratory symptoms. He was initially treated with antibiotics as an outpatient and during a subsequent hospitalization. He was readmitted because of persistent respiratory symptoms and treated presumptively for coccidioidomycosis pneumonia. Hypoxemia persisted and multiple acute pulmonary emboli were evident on imaging. Serological study and organism identification confirmed a diagnosis of coccidioidomycosis infection. Details of this case and 4 additional cases are described. CONCLUSIONS Venous thromboembolism occurred in 5 patients with pulmonary coccidioidomycosis. The etiology of this rare association remains unclear but could be related to regional environmental changes that preceded the appearance of these cases.

Septic pulmonary embolism in China: clinical features and analysis of prognostic factors for mortality in 98 cases.

BACKGROUND: To investigate the clinical features of septic pulmonary embolism (SPE) cases and prognostic factors for in-hospital mortality in China. METHODS: A retrospective analysis was conducted of SPE patients hospitalized between January 2007 and June 2018 in the Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University. RESULTS: A total of 98 patients with SPE were identified. All patients had bilateral multiple peripheral nodules on chest computed tomography. The most common pathogen found in blood culture was Staphylococcus aureus (10/33, 30.3%). Transthoracic echocardiography was performed in 39 patients and 20 showed vegetations. Bronchoscopy was performed in 24 patients. Bronchoalveolar lavage fluid (BALF) was obtained from 15 patients (62.5%) and showed predominantly polymorphonuclear cell infiltration (52%, range of 48%~ 63%). Four patients received transbronchial lung biopsy, and histopathological examinations revealed suppurative pneumonia and organizing pneumonia. The in-hospital mortality rate was 19.4%. Age (odds ratio [OR] 1.100; 95% confidence interval [CI] 1.035-1.169), hypotension (OR 7.260; 95% CI 1.126-46.804) and ineffective or delay of empirical antimicrobial therapy (OR 7.341; 95% CI 1.145-47.045) were found to be independent risk factors for in-hospital mortality, whereas drainage treatment was found to be a protective factor (OR 0.33; 95% CI 0.002-0.677). CONCLUSIONS: SPE cases presented with nonspecific clinical manifestations and radiologic features. Blood cultures and bronchoscopy are important measures for early diagnosis and differential diagnosis. There is relationship between primary infection sites and the type of pathogen. Maintaining normal blood pressure and providing timely and appropriate initial antimicrobial therapy for effective control of the infection could improve prognosis.

Septic pulmonary embolism caused by Pseudomonas aeruginosa after a CO2 laser surgery for rhinitis.

A 26-year-old healthy patient had a fever and chest pain three days after nasal carbon dioxide (CO2) laser surgery for chronic and allergic rhinitis. In the emergency room, he was diagnosed as a right pneumothorax and managed as outpatients with oral antibiotic therapy and close follow-up. Six days later, in follow-up clinic, his presenting signs and symptoms included right chest pain, tachypnoea and elevated levels of white blood cell count and C reactive protein. He was diagnosed as septic pulmonary embolism (SPE) by the detection of multiple nodules with cavitation on chest CT. Culture of pleural fluids showed Pseudomonas aeruginosa Intravenous antibiotic treatment and drainage of the pleural effusion improved his condition. Since SPE occurred after nasal CO2 laser surgery in this case, careful attention should be paid to infectious complications of nasal CO2 laser surgery.

Septic pulmonary embolism associated with periodontal disease: a case report and literature review.

BACKGROUND: Periodontal disease, including periodontitis, has been reported to be a rare cause of septic pulmonary embolism (SPE). It is however extremely difficult to isolate the causative pathogen of periodontal disease-associated SPE from blood cultures of these patients. CASE PRESENTATION: In this study, an 85-year-old Japanese man was admitted with fever and worsening malaise. He was later noted to have multiple bilateral subpleural pulmonary nodules on chest computed tomography scan. After admission, Parvimonas micra (P. micra) was isolated from his blood culture. This was followed by a meticulous search for the primary source of SPE, focusing on the head and neck areas. Consequently, apical periodontitis and infratemporal fossa abscess were identified as the primary sources of SPE. Although P. micra is one of the most frequently detected bacteria in the infected root canals of teeth with chronic apical periodontitis, it has rarely been proven as a causative pathogen of periodontal disease-associated SPE. CONCLUSIONS: This case study demonstrated that periodontal disease is an important primary source of SPE and P. micra could be a causative pathogen of SPE.

Lemierre's syndrome: a case study with a short review of literature.

OBJECTIVE AND IMPORTANCE: Lemierre's syndrome (LS) is a rare condition that typically starts with a bacterial oropharyngeal infection complicated by a thrombophlebitis of the internal jugular vein and septic emboli to the lungs or other organs. The most common organism isolated is Fusobacterium necrophorum, although other causative organisms are isolated in rare cases. CASE PRESENTATION: We discuss a case of LS in a 44-year-old, previously healthy man presenting with an oropharyngeal infection. F. necrophorum was isolated from blood cultures and Computed tomography of the chest demonstrated septic emboli in the lungs. Magnetic resonance imaging showed a thrombophlebitis of the sigmoid and transverse vein with continuity to the internal jugular vein. METHODS: Case report and literature review. RESULTS: F. necrophorum isolates show in vitro susceptibility to metronidazole, clindamycin, beta-lactam/beta-lactamase inhibitor combinations and carbapenems with no signs of resistance or reduced sensitivity. Anticoagulation is believed to play a favourable role in recovery of the disease because of the potential for faster resolution of thrombophlebitis and bacteraemia. Conflicting results exist in literature with many studies or reviews indicating a favourable outcome both with and without anticoagulation. Anticoagulation for LS consists in most cases of Warfarin or Low molecular weight heparins, with the last being the first choice in children. Indications for the use of anticoagulation in literature are significant clot burden, complication of septic emboli, arterial ischemic stroke, poor response to antibiotics, thrombophilia and cerebral infarction. CONCLUSIONS: Antibiotics are considered the mainstay of treatment, although statistically valid trials to evaluate optimal treatment regimens have not yet been conducted due to the low incidence of the infection. The use of anticoagulation in LS is still heavily debated as a result of conflicting results in literature. Due to the disease's low incidence, statistically valid trials that evaluate anticoagulation are lacking. Further prospective and randomized research is needed to establish the benefit of anticoagulation in the treatment of LS.

Embolizing pulmonary aspergillosis, mycobacterial & aspergillous splenic abscess and cytomegalovirus co-infection following steroid induced immunosuppression: a case report.

BACKGROUND: Aspergillosis is a serious infection particularly affecting the immunodeficient host. Its co-infection with tuberculosis and cytomegalovirus has not been reported before. Embolic events are well recognized with aspergillous endocarditis and aortitis. Splenic abscess is a rare serious complication of disseminated aspergillosis and is difficult to treat. We report the first case of multiple embolic events and splenic abscess in a patient with pulmonary aspergillosis and cytomegaloviral and tuberculous co-infection, without endocarditis or aortitis. CASE PRESENTATION: Thirty-year-old male presented with fever and non-productive cough while on glucocorticoids for glomerulonephritis. He was found to have pulmonary aspergillosis and subsequently developed bilateral lower limb and cerebral fungal emboli and fungal abscess in the spleen. He had IgM and B cell deficiency and cytomegalovirus (CMV) and tuberculous co-infections. He recovered after prolonged course of antimicrobials, splenectomy and cessation of glucocorticoid therapy which also lead to the resolution of immune deficiencies. CONCLUSION: This report illustrates rare combination of B and T cell suppressive effects of glucocorticoids leading to co-infections with CMV, Mycobacterium tuberculosis and Aspergillus and systemic fungal embolization from pulmonary aspergillosis.

Necrotizing fasciitis with pulmonary septic emboli following an infected insect bite.

Although systemic infections originating from skin infections caused by insect bites are uncommon, it is imperative to maintain a broad differential diagnosis should patients develop systemic symptoms. Necrotizing fasciitis is a rare diagnosis, and progression to septic pulmonary emboli is even less common. Emergent identification and aggressive treatment of these two disease processes are imperative as both carry high rates of morbidity and mortality.

Bilateral Pneumothoraces: A Rare Complication of Septic Pulmonary Emboli in Intravenous Drug Abusers.

BACKGROUND Right-sided infective endocarditis is a classic complication of intravenous drug abuse. Without timely bactericidal antibiotics, the disease process can progress to septic pulmonary emboli. Rarely, a pneumothorax can occur as a result of the emboli, and progressive persistent valvular disease may require a valve replacement. Tricuspid valve replacement has a high morbidity rate even in stable patients. CASE REPORT We present a case of tricuspid valve replacement in a 39-year-old man with peripheral intravenous drug abuse who had bilateral pneumothoraces secondary to septic pulmonary emboli originating on large tricuspid valve infected vegetations. The patient died 21 days after the valve replacement. CONCLUSIONS Tricuspid valve replacement is an especially dangerous procedure in intravenous drug abusers who present with bilateral pneumothoraces and advanced cardiopulmonary pathology.

Managing pulmonary embolism secondary to suppurative deep vein thrombophlebitis due to community-acquired Staphylococcus aureus in a resource-poor setting.

Deep vein thrombosis and pulmonary thromboembolism are rare and life threatening emergencies in children. We report an 11-year old female who presented with acute complaints of high grade fever, pain in the left thigh and inability to walk and breathlessness since 6 days. On physical examination, there was a diffuse tender swelling of the left thigh, tachypnea, tachycardia with hyperdynamic precordium and bilateral basal crepitations. Ultrasonography and venous doppler of lower limbs showed mild effusion of left hip joint and thrombus in the left common femoral vein and left external iliac vein suggesting a diagnosis of septic arthritis with thrombophlebitis. The tachypnea and tachycardia which was out of proportion to fever and crepitations on auscultation prompted suspicion of an embolic phenomenon. Radiograph of the chest revealed multiple wedge shaped opacities in the right middle zone and lower zone suggestive of pulmonary embolism and left lower zone consolidation. For corroboration, computed tomography pulmonary angiography and computed tomography of abdomen was performed which showed pulmonary thromboembolism and deep venous thrombosis extending up to infrarenal inferior vena cava. On further workup, magnetic resonance imaging of hips showed left femoral osteomyelitis and multiple intramuscular abscesses in the muscles around the hip joint. Blood culture grew methicillin resistant Staphylococcus aureus. Antibiotics were changed according to culture sensitivity and there was a dramatic response. After four weeks of anticoagulation and antibiotics the child became asymptomatic and thrombus resolved. Thus, it is crucial to consider methicillin resistant Staphylococcus aureus infection as an important infection when we encounter such a clinical scenario. This case report highlights an unusual and potentially life threatening presentation of a virulent strain of a common pathogen, which when diagnosed was completely amenable to treatment.

Large septic pulmonary embolus complicating streptococcus mutans pulmonary valve endocarditis.

Large septic pulmonary embolus is a rare finding in right-sided endocarditis. The entity represents a challenging diagnosis due to its variable and nonspecific clinical and radiological presentation and similarities with other conditions. We present a case of a 41 year-old woman who developed a large main pulmonary artery embolus and bilateral cavitary lung nodules in the setting of severe sepsis. Pulmonary artery exploration and clot retrieval ultimately revealed a large septic embolus from Streptococcus mutans native pulmonary valve endocarditis. The diagnosis of septic pulmonary emboli from right-sided endocarditis should be considered in patients with ancillary findings of septic embolic phenomenon, particularly the presence of multifocal cavitary nodules and in the setting of appropriate predisposing factors.

Septic Pulmonary Emboli From Peripheral Suppurative Thrombophlebitis: A Case Report and Literature Review.

BACKGROUND:: We report the case of a 90-year old woman who presented with septic pulmonary emboli due to suppurative thrombophlebitis at an old peripheral intravenous site. METHODS:: After unsuccessful treatment with antibiotics, the patient was taken to the operating room for excision and drainage of the purulent superficial vein. RESULTS:: We review the literature and discuss the presentation, risk factors, treatment options, and complications of this often-overlooked disease entity. CONCLUSIONS:: Suppurative thrombophlebitis is a rare but morbid disease that requires a high level of clinical suspicion to diagnose.

Right-sided infective endocarditis with coronary sinus vegetation.

BACKGROUND: Infective endocarditis (IE) is a rare disease with high mortality. Right-sided IE accounts for 5-10% of cases of IE. The tricuspid valve is most commonly affected, oppositely in coronary sinus (CS). The diagnoses, treatments and outcomes of CS vegetation has not been summarized yet. CASE PRESENTATION: We present a 71-year-old man complained of cough and fever. Transthoracic echocardiography revealed the aneurysmal dilated CS with the band medium-echo mobile structure. A sinus venosus atrial septal defect has been detected. He had a persistent left superior vena cava which drained the right atrium via the aneurysmal dilated CS. Blood cultures were positive for Staphylococcus aureus. After intravenous antibiotic therapy, he had the symptom of dyspnea. The suspicious diagnosis is recurrent septic lung emboli which was confirmed by thoracic contrast enhanced computed tomography. The thoracotomy was performed to repair the atrial septum and remove the CS vegetation. Ten days later, the patient was discharged with only mild cough. CONCLUSION: Both positive blood cultures and echocardiography are major criteria in right-sided IE with CS vegetation. Current treatment options of CS vegetation include medical therapy and surgery. The surgical strategy for CS vegetation should be individualized, due to the controversial indications and optimum time of surgery. Most people have a good prognosis after proper treatment.

Septic pulmonary emboli as a complication of peripheral venous cannula insertion.

Septic pulmonary emboli can occur as a complication of many diseases, most common being right sided infective endocarditis. Septic emboli through a peripheral venous cannula are rarely reported in literature though central venous catheter is commonly implicated. We describe a case of widespread cellulitis and septic pulmonary emboli as a complication of peripheral venous cannulation.

Emergency Department Diagnosis of Septic Pulmonary Embolism due to Infectious Endocarditis Using Bedside Ultrasound.

BACKGROUND: Septic pulmonary embolism (SPE) is a rare disorder caused by metastasis of infectious thrombi to the lungs. Most commonly, this occurs as a result of infectious endocarditis. This clinical entity may easily be confused for more common and less mortal diagnoses such as pneumonia, bronchitis, or pulmonary embolism. CASE REPORT: A 47-year-old woman presented in respiratory distress with a complaint of cough productive of rusty sputum, shortness of breath, and pleuritic chest pain. A bedside ultrasound suggested endocarditis and SPE. She was resuscitated and admitted to the hospital for surgical source control and continued i.v. antibiotics. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SPE is a rare disorder that may be easily missed but carries a high mortality rate. Additionally, the presence of the embolic phenomena makes the diagnosis of infectious endocarditis more attainable in the emergency department (ED). To our knowledge, this case is the first in which ED bedside ultrasound was used to make the diagnosis of SPE due to infectious endocarditis.

Septic pulmonary emboli detected by 18F-FDG PET/CT in children with S. aureus catheter-related bacteremia.

PURPOSE: The role of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) in the diagnosis of metastatic infectious foci in children with catheter-related blood stream infection has been hardly studied, although some authors have reported it benefit in the screening of metastatic foci in adult population. Septic pulmonary emboli are among the most difficult to identify, because many cases do not present pulmonary complaints or abnormal chest radiography. However, diagnosis of these foci has important therapeutic consequences. The purpose of this article is to describe the role of 18F-FDG PET/CT in the diagnosis of septic pulmonary embolism in children with S. aureus catheter-related bacteremia. METHODS: We report 3 children with S. aureus catheter-related bacteremia and normal chest X-ray at admission, in whom 18F-FDG PET/CT led to the diagnosis of unsuspected septic pulmonary emboli, with an impact on clinical management. RESULTS: All patients had hemophilia and implantable venous access ports and presented with fever and normal lung auscultation. Only 1 reported non-specific symptoms (undifferentiated left chest pain). All patients had normal chest X-ray on admission. Catheters were removed within 48 h after admission in 2 cases, and 5 days after admission in the last case, subsiding fever. In 2 children, paired blood cultures were not able to identify bacteremia. However, in all cases catheter tip and subcutaneous port cultures yielded S. aureus and PET/CT detected unsuspected pulmonary metastatic emboli. CONCLUSIONS: 18F-FDG PET/CT should be considered as a useful tool to diagnose septic pulmonary embolism in S. aureus catheter-related bacteremia, especially if conventional diagnostic imaging techniques have failed to reveal possible metastatic foci. Further studies are needed to clarify the usefulness of PET/CT performance in children with CRBSI.