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.

Endocardite aórtica e tricúspide em pacientes de hemodiálise com embolia sistêmica e pulmonar / Aortic and tricuspid endocarditis in hemodialysis patient with systemic and pulmonary embolism

RESUMO Este artigo relata o caso de um homem caucasiano de 43 anos de idade com nefropatia terminal em tratamento com hemodiálise e apresentando endocardite infecciosa das válvulas aórtica e tricúspide. O quadro clínico foi dominado pelo comprometimento neurológico, devido à embolia cerebral e a componentes hemorrágicos. Uma tomografia computadorizada tóraco-abdominal revelou um êmbolo séptico pulmonar. O paciente foi submetido à antibioticoterapia empírica utilizando ceftriaxona, gentamicina e vancomicina, sendo o tratamento modificado para flucloxacilina e gentamicina após o isolamento de S. aureus nas hemoculturas. A equipe multidisciplinar determinou que o paciente deveria ser submetido à substituição de válvulas após estabilização da hemorragia intracraniana; contudo, no oitavo dia após a hospitalização, o paciente entrou em parada cardíaca causada por embolia séptica pulmonar maciça, vindo a falecer. Apesar do risco de agravamento da lesão hemorrágica cerebral, em pacientes de alto risco deveria ser considerado realizar precocemente uma intervenção cirúrgica.

ABSTRACT This is a case report of a 43-year-old Caucasian male with end-stage renal disease being treated with hemodialysis and infective endocarditis in the aortic and tricuspid valves. The clinical presentation was dominated by neurologic impairment with cerebral embolism and hemorrhagic components. A thoracoabdominal computerized tomography scan revealed septic pulmonary embolus. The patient underwent empirical antibiotherapy with ceftriaxone, gentamicin and vancomycin, and the therapy was changed to flucloxacilin and gentamicin after the isolation of S. aureus in blood cultures. The multidisciplinary team determined that the patient should undergo valve replacement after the stabilization of the intracranial hemorrhage; however, on the 8th day of hospitalization, the patient entered cardiac arrest due to a massive septic pulmonary embolism and died. Despite the risk of aggravation of the hemorrhagic cerebral lesion, early surgical intervention should be considered in high-risk patients.

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. .

Primary pyomyositis and disseminated septic pulmonary emboli: a reactivated staphylococcal infection?

Staphylococcal pyomyositis is a severe invasive soft tissue infection with high mortality rate that is increasingly being recognized even in temperate climates. In most cases predisposing factors are identified that include either source of skin penetration or/and impaired host immunocompetence. A case of primary, community-acquired pyomyositis of the left iliopsoas muscle in a 59-year-old immunecompetent woman, which was complicated with septic pulmonary emboli within 24 h after hospital admission, is presented. The patient was subjected to abscess drainage under computed tomography guidance. Both pus aspiration and blood cultures revealed methicillin-susceptible Staphylococcus aureus. Given the absolute absence of predisposing factors and a remote history of staphylococcal osteomyelitis in the same anatomical region 53 years ago, reactivation of a staphylococcal soft tissue infection was postulated. Systematic review of the literature revealed a few interesting cases of reactivated staphylococcal infection after decades of latency, although the exact pathophysiological mechanisms still need to be elucidated.

Embolia pulmonar séptica de origen cutáneo / Septic pulmonary embolism of cutaneous origin

La embolia pulmonar séptica es una enfermedad grave y poco frecuente que se caracteriza por presentar infiltrados pulmonares bilaterales asociados a un foco infeccioso extrapulmonar. Se relaciona principalmente a endocarditis derecha, tromboflebitis pelviana, accesos vasculares y menos frecuentemente a infecciones profundas como osteomielitis, artritis séptica o piomiositis. El Staphylococcus aureus meticilino-resistente adquirido en la comunidad (SAMR-AC) es un patógeno emergente, con alta virulencia y de rápida propagación, que afecta a sujetos sin enfermedades previas relacionadas o factores de riesgo conocidos. Causa infecciones de piel y partes blandas y con menor frecuencia infecciones graves como fascitis necrotizante, artritis séptica, osteomielitis, piomiositis y neumonía necrotizante. Su epidemiología, patogenia y manifestaciones clínicas difieren de las causadas por el SAMR adquirido en el hospital. Presentamos el caso de un varón de 67 años con embolias pulmonares sépticas causadas por SAMR-AC con origen en una infección cutánea.

Septic pulmonary embolism is a serious and rare illness characterized by pulmonary infiltrates associated with an extrapulmonary infectious focus. It is mainly related to right-sided endocarditis, pelvic thrombophlebitis, vascular access and less frequently to deep infections such as osteomyelitis, septic arthritis and pyomyositis. The community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen with high virulence and rapid spread involving subjects without previous related diseases or known risk factors. It causes infections of skin and soft tissue and less frequently other serious infections such as necrotizing fascitits, septic arthritis, osteomyelitis, pyomyositis and necrotizing pneumonia. Epidemiologically, pathogenesis and clinical manifestations differ from those caused by MRSA acquired in the hospital. We present the case of a 67 year-old male with septic pulmonary embolism caused by community acquired MRSA that started with a skin infection.

Staphylococcal sepsis presenting as pulmonary embolism.

Deep vein thrombosis in children is rare and is often secondary to a predisposing condition. Staphylococcal sepsis following furunculosis and complicated by deep vein thrombosis and septic pulmonary emboli in a fourteen-yr-old boy is presented. He was managed successfully with antibiotics and anticoagulation.