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.

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.

An unexpected cause of a subcutaneous nodule: a case report of dirofilaria infection.

Humans are not natural hosts of Dirofilaria; however, pulmonary or subcutaneous infections may occur through mosquitoes transmission. Patients presenting with simple subcutaneous nodules may not seek early medical attention, and hence systemic involvement through hematogenous spread may occur. Definitive diagnosis of Dirofilaria infection is made by histopathological examinations of the infected tissues. We report a patient with an incidental diagnosis of Dirofilaria infection confirmed by histopathological findings of a subcutaneous nodule on the right thigh. The source of infection remains unknown.

Host factors do not influence the colonization or infection by fluconazole resistant Candida species in hospitalized patients.

Nosocomial yeast infections have significantly increased during the past two decades in industrialized countries, including Taiwan. This has been associated with the emergence of resistance to fluconazole and other antifungal drugs. The medical records of 88 patients, colonized or infected with Candida species, from nine of the 22 hospitals that provided clinical isolates to the Taiwan Surveillance of Antimicrobial Resistance of Yeasts (TSARY) program in 1999 were reviewed. A total of 35 patients contributed fluconazole resistant strains [minimum inhibitory concentrations (MICs) > or = 64 mg/l], while the remaining 53 patients contributed susceptible ones (MICs < or = 8 mg/l). Fluconazole resistance was more frequent among isolates of Candida tropicalis (46.5%) than either C. albicans (36.8%) or C. glabrata (30.8%). There was no significant difference in demographic characteristics or underlying diseases among patients contributing strains different in drug susceptibility.

Lymphocytic pleural effusion in acute melioidosis.

An endemic outbreak of melioidosis developed in southern Taiwan following a flood caused by a typhoon in July 2005. A total of 27 patients were diagnosed with the acute and indigenous form of pulmonary melioidosis. Parapneumonic pleural effusions were noted on chest X-rays in six patients. Thoracentesis was done in three patients and all revealed lymphocyte predominance in differential cell count. Burkholderia pseudomallei was isolated in the pleural effusion in one of them. All three patients survived after antibiotic treatment. Lymphocytic pleural effusion is generally seen in tuberculosis or malignancy. However, our findings suggest that melioidosis should be considered in the differential diagnosis of lymphocytic pleural effusion.

Melioidosis outbreak after typhoon, southern Taiwan.

From July through September 2005, shortly after a typhoon, 40 cases of Burkholderia pseudomallei infection (melioidosis) were identified in southern Taiwan. Two genotypes that had been present in 2000 were identified by pulsed-field gel electrophoresis. Such a case cluster confirms that melioidosis is endemic to Taiwan.

Bacteremic melioidosis in southern Taiwan: clinical characteristics and outcome.

BACKGROUND/PURPOSE: In recent years, the number of cases of melioidosis has increased substantially in Taiwan. However, there have been no publications specifically studying patients who have bacteremic melioidosis in Taiwan. This study aimed to determine the clinical characteristics and outcome of patients with bacteremic melioidosis in Taiwan. METHODS: We retrospectively reviewed the records of 30 patients (mean age, 65 years) with blood culture-confirmed melioidosis who were managed at Tainan Municipal Hospital between June 2004 and January 2007. Nineteen out of 30 patients were identified within 1 month after Typhoon Haitang struck in mid-July 2005. A comparison of demographic characteristics, underlying conditions, biochemistry results, and clinical presentations between survivors (n = 21) and non-survivors (n = 9) was analyzed. RESULTS: Underlying conditions were identified in 90% of patients, diabetes mellitus being the commonest (50%). The most common site of infection was the lung (70%), followed by the genitourinary tract (13.3%), peritoneum (6.7%), meninges (3.3%), skin (3.3%), and aorta (3.3%). There were also 20% of cases without a primary site of infection being identified. Twenty percent of patients had multiple sites of infection. The number of bacteremic melioidosis with pneumonia was significantly higher in the post-typhoon outbreak (p = 0.001). Comparing survivors and non-survivors, there were no significant differences in age, gender, underlying conditions, and presence of pneumonia. Significant differences were evident in elevated serum creatinine (p = 0.038) and pH (p = 0.004). Fifty-six percent (5/9) of deaths occurred within 48 hours after presentation to hospital and 67% (6/9) of deaths occurred in the post-typhoon outbreak. Patients with septic shock (p < 0.001), acute renal failure (p = 0.013), and respiratory failure (p = 0.001) had significantly higher mortality. The in-hospital mortality rate was 27% and the relapse rate was 14%. CONCLUSION: The lungs were the most common site of infection in patients with bacteremic melioidosis and rapidly progressive community-acquired pneumonia (CAP) was the major cause leading to mortality. Patients with septic shock, acute renal failure, and acute respiratory failure had a much higher mortality rate. Typhoon Haitang was associated not only with higher numbers of cases and deaths but also with pneumonic presentations. Locally adapted guidelines need to be developed for the treatment of CAP in an endemic area of melioidosis in southern Taiwan and after extreme weather events such as typhoons or heavy rains.