49-year-old male with PMH significant for end stage renal disease s/p external arteriovenous shunt placement for home dialysis presents with complaint of 3 days of fevers, chills, nausea, vomiting, anorexia, cough and pleuritic chest pain. Patient had similar signs and symptoms 1 year, was found to have MSSA bacteremia with septic pulmonary emboli. Following shunt replacement and antimicrobial therapy he demonstrated improvement. Denies tobacco, alcohol or illicit drug use. No family history of pulmonary disease or cancer
101.9 130/90 98 22 97RA
Ill appearing morbidly obese male sitting on side of bed in mild
Mild tachycardia. No murmurs rubs or gallops
Mild tachypnea with decreased breath sounds at base R>L
Soft, nontender, nondistended with normal active bowel sounds
WBC 15.8, H/H 9.7/29.1, Plt 256 G 91%
ESR 105, CRP 19.407
Blood Cx MSSA
AP CXR demonstrates patchy alveolar infiltrates in bilateral lower lung zones. Representing loculated pleural effusions
Chest CT demonstrates bilateral effusions with R>L. Multiple bilateral peripherally distributed nodular opacities with cavitations and feeding vessels leading to the peripheral lung lesions
C- Carcinoma - Squamous is most common
A- Autoimmune - Wegener's granulomatosis, Rheumatoid nodules
V- Vascular - Emboli (septic emboli or bland emboli)
I- Infection - Lung abscess, Bacterial pneumonia, Fungal pneumonia, Tuberculosis, Pneumatocele
T- Trauma - Pulmonary laceration
Y- Young (congenital) - Congenital cystic adenomatoid malformation, Pulmonary sequestration, Bronchogenic cyst
Dx: Septic Pulmonary Emboli
Dx Confirmed by: Based on patients clinical presentation, persistent MSSA bacteremia, typical radiographic findings of septic pulmonary emboli and history of diagnosis.
shunt replacement, exahastive search for other sources and appropriate antimicrobial therapy
Septic pulmonary embolism occur when an infected thrombus fragments and an emboli colonized with bacteria or fungi lodges in the pulmonary arterial circulation. Common sources septic thrombi include vegetative endocarditis and septic thrombophlebitis. Other less common sources include infected transvenous pacemakers, catheters, or shunts.
Organisms most commonly associated with septic pulmonary embolism include, Staphylococcus aureus and group A Streptococcus. However many patients, especially Intravenous drug abusers may harbor polymicrobial emboli, including anaerobic and gram-negative organisms. Blood cultures may be falsely negative, particularly early in the disease process.
Patients with septic pulmonary emboli have varied presentations depending upon the organism and the underlying disease. A high level of clinical suspicion is necessary given most often only non specific signs and symptoms including fevers, chills, nausea, vomiting, anorexia, cough, dyspnea or pluritic chest pain are obvious.
The classic plain film findings of septic pulmonary emboli include multiple pulmonary nodules of variable size with or without cavitation, located predominantly in the periphery and bases. However, most radiographs reveal only ill-defined infiltrates and effusions.
CT is the preferred imaging technique for septic pulmonary emboli. The presence of cavitating nodules with associated feeding vessels in highly specific for septic pulmonary emboli.
Septic Pulmonary Emboli
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