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

Abstract

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.

Figure 1

Liver abscess with septic pulmonary emboli. (A) A chest radiograph shows an air-fluid level in the right upper abdomen (arrow) and multiple nodular opacities in the bilateral lungs (arrowheads). (B) A CT scan shows a gas-forming liver abscess (arrow) and a peripheral wedge-shaped opacity abutting the adjacent pleura (arrow). (C) A lung window of a cross-sectional CT scan shows two peripheral wedge-shaped opacities abutting the adjacent pleura (arrows) and a peripheral nodule with a feeding vessel (arrowhead). The patient was a 61-year-old diabetic woman whose blood and aspirate abscess cultures were positive for Klebsiella pneumoniae.

Figure 2

Necrotizing pneumonia with septic pulmonary emboli. (A) A lung window of a coronal-sectional CT scan shows necrotizing pneumonia in the right lung. Multiple different sizes of nodules with cavities in the left upper lobe (arrows), suggestive of septic pulmonary emboli, are observed. (B) A lung window of a cross-sectional CT scan shows necrotizing pneumonia in the right upper lobe and a cavitary nodule in the left upper lobe (arrows). (C) A peripheral wedge-shaped opacity abutting the adjacent pleura in the right lower lobe (arrow) and pleural effusion are seen. The patient was a 62-year-old diabetic woman whose blood and sputum cultures were positive for methicillin-resistant Staphylococcus aureus.

Figure 3

Tricuspid valve infective endocarditis with septic pulmonary emboli. (A) A chest radiograph shows multiple peripheral patchy opacities in the bilateral lungs (arrowheads). (B) A lung window of a coronal CT scan shows multiple peripheral wedge-shaped opacities (arrowheads). (C) A lung window of a cross-sectional CT scan shows a ground-glass opacity in the right upper lobe (arrow) and a nodule with cavity in the left upper lobe (arrowhead). (D) A peripheral wedge-shaped opacity with central necrosis in the right lower lobe (arrowhead) and a peripheral wedge-shaped opacity without central necrosis in the left lower lobe (arrowhead). The patient was a 50-year-old woman whose blood cultures were positive for methicillin-susceptible Staphylococcus aureus.

Figure 4

Renal abscesses with septic pulmonary emboli. (A) A lung window of a cross-sectional CT scan shows a lung abscess with a diameter of 4.5 cm in the right lower lobe (arrow). (B) A contrast-enhanced CT scan (mediastinum window) in the same image plane shows a lung abscess (arrow) with a feeding vessel sign (arrowhead). (C) A lung window of a cross-sectional CT scan shows two nodules with cavities in the left upper lobe (arrowheads). (D) An abdominal CT scan shows left renal abscesses (arrows). The patient was a 52-year-old woman whose blood cultures were positive for Escherichia coli.