Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contact us Login 
  • Users Online:1432
  • Home
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 296-298

An unusual source of septic pulmonary embolism: Perianal abscess in an immunocompetent patient


1 Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Medicine, Mahamaya Rajkiya Allopathic Medical College, Dr. Ram Manohar Lohia Avadh University, Ambedkar Nagar, Faizabad, Uttar Pradesh, India

Date of Web Publication16-Dec-2015

Correspondence Address:
Surya Kant
Department of Pulmonary Medicine, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.171929

Rights and Permissions
  Abstract 

Septic pulmonary embolism (SPE) is a rare clinical presentation mostly seen in patients who are immunocompromised, in which septic thrombi from an infectious nidus are transported in the vascular system of the lungs. We report a patient presenting with features of sepsis and respiratory distress; chest X-ray and computed tomography (CT) thorax of whom showed multiple bilateral small thick-walled cavities associated with right pleural effusion. He was found to have a septic source of Enterococcus sp. cultured from a perianal abscess with the same bacteremia. Pulmonary septic embolism from the abscess was diagnosed by radiology and correlation of bacteremia from septic foci and blood culture. The clinical condition improved with surgical management of the perianal abscess and appropriate antibiotic treatment.

Keywords: Abscess, embolism, perianal, septic


How to cite this article:
Prakash V, Verma AK, Bhatia A, Kumar V, Kant S, Nagaraju K. An unusual source of septic pulmonary embolism: Perianal abscess in an immunocompetent patient. Arch Med Health Sci 2015;3:296-8

How to cite this URL:
Prakash V, Verma AK, Bhatia A, Kumar V, Kant S, Nagaraju K. An unusual source of septic pulmonary embolism: Perianal abscess in an immunocompetent patient. Arch Med Health Sci [serial online] 2015 [cited 2019 Jun 20];3:296-8. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/296/171929


  Introduction Top


Septic emboli is a rare clinical entity, commonly undiagnosed, mostly seen in patients who are immunocompromised as a result of infections that typically originate from an extrapulmonary source. Clinicoradiological characteristics at presentation are usually non-specific, and the diagnosis of this disorder is usually delayed.

We present an unusual cause of septic pulmonary embolism (SPE) from perianal abscess which resolved after successful treatment of the infective focus.


  Case Report Top


A 40-year-old, non-diabetic male farmer, presented with high-grade continuous fever, right-sided chest pain, and respiratory distress for past 5 days. There was no history of trauma, recent travel, or history of drug abuse. No immunodeficiency condition was noted after the admission to hospital investigation, including a negative human immunodeficiency virus (HIV) test. At presentation, the patient was febrile, blood pressure was 90/54 mmHg, respiratory rate was 30 breaths per minute, and pulse was 114 beats per minute. Arterial blood gas (ABG) findings were: pH 7.44: pO 2:43 mm Hg, pCO2 46 mm Hg, SO2 82%, HCO3:31 mmHg. On respiratory examination, bilateral crepitations were heard. Other system examinations were normal. On thorough clinical examination, we found a carbuncle on his left buttock which was tender, hard with pus discharge. His white blood count was 26800/mm 3 . Chest radiography [Figure 1] showed multiple ill-defined cavitatory lesions over the bilateral lung field with right sided pleural effusion. Chest CT [Figure 2] revealed multiple small thick-walled cavities with adjacent fibrosis in bilateral lung fields associated with right pleural effusion. Pleural effusion was tapped which was exudative with predominant neutrophils. Echocardiography did not demonstrate any vegetation on cardiac valves. After conducting a thorough examination, no other infectious sources were found except for perianal abscess [Figure 3].
Figure 1: Multiple ill-defined cavitatory lesions over the bilateral lung field with right sided pleural effusion

Click here to view
Figure 2: Multiple small thick walled cavities with adjacent fi brosis in bilateral lung fields associated with right pleural effusion suggestive of septic emboli. Feeding vessel shown by a white arrow

Click here to view
Figure 3: Perianal abscess drained surgically

Click here to view


Surgical reference was sought for the abscess which was then incised and drained. The pus sent for culture revealed growth of enterococcus sensitive to vancomycin.

After 3 weeks of vancomycin treatment, the patient showed significant clinical improvement as well as the septic pulmonary lesion on chest radiography. After 3 months of follow-up, the patient did not suffer a recurrence of the previous infection.


  Discussion Top


SPE is an uncommon but important disorder in which a thrombus containing micro-organisms in a fibrin matrix are mobilized from an infectious area and transported in the venous system to implant in the vascular system of the lungs. [1]

Diagnosis of septic embolism is not easy as both clinical picture and radiological features are not characteristic. Usual symptoms and signs include a septic course, dyspnea, cough pleuritic pain, and hemoptysis.

Our case is an unusual one and it showed a very rare presentation of septic emboli associated with a perianal abscess as very few cases have been reported in literature. [2]

Septic emboli can originate from varying sources - tricuspid valve endocarditis; skin, soft tissue infections with associated septal defects; infected deep venous thrombosis; immunologic deficiencies; infected catheters - lines, pacemaker wires; post anginal septicemia; and peri-odontal disease. [3],[4]

CT thorax plays an important role in the diagnosis of pulmonary septic embolism. High-resolution computed tomography (HRCT) features include subpleural nodular lesions or wedge-shaped densities (usually range between 5-35 mm) with or without necrosis caused by septic infarcts, with a predilection for dependent, lower zone. [5],[6],[7] Radiographic picture also includes the feeding vessel sign-peripheral nodules with clearly identifiable feeding vessels seen in lung abscesses. [8]

The diagnosis rests on clinical suspicion along with radiological findings coupled with evidence of a septic focus elsewhere in the body. Investigating the septic foci and isolating the micro-organism is an important step in the commencement of treatment in these patients.

Establishing the diagnosis and the relationship between septic foci (perianal abscess) and pulmonary septic embolism is difficult; however, we had strong evidence that both the abscess and blood culture grew the same pathogen of Enterococcus.

 
  References Top

1.
Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respir Med 2014;108:1-8.  Back to cited text no. 1
    
2.
Chang E, Lee KH, Yang KY, Lee YC, Perng RP. Septic pulmonary embolism associated with a peri-proctal abscess in an immunocompetent host. BMJ Case Rep 2009;2009.  Back to cited text no. 2
    
3.
Engelke C, Schaefer-Prokop C, Schirg E, Freihorst J, Grubnic S, Prokop M. High-resolution CT and CT angiography of peripheral pulmonary vascular disorders. Radiographics 2002;22:739-64.  Back to cited text no. 3
    
4.
Mattar CS, Keith RL, Byrd RP Jr, Roy TM. Septic pulmonary emboli due to periodontal disease. Respir Med 2006;100:1470-4.  Back to cited text no. 4
    
5.
Wong KS, Lin TY, Huang YC, Hsia SH, Yang PH, Chu SM. Clinical and radiographic spectrum of septic pulmonary embolism. Arch Dis Child 2002;87:312-5.  Back to cited text no. 5
    
6.
Huang RM, Naidich DP, Lubat E, Schinella R, Garay SM, McCauley DI. Septic pulmonary emboli: CT-radiographic correlation. AJR Am J Roentgenol 1989;153:41-5.  Back to cited text no. 6
    
7.
Kuhlman JE, Fishman EK, Teigen C. Pulmonary septic emboli: Diagnosis with CT. Radiology 1990;174:211-3.  Back to cited text no. 7
    
8.
Dodd JD, Souza CA, Müller NL. High-resolution MDCT of pulmonary septic embolism: Evaluation of the feeding vessel sign. AJR Am J Roentgenol 2006;187:623-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed1462    
    Printed19    
    Emailed0    
    PDF Downloaded93    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]