|Year : 2015 | Volume
| Issue : 2 | Page : 296-298
An unusual source of septic pulmonary embolism: Perianal abscess in an immunocompetent patient
Ved Prakash1, Ajay Kumar Verma1, Ankit Bhatia1, Virendra Kumar2, Surya Kant1, Karthik Nagaraju1
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 Publication||16-Dec-2015|
Department of Pulmonary Medicine, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
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 Oct 15];3:296-8. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/296/171929
| Introduction|| |
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|| |
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
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|| |
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. 
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. 
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. ,
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. ,, Radiographic picture also includes the feeding vessel sign-peripheral nodules with clearly identifiable feeding vessels seen in lung abscesses. 
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|| |
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.
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.
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.
Mattar CS, Keith RL, Byrd RP Jr, Roy TM. Septic pulmonary emboli due to periodontal disease. Respir Med 2006;100:1470-4.
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.
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.
Kuhlman JE, Fishman EK, Teigen C. Pulmonary septic emboli: Diagnosis with CT. Radiology 1990;174:211-3.
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.
[Figure 1], [Figure 2], [Figure 3]