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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
Case of the Month
Clinical Profile:
Clinical Profile:
A 13 year old boy came with swelling and tenderness in the left knee. On examination, there was local warmth and redness. He was diagnosed to have septic arthritis. A few days later, he developed breathlessness and fever.
A 13 year old boy came with swelling and tenderness in the left knee. On examination, there was local warmth and redness. He was diagnosed to have septic arthritis. A few days later, he developed breathlessness and fever.
A chest radiograph was obtained.
A chest radiograph was obtained.
Radiological Investigations:
Radiological Investigations:
There are ill defined patchy consolidations in both lung fields , predominantly along the lung periphery, few of them showing nodule formation.
Ten days later there are nodular opacities seen in both lung fields with few of them showing lucencies within and few of them showing thin walled cyst formation.
CT chest: multiple, peripherally located cavitating nodules are scattered throughout both lung fields. A few of them show a feeding vessel within.
Radiological Diagnosis:
Radiological Diagnosis:
Chest radiographs show peripheral, opacities - predominantly in the lower lobes.
Chest radiographs show peripheral, opacities - predominantly in the lower lobes.
There are bilateral nodular soft tissue densities in varying stages of cavitation. There are pleural effusions.
There are bilateral nodular soft tissue densities in varying stages of cavitation. There are pleural effusions.
CT Scan: shows feeding vessel sign - Peripheral nodules with clearly identifiable feeding vessels.
CT Scan: shows feeding vessel sign - Peripheral nodules with clearly identifiable feeding vessels.
Subpleural nodular lesions or wedge shaped densities with or without necrosis due to septic infarcts. These have dependent lower zone predilection.
Subpleural nodular lesions or wedge shaped densities with or without necrosis due to septic infarcts. These have dependent lower zone predilection.
Pathological examination:
Pathological examination:
Blood culture of the patient showed Acinetobacter.
Blood culture of the patient showed Acinetobacter.
Further clinical course:
Further clinical course:
The patient developed profound septicemia leading to in septic shock with multi organ failure. He succumbed to it.
The patient developed profound septicemia leading to in septic shock with multi organ failure. He succumbed to it.
Discussion:
Discussion:
Septic pulmonary emboli occur due to the hematogenous dissemination of thrombi containing microorganisms into the lungs.
Septic pulmonary emboli occur due to the hematogenous dissemination of thrombi containing microorganisms into the lungs.
Usually an extrapulmonary infective focus is found which include-
Usually an extrapulmonary infective focus is found which include-
✓Infected DVT.
✓Infected DVT.
✓Infected catheters/lines
✓Infected catheters/lines
✓Periodontal disease
✓Periodontal disease
✓Immunodeficiency
✓Immunodeficiency
✓Right sided infective endocarditis
✓Right sided infective endocarditis
The recognised complications include:
The recognised complications include:
•Empyema formation.
•Empyema formation.
•Pneumothorax formation.
•Pneumothorax formation.
The differential diagnosis include:
The differential diagnosis include:
1. Septic pulmonary emboli.
1. Septic pulmonary emboli.
2. Malignancy- primary or metastasis
2. Malignancy- primary or metastasis
3. Infection:
3. Infection:
➢Tb
➢Tb
➢Round pneumonia
➢Round pneumonia
➢Hydatid cyst
➢Hydatid cyst
➢Abscess
➢Abscess
4. Benign etiologies:
4. Benign etiologies:
➢Wegener's granulomatosis
➢Wegener's granulomatosis
➢Pulmonary hamartoma
➢Pulmonary hamartoma
➢Pulmonary AVM
➢Pulmonary AVM
➢Rheumatoid nodule
➢Rheumatoid nodule
➢Bronchogenic cyst
➢Bronchogenic cyst
References:
References:
1. Jaffe RB, Koschmann EB. Septic pulmonary emboli. Radiology. 1970;96 (3): 527-32. Radiology (abstract) - doi:10.1148/96.3.527 - Pubmed citation
1. Jaffe RB, Koschmann EB. Septic pulmonary emboli. Radiology. 1970;96 (3): 527-32. Radiology (abstract) - doi:10.1148/96.3.527 - Pubmed citation
2. Wong KS, Lin TY, Huang YC et-al. Clinical and radiographic spectrum of septic pulmonary embolism. Arch. Dis. Child. 2002;87 (4): 312-5. Arch. Dis. Child. (full text) - doi:10.1136/adc.87.4.312 - Free text at pubmed - Pubmed citation
2. Wong KS, Lin TY, Huang YC et-al. Clinical and radiographic spectrum of septic pulmonary embolism. Arch. Dis. Child. 2002;87 (4): 312-5. Arch. Dis. Child. (full text) - doi:10.1136/adc.87.4.312 - Free text at pubmed - Pubmed citation
3. Huang RM, Naidich DP, Lubat E et-al. Septic pulmonary emboli: CT-radiographic correlation. AJR Am J Roentgenol. 1989;153 (1): 41-5. doi:10.2214/ajr.153.1.41 - Pubmed citation
3. Huang RM, Naidich DP, Lubat E et-al. Septic pulmonary emboli: CT-radiographic correlation. AJR Am J Roentgenol. 1989;153 (1): 41-5. doi:10.2214/ajr.153.1.41 - Pubmed citation
4. Zelefsky MN, Lutzker LG. The target sign: a new radiologic sign of septic pulmonary emboli. AJR Am J Roentgenol. 1977;129 (3): 453-5. doi:10.2214/ajr.129.3.453 - Pubmed citation
4. Zelefsky MN, Lutzker LG. The target sign: a new radiologic sign of septic pulmonary emboli. AJR Am J Roentgenol. 1977;129 (3): 453-5. doi:10.2214/ajr.129.3.453 - Pubmed citation
5. Engelke C, Schaefer-Prokop C, Schirg E et-al. High-resolution CT and CT angiography of peripheral pulmonary vascular disorders. Radiographics. 2002;22 (4): 739-64. Radiographics (full text) - Pubmed citation
5. Engelke C, Schaefer-Prokop C, Schirg E et-al. High-resolution CT and CT angiography of peripheral pulmonary vascular disorders. Radiographics. 2002;22 (4): 739-64. Radiographics (full text) - Pubmed citation
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