AJTCCM VOL. 30 NO. 2 2024 67
CORRESPONDENCE: CASES
To the editor: Septic pulmonary embolism (SPE) occurs when
septic material aggregates in the pulmonary circulation from an
extrapulmonary infective focus, resulting in substantial clinical
symptoms. e common sources of SPE include skin and so-tissue
infection, intravascular catheters, infective endocarditis, liver or
kidney abscess, septic thrombophlebitis, Lemierre’s syndrome, use of
intravenous drugs, and periodontal infection.
A 25-year-old man, HIV negative and a self-reported
methamphetamine (tik) and methaqualone (Mandrax) user, with no
medical history, was referred to our emergency department by his
primary care doctor because of swelling and erythema of the little
nger of his le hand for 5 days before presentation.
On examination, he was conscious and febrile, appeared toxic with
a heart rate of 119 bpm, and was normotensive (blood pressure 120/70
mmHg) with a respiratory rate of 28/min and oxygen saturation
of96%. Arterial blood gas analysis (room air) showed arterial partial
pressure of oxygen 10 kPa, partial pressure of carbon dioxide 5.37
kPa, oxygensaturation 94.8% and pH 7.406. e chest had bilateral
crepitations. On local examination, there was severe paronychia with
dorsal tissue necrosis, erythema, and oedema up to the 7th extensor
compartment of the dorsum of the hand. e sensation of the nger
pulp remained intact.
Laboratory investigations revealed haemoglobin 15 g/dL, total
leucocyte count 18.8 × 109/L (neutrophils 38%), C-reactive protein
131 mg/L, serum sodium 129 mmol/L and serum potassium 5.1
mmol/L. e results of liver and kidney function tests were normal.
Wound and blood cultures grewStaphylococcus aureus. No growth
was seen on tracheal and urine cultures.
Imaging of the hand showed soft-tissue swelling with a subtle
periosteal reaction (Fig. 1A).
The patient was taken to theatre for surgical debridement under
regional anaesthesia with a Bier block, and deep tissue samples were
taken and sent for microbiological testing. Based on culture sensitivity,
intravenous cloxacillin 2 g 6-hourly was commenced immediately,
and the wound was allowed to heal by secondary intention with
appropriate dressings. However, he continued to have spikes of high-
grade fever with rigors and complained of pleuritic chest pain and
minor haemoptysis.
A chest radiograph (Fig. 1B) showed multiple nodules, some
of which were cavitating. At this stage, both community-acquired
pneumonia and cavitating malignancy were in the differential
diagnosis, together with COVID-19 pneumonia, as it was during the
height of the COVID-19 pandemic. An abdominal ultrasound scan
ruled out any abdominal sources of sepsis or underlying malignancy.
Computed tomography (CT) pulmonary angiography (Fig. 1C)
revealed innumerable bilateral randomly distributed, well-dened
and variably sized cavitary nodular lesions in keeping with SPE. ere
were no radiological or laboratory ndings of COVID-19. Findings
on echocardiography were normal with no features of infective
endocarditis. e patient continued to receive intravenous cloxacillin
and supportive care in the surgical ward for 2 more weeks and was
discharged aer a total stay of 4 weeks. His progress was satisfactory
on follow-up in the outpatient department.
SPE is an uncommon form of lung disease that develops when a
thrombus containing micro-organisms embolises into the veins,
circulates to the heart and lodges in the pulmonary arteries, causing
infection, infarction, and bilateral nodules and/or cavities in the lung
parenchyma.[1] Insidious onset of fever, shortness of breath, cough,
haemoptysis, and chest pain associated with pulmonary inltrates are
the most common clinical presentations of patients with SPE.[2]
A case of septic pulmonary embolism associated with hand sepsis
in an immunocompetent host
A B C
Fig. 1. (A) Frontal radiograph of the hand demonstrating subtle irregularity of the medial cortex, periosteal reaction and so-tissue swelling around
the distal phalange of the le little nger. ere is no associated joint eusion, foreign body or fracture. (B) Frontal chest radiograph showing
innumerable cavitary pulmonary lesions with no zonal predilection. (C) Axial computed tomography scan of the chest in lung window conrms
multiple air- and uid-lled cavitary lesions randomly distributed within the pulmonary parenchyma.
68 AJTCCM VOL. 30 NO. 2 2024
CORRESPONDENCE: CASES
Depending on the embolic source, SPE can be classied as cardiac,
peripheral endogenous or exogenous,each manifesting in dierent
epidemiological and clinical ways.[3] e most common causative
organisms of SPE are methicillin-susceptible S. aureus (32%),
methicillin-resistantS. aureus(18%), fusobacteria (7%), Klebsiella
(7%) and Candida (4%) species, andStreptococcus viridans(3%).[4]
SPE has a high mortality rate and remains a diagnostic challenge in
clinical practice because of its nonspecic clinical manifestations and
life-threatening complications.[3]
e diagnosis of SPE is usually suggested by the presence of a
predisposing factor, febrile illness, and CT findings of multiple
randomly distributed nodular lung infiltrates, with or without
cavitation. e feeding vessel sign on the CT chest scan is highly
suggestive and has been reported in both uncomplicated pulmonary
emboli and pulmonary metastases, and simply indicates the
haematogenous origin of the parenchymal nodule.[5] Our patient
had a febrile illness and an extrapulmonary source of infection, and
S. aureus was isolated both from the wound and on blood culture,
making SPE the main consideration in the dierential diagnosis of
cavitating pulmonary nodules. e presence of S. aureus bacteraemia
is consistent with previous findings in a South African study by
Meel and Essop,[6] which showed that S. aureus is the most common
organism isolated. Interestingly, they highlighted that SPE was
common in intravenous recreational drug users, although our patient
smoked drugs rather than injecting intravenously. Echocardiography
is an important diagnostic modality to exclude infective endocarditis
in patients with S. aureus bacteraemia, as in our case, because infective
endocarditis is one of the major causes of SPE.
Management of SPE comprises prompt administration of
appropriate antibiotic therapy for 4 - 6 weeks and control of infectious
sources, along with surgical debridement and supportive care.[1]
In conclusion, an early diagnosis of SPE is the key to improving
patient outcomes, and clinicians should be aware of radiological
ndings in SPE, which serve as an invaluable diagnostic tool.
T Zobair, MB ChB, MD, Cert Pulmonology (SA), MPhil (Pulm)
Division of Pulmonology, Faculty of Health Sciences, University of
Cape Town and Groote Schuur Hospital, Cape Town, South Africa
dr.tarig@hotmail.com
I Sihlahla, MB ChB, MMed (Rad), FC Rad (SA)
Division of Radiology, Faculty of Health Sciences, University of Cape
Town and Groote Schuur Hospital, Cape Town, South Africa
D B Arnolds, MB ChB, MMed (Orth), FCS Orth (SA)
Division of Orthopaedic Surgery, Faculty of Health Sciences,
University of Cape Town and Groote Schuur Hospital, Cape Town,
South Africa
R I Raine, MB ChB, MMed (Med), FCP (SA)
Division of Pulmonology, Faculty of Health Sciences, University of
Cape Town and Groote Schuur Hospital, Cape Town, South Africa
G Calligaro, BSc Hons (Phys), MB ChB, FCP (SA), MMed (Med),
Cert Pulmonology (SA)
Division of Pulmonology, Faculty of Health Sciences, University of
Cape Town and Groote Schuur Hospital, Cape Town, South Africa
1. Cook RJ, Ashton RW, Aughenbaugh GL, Ryu JH. Septic pulmonary embolism:
Presenting features and clinical course of 14 patients. Chest 2005;128(1):162-166.
https://doi.org/10.1378/chest.128.1.162
2. Jiang J, Liang Q-L, Liu L-H, et al. Septic pulmonary embolism in China: Clinical
features and analysis of prognostic factors for mortality in 98 cases. BMC Infect Dis
2019;19(1):1082. https://doi.org/10.1186/s12879-019-4672-1
3. MacMillan JC, Milstein SH, Samson PC. Clinical spectrum of septic pulmonary
embolism and infarction. J orac Cardiovasc Surg 1978;75(5):670-678.
4. Ye R, Zhao L, Wang C, et al. Clinical characteristics of septic pulmonary embolism in
adults: A systematic review. Respir Med 2014;108(1):1-8. https://doi.org/10.1016/j.
rmed.2013.10.012
5. Kuhlman JE, Fishman EK, Teigen C. Pulmonary septic emboli: Diagnosis
with CT. Radiology 1990;174(1):211-213. https://doi.org/10.1148/
radiology.174.1.2294550
6. Meel R, Essop MR. Striking increase in the incidence of infective endocarditis
associated with recreational drug abuse in urban South Africa. S Afr Med J
2018;108(7):585-589. https://doi.org/10.7196/SAMJ.2018.v108i7.13007
Received 23 April 2023. Accepted 25 March 2024. Published 4 July 2024.
Afr J Thoracic Crit Care Med 2024;30(2):e1014. https://doi.
org/10.7196/AJTCCM.2024.v30i2.1014
