United States Air Force, Beavercreek, OH
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Fellow Case Report Slide: Venous Thromboembolic Disease
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Tuesday, October 25, 2016 at 04:30 PM - 05:30 PM
INTRODUCTION: Pulmonary infarction is an infrequent complication of pulmonary embolism due to the dual blood supply of the lung. We describe a rare case of acute pulmonary embolism with pulmonary infarction leading to cavitation and subsequent abscess formation requiring left lower lobe resection.
CASE PRESENTATION: A 62 year-old male presented to the emergency department with chest pain and dyspnea. CTPA revealed acute pulmonary emboli within the left lower lobe segmental and subsegmental pulmonary arteries. Intravenous heparin and warfarin therapy were initiated. The patient was discharged in good condition however the patient returned 3 weeks later with a severe cough. CXR showed interval development of a left lower lobe consolidation with a large left-sided pleural effusion. CTPA demonstrated a large cavitary lesion of the left lower lobe with an air-fluid level and a loculated pleural fluid collection. A pulmonary embolus was still evident in the segmental pulmonary artery of posterior-basilar segment of the left lower lobe. The patient was started on intravenous antibiotics prior to the placement of a percutaneous drain into the lung abscess. The patient underwent a left thoracotomy and lysis of adhesions with resection of the left lower lobe. The entire left lower lobe was an abscess cavity containing copious amounts of purulent material. The procedure was tolerated well and he was transitioned to PO antibiotics. Cultures obtained from the percutaneous drain and surgical pathology did not exhibit growth of any organism.
DISCUSSION: Autopsy studies have revealed cavitation in 4-5% of all pulmonary infarctions. Pulmonary infarction with subsequent cavitation and abscess formation is a very rare complication of pulmonary embolism. Only a few case reports exist in the literature and major pulmonary textbooks do not describe this possible catastrophic consequence in chapters pertaining to pulmonary embolism. The frequency of secondary abscess formation is unclear and there is no available data to support the use of prophylactic antibiotics.
CONCLUSIONS: Clinicians should be aware of pulmonary cavitation following pulmonary infarction and the risk of secondary bacterial infections, which carry a high mortality rate and may require surgical intervention.
Reference #1: Rajagopala SR, Devaraj UM, D'Souza GE. Infected Cavitating Pulmonary Infarction. Respiratory Care. 2011; 56 (5): 707-709
Reference #2: Libby LS, King TE, LaForce FM, Schwarz MI. Pulmonary cavitation following pulmonary infarction. Medicine (Baltimore). 1985 Sep; 64(5):342-8
DISCLOSURE: The following authors have nothing to disclose: Matt Koroscil, Timothy Hauser
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