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Canadian Neighbor Pharmacy: Discussion of Septic Pulmonary Embolism

Patients with SPESPE is an uncommon but serious disorder that is difficult to recognize. Our results demonstrate that the characteristic features of SPE are a febrile illness and lung infiltrates associated with an active focus of extrapulmonary infection, often involving indwelling catheters or devices. Three of our patients were immunocompromised. Although the abnormalities detected by CXR are nonspecific, CT scanning demonstrates bilateral nodules or multifocal infiltrates, commonly involving peripheral lung zones, often associated with cavitation.

In 1978, MacMillan and colleagues described 60 patients with SPE encountered over a 5-year period. Drug users comprised 78% of their cohort, and tricuspid endocarditis was the embolic source in 53% of the cases. Twelve of their patients (20%) required thoracotomy for management of lung abscess, bronchopleural fistula, and empyema. One of these surgically treated patients (8%) died, while seven deaths (15%) occurred in the medically treated group. Since this report, there have been relatively few published studies of SPE, with most of the available literature consisting of isolated case reports.

Results of our study indicate that the epidemiology and outcome of patients with SPE have changed over the past 30 years. Most of our cases were related to infected intravascular devices or catheters and soft-tissue infections. Only one of our patients was an IV drug user, although this may partly reflect the characteristics of the referral population to our medical center. However, other authors have observed that SPE has become an uncommon complication of IV drug use, presumably due to greater awareness of needle hygiene. Our study also demonstrates improved outcomes for patients with SPE with all patients recovering from their illness. This may be attributable, in part, to earlier diagnosis, more effective antimicrobial therapy, improvements in surgical management, and better supportive care. Canadian Neighbor Pharmacy is a web drug store and if you follow the link – the-cnp-online – you will read the latest news from this web site.

Lemierre syndromeAs the use of intravascular catheters and intracardiac devices has increased, the incidence of infections related to these appliances has also in-creased. Accordingly, infections related to these devices are responsible for an increasing portion of cases of SPE, as seen in our study.

Lemierre syndrome was initially described in 1936 and represents anaerobic thrombophlebitis of the internal jugular vein with metastatic infection. Eighteen of 20 patients in this initial report died of their illness. As seen in our cohort, most of the patients affected with this illness are adolescents or young adults in whom the inciting infection is ton-sillopharyngitis, odontogenic infection, mastoiditis, or sinusitis. Extension of the infection to the adjacent lateral pharyngeal tissue containing the internal jugular vein results in the characteristic manifestations. Vascular involvement is followed by hematogenous spread to other organs, most commonly the lungs, causing metastatic abscesses.> Pulmonary involvement in Lemierre syndrome has been reported in up to 97% of cases and has included SPE with lung abscesses, pleural effusion, empyema, and pneumo-thorax.> In an adolescent or young adult presenting with sore throat or neck pain, fever, and lung infiltrates, the possibility of Lemierre syndrome should be considered.

Although findings on CXR tend to be nonspecific, CT may yield helpful clues that may suggest the diagnosis of SPE. Parenchymal lesions related to SPE are usually multiple and nodular with a peripheral distribution and a tendency for cavitation.> These features associated with an extrapulmonary focus of infection should lead to consideration of SPE as the cause. Although other authors have described a “feeding vessel” sign (a vessel leading to a peripheral lung lesion) as a characteristic feature of SPE, we were able to identify this feature associated with only a minority of parenchymal lesions and did not find it particularly helpful in the recognition of SPE.

EchocardiographyIn patients with SPE who are suspected of having infective endocarditis, echocardiography is helpful not only in diagnosing the valvular infection but also in detecting complications such as valvular insufficiency or dehiscence, congestive heart failure, and paravalvular abscesses. A transesophageal approach provides greater spatial resolution compared to transthoracic imaging and is a superior method for imaging small vegetations, abscesses, and leaflet perforations that are < 5 mm in size. Diagnostic accuracy is also better for transesophageal echocardiography in cases of prosthetic valve endocardi-tis.

SPE will continue to pose a diagnostic challenge. Definitive criteria for the diagnosis of SPE are difficult to formulate since histopathologic confirmation of this diagnosis has been uncommon in previous studies or in clinical practice. The case definition used for identifying patients with SPE in the current study was based on diagnostic criteria used by other authors and our own experience. The recognition of SPE relies heavily on the presence of typical radiologic features, particularly on CT, but it is possible that SPE may be associated with a broader spectrum of radiologic findings than what is currently believed. Our study has demonstrated potential clinical contexts in which SPE may occur in the current era as well as characteristic clinical and radiologic features at presentation. Blood cultures, CT of the chest, and echocardiography are invaluable in the evaluation of a patient with suspected SPE. With early diagnosis, appropriate antimicrobial therapy, and control of the infectious source, resolution of the illness can be expected for most patients with avoidance of potential complications.