JAP Volume 7 Issue 1 Case Report
Sepsis, drugs and SPE
Intravenous drug abuse is a global issue with increased risk of premature deaths. Shyju Paremal, Kumud Bhattarai, Sanjay Dashpande andOliver Schulte describe a case of chronic usage of superficial, deep and central veins, laeding to life-threatening septic vein thrombosis and more serious septic embolism.
Case report We present a case of a 38-year-old woman who was admitted to
ITU with a two-day history of general malaise, shortness of breath, productive cough with purulent sputum, right upper quadrant abdominal pain and jaundice. Surgeons ruled out an acute abdomen and referred the patient to the physicians. The patient has been an intravenous (IV) drug user since the age of 13. She was on methadone detoxification programme, and also was abusing alcohol. On assessment, she was pyrexial, jaundiced, looked unwell and was clinically septic. On examination, her heart sounds were normal, but harsh breath
sounds throughout her lung fields. There was dullness on percussion and reduced air entry in the right base. Abdominal examination revealed tender right upper quadrant with guarding. Her right leg was swollen, and a discharging sinus in the right groin was noted. Blood tests revealed normal WCC, remarkably low platelets
(6x109/l) normal U&E, elevated C-reactive protein (CRP) (174mgL), and normal amylase. Her liver function test (LFT) showed ALT 35U/L, ALP 89U/L, and a bilirubin of 63mmol/L. Her chest x-ray on admission showed bilateral patchy consolidation predominantly on the right side. Her abdominal ultrasound scan was normal. Ultrasound scan of her right groin showed extensive thrombosis of her common femoral vein with no evidence of collection or abscess around the sinus. Both her trans-thoracic and trans-oesophageal echocardiograms were normal with no evidence of infective endocarditis. She was diagnosed with septic shock secondary to right basal
pneumonia, which was treated with IV Metronidazole and Linezolid. Her condition deteriorated, eventually requiring intubation, ventilation and inotropic support. The helical computed tomography (CT) scan of her chest and
abdomen post IV contrast showed varying degrees of cavitations in both lungs with ‘feeding vessels’ suggestive of septic embolism. The scan also reported bilateral areas of diffuse alveolar ground glass opacity, bilateral pleural effusions and segmental collapse and consolidations of lower lobes (see Figure 1). The abdominal CT scan showed a thrombosis of the right common
femoral vein, the external and common iliac vein, which extended into the mid IVC (see Figure 2). Blood culture and sensitivity showed growth of Corynebacterium
sp, Bacterioides, Eggerthella lenta and Diphtheroids. Staphylococcus aureus, Candida albicans, and Candida krusei were grown from her tracheal aspirate. Following all the above investigations, she was diagnosed with
septic pulmonary emboli originating from an infected deep vein thrombosis (DVT). She was treated with appropriate antibiotics and anticoagulation. The case was discussed with the vascular surgeons for
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consideration of insertion of an IVC filter to prevent further pulmonary emboli. Their opinion was that neither IVC filter insertion nor an embolectomy was necessary at this stage as the thrombus looked stable. However, should any further thrombo-embolic event occur in the future then an IVC filter should be considered but only once the infection was controlled. The patient recovered and was discharged from ITU after 28 days and was subsequently discharged from hospital with six months of anticoagulation. The patient had repeat Computed Tomography Pulmonary Angiogram (CTPA) ten months after the initial presentation in October 2008, and this showed complete resolution of lung changes.
Discussion In IV drug users superficial and deep veins get thrombosed
secondary to trauma and local infection caused by repeated venepuncture. The irritant nature of drugs and additives can also contribute to thrombophlebitis.3-6 Factors favouring DVT to become septic are additives, use
of unsterile needles, the sharing of equipment and lack of skin antisepsis.7-9
Saliva is sometimes used to clean the skin or dilute
drugs. The pathogens from both the oral flora and the skin can contribute to the development of sepsis in these cases. Clinical diagnosis of septic thrombophlebitis is by local signs of
thrombosis such as swelling and erythema. Radiological investigation will confirm the presence of DVT and distant emboli. Imaging studies are imperative to rule out thrombosis of deep veins, though they cannot distinguish between septic and non-septic thrombophlebitis.10 The use of Doppler ultra sonography or contrast enhanced CT scan to diagnose DVT is of benefit.1 Septic pulmonary embolism (SPE) is a rare disorder with clinical
manifestation of fever and respiratory symptoms associated with lung infiltrates. In SPE, the embolic blood clot in pulmonary arteries causes pulmonary infarction and subsequently large lung abscesses. The lesions may extend to pleura, causing empyema, bronchopleural fistula and sometimes pneumothorax.11 In SPE, clinical and radiological features at presentation are usually
non-specific and the diagnosis is delayed. Usually SPE is associated with tricuspid valve endocarditis, septic thrombophlebitis or infected central lines. Chest x-ray in SPE is non-specific. CTPA is useful in diagnosing pulmonary embolism and differentiating alternative diagnoses.12
In
a chest x-ray, the emboli may present as small, scattered areas of consolidation simulating bronchopneumonia, or as round wedge- shaped peripheral opacities. CTPA may show multiple peripheral nodules with clearly identifiable ‘feeding vessels’ in-keeping with haematogenous spread. CTPA also may show evidence of necrosis, or peripheral wedge-shaped lesions adjoining the pleura. Once an
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