**26. Clinical features**

The clinical features of SPE are non-specific and patients generally present with a febrile illness, cough, hemoptysis, dyspnea and pleuritic chest pain. Diffuse cavitary lung nodules and infiltrates associated with an active focus of extra-pulmonary infection should clue the

Non-Thrombotic Pulmonary Embolism 89

Clinical and radiological features at presentation are usually nonspecific and the diagnosis is frequently delayed (Huang et al., 1989). Radiographic findings, predisposing background or illness, and clinical evidence of infection usually are clues to the diagnosis. Blood cultures, chest CT and echocardiography are valuable when evaluating a patient with suspected SPE. Basic laboratory testing provides some clues to diagnosis. Patients typically have a neutrophil predominant leucocytosis. Liver function tests are abnormal in approximately

Microbiology: The diagnosis of bacteremia or fungemia is confirmed by recovery of the same species of micro-organisms from the peripheral blood cultures and from quantitative cultures obtained from the source of SPE. Pus drained from any site should be sent for culture, including catheter tip, localized abscesses in the neck, empyema, septic arthritis,

Chest radiograph findings are usually nonspecific with a spectrum of radiological abnormalities. The usual findings include patchy air space opacities simulating nonspecific broncho-pneumonia, multiple ill-defined nodules (usually 1-3 cm) in various stages of cavitation with irregular thick walls or wedge-shaped densities of varying sizes located peripherally abutting the pleura. Other x-ray features also include blunting of the

Computed tomography (CT) of the chest: Common findings are patchy consolidation with air bronchograms, nodules in various stages of cavitation (predominant in the lower lobes), wedge-shaped peripheral lesions abutting the pleura with or without extension into the pleural space - pleural effusion/empyema, and hilar or mediastinal lymphadenopathy. The *"feeding vessel sign"* has been considered highly suggestive (although not pathognomonic) of septic PE and consists of a distinct vessel leading directly into the center of a nodule (Fig 5). This sign may represent hematogenous spread to the lungs and may also be seen in metastasis. The prevalence of this sign varies from 67–100% in various series and the heterogeneous sub pleural wedge-shaped opacities are seen in 70–75% of patients (Kwon et al., 2007). Multi-detector CT is faster and superior to the classical CT technology for

Fig. 5. The "Feeding vessel" sign and multiple peripheral cavitating lesions suggestive of

50% of patients. C-reactive protein is invariably raised.

costophrenic angle, indicating small pleural effusions or empyema.

**27. Diagnosis** 

bone, and soft tissue abscesses.

detection of this sign (Dodd et al., 2006).

SPE

clinician into thinking about a diagnosis of SPE. Other pulmonary complications of SPE include pleural effusion, empyema, and rupture of subpleural lesions leading to spontaneous pneumothorax.

Fig. 4. Clinical manifestations of SPE

Lemierre's syndrome usually occurs in previously healthy adolescent or young adults, generally presenting with high grade fever (39-41C) and rigors. History is usually significant for sore throat, tooth ache, odynophagia, dysphagia and chest pain in the week preceding the presentation. On examination the patient appears ill, may have signs of periodontal disease, the tonsils are usually inflamed with exudates and peritonsillar abscesses releasing foul-smelling pus. ''The diagnosis of this infection may be suggested by the peculiar odour—like Limburger or overripe Camembert cheese—of pus produced by it.''(Alston, 1955). Signs of internal jugular vein thrombosis may be present in 26–45% of cases. Features suggestive of the development of internal jugular vein thrombophlebitis include neck pain and stiffness, cervical lymphadenopathy often in the anterior triangle and more characteristically a tender (normally unilateral) swelling at the angle of the jawanterior to, and parallel with, the sternomastoid muscle (Riordan & Wilson, 2004).
