Resident Physician Brookwood Baptist Health, Alabama, United States
Introduction: Acute pulmonary embolism leads to pulmonary infarction in about 8% of the cases, 5% of which can be complicated by pneumonia. The parenchymal necrosis caused by pulmonary infarction can lead to a cavitary necrotizing pneumonia, a dreaded complication with high mortality rate. Here we present a case of an elderly male with no known risk factors who presented with pulmonary embolism complicated by resistant necrotizing pneumonia.
Description: 90-year-old male with no past medical history presented to the hospital complaining of worsening dyspnea, fatigue, and generalized malaise for one week. On presentation, he was febrile, tachycardic, and hypoxic. Chest X-ray was significant for an indistinct opacity in the right lung base. CT scan of the chest showed thromboemboli within the distal right main pulmonary artery with extension into the secondary and tertiary branches. He was started on intravenous unfractionated heparin. The scan also showed a developing right lower lobe pneumonia, so he was started on IV Vancomycin and Cefepime. However, the patient’s respiratory status worsened significantly, ultimately requiring intubation and mechanical ventilation. Despite appropriate treatment, his oxygen requirements did not improve, so a repeat CT scan was obtained, which revealed a large cavitary lesion with internal septation. Bronchoalveolar lavage grew pseudomonas resistant to cefepime, so he was switched to Meropenem instead. Despite 14 days of treatment, patient did not progress enough to be extubated safely. Ultimately, family opted to withdraw all care and patient passed away shortly afterward.
Discussion: The differential diagnosis for a cavitary lung lesion includes primary lung malignancy, sarcoidosis, granulomatosis with polyangiitis, tuberculosis, bacterial and fungal infections. Because there was no cavitation on initial imaging, our leading explanation is that the infarction caused by the pulmonary embolism led to a cavitation and provided the milieu for necrotizing infection with pseudomonas. This case illustrates a devastating complication of pulmonary thromboembolism. Our patient did not have any discernible risk factors except for his advanced age, which made him more susceptible to developing a complication and less likely to survive it despite aggressive treatment.
