Computed tomography diagnosis of pulmonary infarction in acute pulmonary embolism.

INTRODUCTION: Pulmonary infarction is a common sequela of pulmonary embolism (PE) but lacks a diagnostic reference standard. CTPA in the setting of acute PE does not reliably differentiate infarction from other consolidations, such as reversible alveolar hemorrhage or atelectasis. We aimed to assess the diagnostic accuracy for recognizing pulmonary infarction on CT in the acute phase of PE, with follow-up CT as reference. MATERIALS AND METHODS: Initial and follow-up CT scans of 33 patients with acute PE were retrospectively assessed. Two radiologists independently evaluated the presence and size of suspected pulmonary infarction on the initial CT. Confirmation of infarction was established by detection of residual densities on follow-up CT. Sensitivity, specificity and interobserver variability were calculated. RESULTS: In total, 60 presumed infarctions were found in 32 patients, of which 34 infarctions in 21 patients could be confirmed at follow-up. On patient-level, observers' sensitivity/specificity were 91 %/9 %, and 73 %/46 %, respectively, with interobserver agreement by Kappa's coefficient of 0.17. Confirmed infarctions were usually larger than false positive lesions (median approximate volume of 6.6 mL [IQR 0.84-21.3] vs. 1.3 mL [IQR 0.57-6.5], p = 0.040), but still small. An occluding thrombus in a supplying vessel was predictive for confirmed infarction (OR 11, 95%CI 2.1-55), but was not discriminative. CONCLUSIONS: Pulmonary infarction is a common finding in acute PE, and generally small. Radiological identification of infarction was challenging, with considerable interobserver variability. Complete obstruction of the supplying (sub)segmental pulmonary artery was found as the strongest predictor for pulmonary infarction but was not demonstrated to be discriminative.

A Case of Chronic Pulmonary Aspergillosis due to Pulmonary Infarction, Mimicking Cryptogenic Organising Pneumonia.

A patient initially treated with corticosteroids for cryptogenic organising pneumonia following pulmonary infarction, developed a worsening condition with progressive cavitary formations in both lower lung lobes. Contrast-enhanced chest computed tomography revealed a pulmonary embolism, and serum anti-Aspergillus IgG antibody analysis yielded a strong positive result. Consequently, the patient was diagnosed with pulmonary infarction with Aspergillus infection; organising pneumonia in surrounding areas reflected the repair process. Following treatment with anticoagulants and antifungal agents, the patient was successfully discharged. Hence, pulmonary infarction should be considered in cases of refractory lung lesions. LEARNING POINTS: Pulmonary infarction should be considered in case of refractory lung lesions, even if the patient does not have the risk of embolism.Organising pneumonia should be assessed carefully because it may occur as a repair process of various lung diseases.

Characteristics of pulmonary infarction in patients with acute pulmonary embolism in China: a single-center retrospective observational study.

Background: Pulmonary infarction (PI) is an uncommon complication of pulmonary embolism (PE). The risk factors of PI are still relatively unclear. Methods: This was a single-center retrospective review conducted on 500 patients with PE. After applying the inclusion and exclusion criteria, 386 patients diagnosed with PE were enrolled in our study. These patients were then categorized into the PI group (n=64) and the non-PI group (n=322). A comparison was conducted between the two groups regarding the clinical characteristics. Results: The occurrence of PI secondary to PE was 16.58%. In univariate analysis, recent trauma (21.9% vs. 9.9%, P=0.007), pleuritic chest pain (46.9% vs. 17.4%, P<0.001), hemoptysis (29.7% vs. 2.5%, P<0.001), fever (26.6% vs. 8.1%, P<0.001), lower limb edema/pain (37.5% vs. 14.0%, P<0.001), white blood cell (WBC) counts (37.5% vs. 24.5%, P=0.032), C-reactive protein (CRP) (65.6% vs. 41.3%, P<0.001), and pleural effusion (45.3% vs. 18.6%, P<0.001) were associated with an increased risk of PI. Multivariate analysis demonstrated that age [odds ratio (OR) 0.975, 95% confidence interval (CI): 0.951-0.999, P=0.045], pleuritic chest pain (OR 2.878, 95% CI: 1.424-5.814, P=0.003), hemoptysis (OR 10.592, 95% CI: 3.503-32.030, P<0.001), lower limb edema/pain (OR 2.778, 95% CI: 1.342-5.749, P=0.006) and pleural effusion (OR 3.127, 95% CI: 1.531-6.388, P=0.002) were independent factors of PI due to PE. No significant difference was recorded between the two groups in treatment and mortality. Conclusions: Young patients were found to be a higher risk of PI. Pleural effusion was found to be a factor for PI. PI should be considered when pleuritic chest pain, hemoptysis, or lower limb edema/pain are present with peripheral opacity.

Infarto pulmonar: signos que no debemos dejar pasar en TC de tórax sin contraste / Pulmonary infarction: the signs that we must not miss in chest CT without contrast

Resumen El infarto pulmonar (IP) resulta de la oclusión de las arterias pulmonares distales que generan isquemia, hemorragia y finalmente necrosis del parénquima pulmonar, siendo la causa más frecuente la embolia pulmonar (EP). El diagnóstico oportuno de IP permite el inicio precoz del tratamiento y el respectivo manejo de sostén, disminuyendo así la morbimortalidad asociada. El objetivo de esta revisión es remarcar la importancia de identificar aquellos signos, que en la tomografía computada (TC) sin contraste son altamente sensibles y específicos para el diagnóstico de IP. La TC de alta resolución constituye el método que más información aporta, pudiendo observar signos clásicos de IP como la opacidad en forma de cuña, opacidad con radiolucencia central y el signo del vaso nutricio; así como signos con alto valor predictivo negativo para IP, como la opacidad consolidativa con broncograma aéreo, sugestivo de otras patologías, ya sean infecciosas o tumorales.

Abstract Pulmonary infarction (PI) results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage, and necrosis of the pulmonary parenchyma. The most common cause of pulmonary infarction is pulmonary embolism (PE). Early diagnosis of PI allows early initiation of treatment and supportive care, thus reducing the associated morbidity and mortality. This review aims to highlight the importance of identifying signs that are highly sensitive and specific for the diagnosis of PE even without IV contrast. High-resolution computed tomography (CT) is the method that provides the most information, as it observes classic signs of PI such as wedge-shaped opacity, central lucencies in peripheral consolidation, and the feeding vessel sign, as well as signs with high negative predictive value such as consolidating opacity with air bronchogram that are suggestive of other pathologies, whether infectious or tumoural.

The Reversed Halo Sign in Pulmonary Infarction due to Acute Pulmonary Embolism.

The reversed halo sign, or atoll sign, is a specific sign with ring-shaped consolidation and central lucency, which is historically considered typical for cryptogenic organising pneumonia. The presence of this sign in subpleural, posterior basal parts of the lower lobes, especially when solitary, should however raise suspicion for other causes, such as pulmonary infarction. Here, we present a case of pulmonary embolism with pulmonary infarction that was detected on HRCT without contrast. Teaching Point: The presence of a reversed halo sign, especially when solitary and located in the periphery of the lower lobes, should raise suspicion of a pulmonary infarction.

Right Ventricle Thrombus in a Massive Pulmonary Embolism COVID-19 Patient.

The coronavirus disease 2019 (COVID-19) infection presents with a wild range of clinical manifestations. Increased inflammatory response and thrombotic risk have been described, being pulmonary embolism a potential cause of death in these patients. Pulmonary embolisms with right ventricle thrombus are rare and have higher mortality rates. This case report concerns a rare clinical presentation of a 75-year-old male with a medical history of right renal transplantation 36 years ago, that presented with a ten-day history of asthenia, followed by fever, shortness of breath, and cough since the day before. He was admitted with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pneumonia and respiratory insufficiency. The next morning the patient worsened, he presented with hypotension, tachycardia, severe refractory hypoxemia, and chest pain. Contrast CT showed a massive pulmonary embolism with a right ventricle thrombus, confirmed by an echocardiogram. Anticoagulation and IV fluids were started, and the patient was transferred to the ICU. He developed obstructive shock, so thrombolysis was performed with a full dose of alteplase. The outcome was good with complete recovery. Posterior investigation excluded other causes for pulmonary embolism. The severity of pulmonary parenchymal disease secondary to COVID-19 correlates with thromboembolic complications, which demand a swift response to avoid death. An abrupt deterioration in oxygenation should raise suspicion for PE in COVID-19 patients, and mostly in the presence of hypotension and tachycardia. In our case report, there was a massive pulmonary embolism with a rare right ventricle thrombus that had a good outcome with medical treatment.

Clinical predictors and outcomes of pulmonary infarction in patients with central pulmonary embolism.

BACKGROUND: Given the heterogeneity of predisposing factors associated with pulmonary infarction (PI) and the lack of clinically relevant outcomes among patients with acute pulmonary embolism (PE) complicated by PI, further investigation is required. METHODS: Retrospective study of patients with central PE in an 11-year period. Data were stratified according to the diagnosis of PI. Multivariable logistic regression analysis was used to analyze factors associated with PI development and determine if PI was associated with severe hypoxemic respiratory failure and mechanical ventilation use. RESULTS: Of 645 patients with central PE, 24% (n = 156) had PI. After adjusting for demographics, comorbidities, and clinical features on admission, only age (OR 0.98, CI 0.96-0.99; p = 0.008) was independently associated with PI. Regarding outcomes, 35% (n = 55) had severe hypoxemic respiratory failure, and 19% (n = 29) required mechanical ventilation. After adjusting for demographics, PE severity, and right ventricular dysfunction, PI was independently associated with severe hypoxemic respiratory failure (OR 1.78; CI 1.18-2.69, p = 0.005) and mechanical ventilation (OR 1.92; CI 1.14-3.22, p = 0.013). CONCLUSIONS: Aging is a protective factor against PI. In acute central PE, subjects with PI had higher odds of developing severe hypoxemic respiratory failure and requiring mechanical ventilation.

The Great Mimicker: Pulmonary Embolism Presenting as Flank Pain in a Sickle Cell Disease Patient.

Pulmonary embolism can be a challenging condition for physicians to manage. They often have to diagnose this disease with a high fatality rate via the presence of non-specific symptoms. Another unusual presentation is abdominal pain, which can delay diagnosis due to a broad differential. We report the case of a 30-year-old female with a history of sickle cell anemia who presented to the Emergency Department with several days of right flank pain and urinary symptoms. Unfortunately, her initial urine analysis and chest radiograph could have been misdiagnosed as pyelonephritis. Early diagnosis and timely treatment are critical factors in reducing the mortality rate from pulmonary embolism.

Infarto pulmonar cavitado en mujer con lupus eritematoso sistémico asociado a síndrome antifosfolípido

Tanto lupus eritematoso sistémico como el síndrome antifosfolípido son enfermedades autoinmunes con potencial tromboembólico, sobre todo por la presencia de anticuerpos trombogénicos. El pulmón es un lugar común donde suele asentarse un trombo y generar una tromboembolia, a veces con posterior infarto y cavitación. Existen pocos estudios que informen un infarto pulmonar cavitado en un paciente con lupus asociado a síndrome antifosfolípido. Presentamos el caso de una mujer de 24 años con síntomas generales y lesión pulmonar derecha cavitada. Fue tratada inicialmente como infección tuberculosa o fúngica. La analítica y las imágenes orientaron y diagnosticaron lupus asociado a síndrome antifosfolípido, complicado con tromboembolismo pulmonar que luego pasó a cavitarse. La paciente mejoró considerablemente con anticoagulantes, corticoides y ciclofosfamida.

Both systemic lupus erythematosus and antiphospholipid syndrome are autoimmune diseases with thromboembolic potential, especially due to the presence of thrombogenic antibodies. The lung is a common place where a thrombus usually settles and generates a thromboembolism, sometimes with subsequent infarction and cavitation. There are few studies reporting cavitary pulmonary infarction in a patient with lupus associated with antiphospholipid syndrome. We present the case of a 24-year-old woman with general symptoms and cavitated right lung lesion. She was initially treated as tuberculous or fungal infection. Laboratory tests and images guided and diagnosed lupus associated with antiphospholipid syndrome, complicated by pulmonary thromboembolism that later became cavitated. The patient improved considerably with anticoagulants, corticosteroids, and cyclophosphamide.

Impact of pulmonary infarction in pulmonary embolism on presentation and outcomes.

BACKGROUND: Pulmonary infarction (PI) is relatively common in pulmonary embolism (PE). The association between PI and persistent symptoms or adverse events is largely unknown. AIM: To evaluate the predictive value of radiological PI signs at acute PE diagnosis on 3-month outcomes. METHODS: We studied a convenience cohort with computed tomography pulmonary angiography (CTPA)-confirmed PE for whom extensive 3-month follow-up data were available. The CTPAs were re-evaluated for signs of suspected PI. Associations with presenting symptoms, adverse events (recurrent thrombosis, PE-related readmission and mortality) and self-reported persistent symptoms (dyspnea, pain and post-PE functional impairment) at 3-month follow-up were investigated using univariate Cox regression analysis. RESULTS: At re-evaluation of the CTPAs, 57 of 99 patients (58 %) had suspected PI, comprising a median of 1 % (IQR 1-3) of total lung parenchyma. Patients with suspected PI more often presented with hemoptysis (11 % vs. 0 %) and pleural pain (OR 2.7, 95%CI 1.2-6.2), and with more proximal PE on CTPA (OR 1.6, 95%CI 1.1-2.4) than patients without suspected PI. There was no association with adverse events, persistent dyspnea or pain at 3-month follow-up, but signs of PI predicted more functional impairment (OR 3.03, 95%CI 1.01-9.13). Sensitivity analysis with the largest infarctions (upper tertile of infarction volume) yielded similar results. CONCLUSIONS: PE patients radiologically suspected of PI had a different clinical presentation than patients without those signs and reported more functional limitations after 3 months of follow-up, a finding that could guide patient counselling.

Pulmonary venous thrombosis of traumatic origin as cause of bilobar infarction.

Background: Penetrating chest trauma that is associated with pulmonary injuries can trigger different sequelae, the most frequent being the presence of contusions or pulmonary lacerations that are accompanied by hemopneumothorax. Materials and methods: Description of a clinical case of interest and review of the literature on the topic. Results: In this study, we present an unusual consequence of this type of trauma, a pulmonary infarction secondary to an extensive pulmonary venous thrombosis stemming from a firearm injury. This finding associated with lung tissue necrosis led to the need for right upper pulmonary bilobectomy. Conclusions: The aim of this study is to understand this unusual form of presentation of pulmonary trauma, understand the pathophysiology that triggers lung injury, review the medical literature on the subject, and expand the general knowledge on this topic. Study type: Therapeutic/care management.

Awareness Regarding Venous Thromboembolism and Pulmonary Embolism After Pregnancy and Cesarean Section in Female Population in the Aseer Region, Saudi Arabia.

Introduction A pulmonary embolism (PE) occurs when an embolus that has traveled through the venous system from another part of the body obstructs an artery in the lungs. Chest pain, especially while breathing in, coughing up blood, and shortness of breath are all possible signs of PE. There could also be signs of a blood clot in the leg, like a painful, swollen, red, and warm leg. As a high-risk group, particularly during childbearing age, the aim of this study is to evaluate the general awareness of females regarding PE and identify areas of knowledge deficit and factors contributing to their awareness level. Methods A cross-sectional descriptive survey of Saudi women in general over the age of 18 was carried out. Participants were asked to respond to a structured questionnaire that was used to gather data. The questionnaire was formulated in Google Forms with an Arabic translation of the form and the link generated and was sent to each participant for completion. In total, 827 respondents filled out the survey with accurate and complete information. Results The study comprised 827 female volunteers, with a mean age of 33.2 ± 9.4 years, ranging in age from 15 to 60. Additionally, 52.8% of the female sample had graduated from college, compared to about 4% who were illiterate. In general, 40.2% of the girls knew everything there was to know about PE. Conclusions According to the study's findings, the public female population knew less about PE overall - that is, about risk factors, symptoms, and preventive measures. As more knowledge about the dangers, causes, prevention, diagnosis, and treatment of PE becomes available, it is imperative that healthcare professionals translate and actively distribute this information to the public, particularly to women.

Clinical and 18F-FDG PET/CT imaging features of hilar tumor pulmonary infarction / 中华核医学与分子影像杂志

Objective:To investigate the clinical manifestations and 18F-FDG PET/CT imaging features of hilar tumor pulmonary infarction. Methods:From July 2016 to June 2021, 49 patients (40 males, 9 females; age 32-81 years) with hilar tumor pulmonary infarction who underwent PET/CT and enhanced CT in the second Hospital of Shandong University and Shandong Cancer Hospital and Institute, Shandong First Medical University were retrospectively enrolled. All patients were diagnosed by imaging follow-up or pathology. Clinical features and 18F-FDG PET/CT imaging features were analyzed. Results:A total of 108 infarcts were found in 49 patients by 18F-FDG PET/CT. Small cell carcinoma was the most common hilar tumor (67.35%, 33/49). The most common clinical manifestations of hilar tumor pulmonary infarction were cough (69.39%, 34/49) and hemoptysis (34.69%, 17/49). Pulmonary infarction was mainly multiple (69.39%, 34/49), and multiple lung lobes might be involved. The CT morphology of infarcts was wedge-shaped (46.30%, 50/108) or patchy (53.70%, 58/108), and the density was mainly bubble consolidation (61.11%, 66/108). There were 91 (84.26%, 91/108) infarcts showing FDG hypermetabolism, with the SUV max of 1.48-6.62, and the hypermetabolism mode was rim sign (36.11%, 39/108) or heterogeneous hypermetabolism (48.15%, 52/108). Nineteen patients (38.78%, 19/49) were complicated with pulmonary vein involvement, and 26 patients (53.06%, 26/49) had ipsilateral pleural effusion. Conclusions:Hilar tumor pulmonary infarction is characterized by cough. It is helpful for the diagnosis of hilar tumor pulmonary infarction in patients with hilar tumor when wedge-shaped, bubble consolidation, rim sign and heterogeneous hypermetabolism lesions are found in 18F-FDG PET/CT images.

Pneumonia and concealed pulmonary embolism: A case report and literature review.

Pneumonia is one of the illnesses for which pulmonary embolism (PE) is most often mistaken because of the considerable overlap in their clinical picture. Moreover, pneumonia may occasionally mask PE, particularly in patients with predominant systemic symptoms such as fever, and with no evidence of deep vein thrombosis (DVT) or trauma. In this report, we presented a 35-year-old male patient with pneumonia and PE in whom pneumonia initially masked the diagnosis of PE. The patient presented with fever, productive cough associated with streaks of blood and pleuritic chest pain for 3 days duration, and was admitted as a case of lobar pneumonia based on his clinical presentation as well as on chest X-ray and non-enhanced computed tomography chest. He had an initial improvement in response to antibiotics; however, during his follow-up at the clinic, he appeared sick, complaining of right-sided persistent pleuritic chest pain and persistent cough, occasionally associated with streaks of blood and breathlessness on exertion. The patient was readmitted and PE was confirmed by computed tomography pulmonary angiography. Anticoagulation initiated with noticeable clinical improvement. This case highlights the importance of considering PE in patients with pneumonia when there was an initial therapeutic response followed by worsening of the condition during the treatment of pneumonia.

Anomalous systemic arterial supply to the left lower lung lobe: A case report.

Background: An anomalous systemic arterial supply to the lung lobes is a rare congenital pulmonary vascular malformation. Current treatments include thoracoscopic lobectomy, anatomical segmentectomy, simple ligation and arterial embolization. However, the optimal treatment remains controversial. Case presentation: A 29-year-old man was diagnosed with anomalous systemic arterial supply to the left lower lobe through contrast-enhanced computed tomography and three-dimensional reconstruction. He underwent coil embolization of the anomalous artery and was followed up for 1 year. Conclusions: Blockage of the blood flow of the anomalous systemic artery alone does not improve the blood supply of the pulmonary artery to lung tissue and thus cannot restore normal gas exchange through the blood-gas barrier. Coil embolization of the anomalous arterial supply can cause early postoperative pulmonary infarction.

Pulmonary Embolism Presenting with Pulmonary Infarction: Update and Practical Review of Literature Data.

Pulmonary infarction (PI) is a possible consequence of pulmonary embolism (PE). The real incidence of PI could be underestimated considering only non-fatal PE presentation. However, following postmortem examination, the prevalence of PI is considerably higher. This evidence suggests the necessity of proper diagnostic protocol for identifying PI. Unfortunately, PI diagnosis can sometimes be challenging, due to the overlapping of symptoms with other diseases. Nowadays, the diagnosis is mainly based on radiological evaluation, although the combination with emerging imaging techniques such as ultrasound and nuclear scanning might improve the diagnostic algorithm for PI. This review aims to summarize the available data on the prevalence of PI, the main predisposing factors for the development of PI among patients with PE, to resume the possible diagnostic tools, and finally the clinical and prognostic implications.

Post-COVID-19 Pulmonary Infarction Complicated by Spontaneous Pneumothorax: A Case Report.

Pulmonary cavitation is an atypical finding in COVID-19 patients. In this rare case report, a 63-year-old woman (35 days from COVID-19 symptom onset) presented to our emergency department with acute chest pain and shortness of breath. A chest X-ray established right-sided total pneumothorax, hence a tube thoracostomy was performed. Due to a persistent air leak, chest computed tomography was performed, which showed areas of lung consolidation and a cavitary mass in the upper lobe of the right lung. The woman undertook a thoracoscopy, which established multiple petechiae on the lung surface and a bronchopleural fistula of the right lung's upper lobe. The treatment of choice was an atypical lung resection to remove the necrotic cavitary lesion. Histological and microbiological examination of the resected lung specimen showed a bland (aseptic) cavitary pulmonary infarct. Pulmonary infarction is a rare cause of cavitation in COVID-19 patients, nonetheless, something that should be considered in those presenting with respiratory symptoms or complications during or post-COVID-19.

Peripheral Pulmonary Lesions in Confirmed Pulmonary Arterial Embolism: Follow-up Study of B-Mode Ultrasound and of Perfusion Patterns Using Contrast-Enhanced Ultrasound (CEUS).

PURPOSE: This retrospective study aimed to describe the B-mode lung ultrasound (B-LUS) and contrast-enhanced ultrasound (CEUS) follow-up patterns of peripheral pulmonary lesions (PPLs) in patients with confirmed pulmonary embolism (PE). PATIENTS AND METHODS: Data from 27 patients with a confirmed diagnosis of PE and PPLs over 5 mm from October 2009 to November 2018 were included retrospectively in the study. The inclusion criteria were performance of a baseline CEUS examination, a short-term B-LUS and CEUS follow-up, and a long-term B-LUS follow-up of PPLs. The homogeneity of enhancement of PPLs (homogeneous/inhomogeneous/absent) on CEUS and the presence and size of PPLs on B-LUS were evaluated. RESULTS: A total of n = 25/27 (92.6%) lesions showed absent or inhomogeneous enhancement during baseline examination or short-term follow-up, indicating impaired perfusion. On short-term CEUS follow-up, 9/27 cases (33.3%) showed a pattern shift. On B-LUS long-term follow-up, 26/27 lesions (96.3%) were detectable for an average of 10 weeks (range 3-32 weeks). The size of reference lesions was significantly reduced at the time of the final follow-up examination (P < .05). CONCLUSION: B-LUS follow-up showed that, in patients with confirmed PE, PPLs had a delayed regression. On CEUS follow-up examination, various perfusion patterns of PPLs were observed, indicating the different ages and the variable reparative processes of pulmonary infarction. In PPLs independent of the underlying signs and symptoms, follow-up B-LUS and CEUS examinations may be helpful for a possible retrospective diagnosis of peripheral pulmonary infarction suggestive of PE.

Low-dose oestrogen-progestin associated pulmonary infarction mimicking pneumonia and pleurisy.

A 28-year-old woman with a history of treatment with a low-dose oestrogen-progestin (LEP) formulation presented to our hospital due to right chest pain. She had just been discharged from another hospital for pneumonia and pleurisy which had improved with antibiotics. Contrast-enhanced computed tomography (CT) revealed bilateral pulmonary emboli corresponding to the peripheral consolidations. The pulmonary emboli indicated that the peripheral consolidation was due to pulmonary infarction (PI). No aetiological factors were identified except for the history of LEP therapy. Although the typical CT images of PI are consolidations in the peripheral area, these finding are non-specific for PI. This case of PI was misdiagnosed as infection because of response to antibiotics and similar CT findings. Therefore, careful evaluation of the patient history and clinical findings are imperative for accurate diagnosis. Venous thromboembolism can occur frequently around 3 months after the start of LEP treatment.