Radiology Case Reports 19 (2024) 721–726

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Case Report

Radiological findings in septic pulmonary

embolism with detection of gram-negative and
gram-positive bacteria in microbiological culture: A
rare pediatric case report ✩

Candra Harmindasatya, MD, Lenny Violetta, MD∗

Department of Radiology, Faculty of Medicine Universitas Airlangga - Dr. Soetomo Academic General Hospital,
Surabaya, Indonesia

a r t i c l e i n f o a b s t r a c t

Article history: Septic pulmonary embolism rarely occurs in children, displaying fairly distinctive radiolog-
Received 5 October 2023 ical features that can, however, lead to misdiagnosis. We present a case of an Indonesian
Revised 31 October 2023 pediatric patient with an infection originating from cellulitis in his right calf, who under-
Accepted 2 November 2023 went a chest X-ray followed by a CT scan. The findings from these examinations revealed
characteristics consistent with septic pulmonary embolism, correlating with the growth of
both gram-positive and gram-negative bacteria in microbiological cultures obtained from
Keywords: wound specimens, as indicated in the literature. Awareness of specific imaging features is
Septic pulmonary embolism crucial for accurately diagnosing septic pulmonary embolism in this case and initiating ap-
X-Ray propriate treatment.
CT-scan © 2023 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
Pediatric This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

[1]. While it has been considered rare in children, recent stud-

Introduction
Septic pulmonary embolism is an uncommon yet life-
threatening condition characterized by the implantation of
infected thrombi into the pulmonary vasculature, primarily
originating from different infectious sites. This results in a
parenchymal infection that typically presents with an insidi-
ous onset of fever and respiratory symptoms, including cough,
shortness of breath, pleuritic chest pain, and lung infiltrates
ies suggest a continuous increase in its incidence rate [2].
Treatment in cases like this requires antibiotic therapy, either
empirical or based on the results of bacterial culture and sen-
sitivity testing [3].
Radiological findings in children with septic pulmonary
embolism cases are generally similar to those in adults.
Common radiological findings include diffuse, bilateral nodu-
lar consolidations, which can be accompanied by cavities
and feeding vessel signs. Additionally, pleural effusion or

✩
Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could
have appeared to influence the work reported in this paper.
∗
Corresponding author.
E-mail address: violettalenny@gmail.com (L. Violetta).
https://doi.org/10.1016/j.radcr.2023.11.004
1930-0433/© 2023 The Authors. Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
722 Radiology Case Reports 19 (2024) 721–726
Fig. 1 – A 9-year-old boy with chest pain, fever and rapid breathing. Findings: Wound of the right ankle that was discharging
pus and blood as source of infection.
empyema may also be present, and in some cases, pneumoth-
orax can occur [4]. Pleural effusion can manifest in various
forms on chest radiographs, including lamellar, encysted, and
subpulmonic. Encysted pleural fluid, in particular, can mimic
the radiological appearances of parenchymal lung masses or
nodules on chest radiographs, often leading to a diagnostic
dilemma [5].
In another study that examined the differences in char-
acteristics of septic pulmonary embolism on CT scans based
on both gram-positive and gram-negative bacterial etiology
of the infection, peripheral wedge-shaped opacity, cavitation,
and air bronchogram in the nodule were found to be more
commonly seen in the gram-positive group than in the gram-
negative patient group of septic pulmonary embolism. Ad-
ditionally, the size of the nodule in the gram-positive group
was larger than that in the gram-negative group. In contrast,
a well-demarcated margin and the ground-glass attenuation
halo (CT “halo sign”) of the nodule, as well as the feeding
vessel sign, were more frequently seen in the gram-negative
group [6].
This case presentation aims to provide X-ray and contrast-
enhanced CT scan findings of septic pulmonary embolism, in
which both gram-positive and gram-negative bacteria were
detected in microbial culture examination.
Case presentation
A 9-year-old boy slipped and fell while playing, with his right
ankle hitting the edge of the floor. Although there were no
visible wounds or bleeding, the patient’s leg developed signif-
icant bruising over the course of several days. Three weeks
after the incident, the patient began complaining of swelling
in his right leg, starting from the ankle and extending up to
the right calf (Fig. 1). The skin in this area appeared red, and
there was a wound that was discharging pus and blood from
the right ankle. Additionally, the patient had been experienc-
ing a fever, with the highest recorded temperature reaching
38°C, for the 2 days leading up to admission. Furthermore, the
patient presented with chest pain, rapid breathing, pale skin,
and weakness. Despite these symptoms, he maintained his
appetite and was able to eat and drink. The initial diagnosis
indicated cellulitis with an abscess and a suspected case of
pneumonia.
The patient is the second child of 2 siblings and was de-
livered via C-section during a full-term pregnancy, primarily
due to a prior C-section. The baby has no record of cyanosis
or jaundice. There is no history of similar illnesses or previous
episodes of immunocompromised conditions. The patient has
a comprehensive immunization history and has achieved age-
appropriate developmental milestones. Anthropometric mea-
surements taken at the onset of illness indicate a weight of 30
kg and a height of 130 cm.
On admission, his temperature was 36.7°C, blood pres-
sure was 100/60 mm Hg, respiratory rate was 28 breaths/min,
and SpO2 was 98% with room air. He presented with tachy-
cardia (140 beats/min). On examination, there was swelling
and erythema suggesting cellulitis of the right leg. Blood
tests revealed a white blood cell count (WBC) of 21,430/μL,
hemoglobin of 10.2 g/dL, and a platelet count of 464,000/μL.
The results of blood chemistry tests were as follows: as-
partate aminotransferase 24.3 IU/L, alanine aminotransferase
21.8 IU/L, albumin 3.28 g/dL, blood urea nitrogen 14.1 mg/dL,
and creatinine 0.522 mg/dL. C-reactive protein was 8.63 mg/dL,
and procalcitonin was 2.3 ng/mL. Mycobacterial Tuberculosis
screening examination showed a negative result, and SARS-
CoV-2 PCR examination was not detected.
Further examination of the wound on his right calf in-
cluded a bacterial culture test. From the pus specimen, the
growth of Staphylococcus aureus bacteria, which are gram-
positive, was found. Meanwhile, from the tissue specimen,
Acinetobacter baumannii bacteria, which are gram-negative,
were detected. The patient then received combination ther-
apy with broad-spectrum antibiotics, namely Ampicillin, Peni-
cillin G, and Cotrimoxazole. After undergoing the treatment,
the complaints related to the lungs gradually improved, and
he was discharged from the hospital.
As for the cellulitis and abscess treatment on his right calf,
further interventions were performed in collaboration with
colleagues from the fields of surgery and orthopedics due to
suspected soft tissue infection extending into adjacent bone
tissue.
 Radiology Case Reports 19 (2024) 721–726 723

Fig. 2 – A 9-year-old boy with chest pain, fever and rapid breathing. Findings: Initial chest X-ray anterior projection (2A)
shown multiple well-defined consolidation nodules was visible on the peripheral sides of both the right and left lungs (blue
arrows). Well-defined opacity that overlaps with the left heart border in the left hemithorax, accompanied by a hilar overlay
sign (blue star) (A and B) and ill-defined opacification of lower right hemithorax accompanied with narrowing of the right
lower intercostal space (red star) (A and B). On lateral projection (2B) the opacification seen in the left hemithorax projected
in the upper hemithorax suggests pocketed pleural effusion (blue star) and also seen pleural effusion in the lower posterior
region of the right hemithorax (red star).

From anterior chest X-ray examination, it appears multiple
well-defined consolidation nodules are visible on the periph-
eral sides of both the right and left lungs. Additionally, there is
a well-defined opacity that overlaps with the left heart border
in the left hemithorax, and an ill-defined opacification in the
lower right hemithorax, accompanied by a narrowing of the
right intercostal space. These findings raise suspicion of pleu-
ral effusion in both hemithorax and the possibility of another
thoracic mass that needs to be ruled out (Fig. 2).
The examination continued with a contrast-enhanced CT-
scan of the chest, which showed multiple non-enhancing
wedge-shaped opacities distributed peripherally on both the
right and left sides of the lungs. Most of them lacked cavita-
tion, while a small portion had cavities within lesions. The
feeding vessel sign was clearly visible, but there was no ev-
idence of a CT-Halo sign. On the anterior side of the left
hemithorax and posterior inferior side of the right hemitho-
rax, there is a contained fluid collection, with a smooth, lentic-
ular shape, that forms an obtuse angle against the pleural wall.
This collection is accompanied by the compression and dis-
placement of some portions of the adjacent lung tissue. These
affected areas include the superior and inferior lingula seg-
ments of the superior lobe of the left lung, as well as the su-
perior and posterior basal segments of the lower lobe of the
right lung. These findings are indicative of a presentation con-
sistent with septic pulmonary embolism on both the right and
left sides of the lungs, accompanied by a pleural effusion in
both hemithorax (Figs. 3 and 4).
Discussion
Septic pulmonary embolism is an unusual condition charac-
terized by the implantation of infected thrombi into the pul-
monary vasculature, primarily originating from different in-
fectious sites. This results in a parenchymal infection that typ-
ically presents with an insidious onset of fever and respira-
tory symptoms, including cough, shortness of breath, pleuritic
chest pain, and lung infiltrates [1]. While it has been consid-
ered rare in children, recent studies suggest a continuous in-
crease in its incidence rate, among all the children in the com-
munity, PE incidences range from 0.14 to 0.90 per 100,000 per
year [2].
An extrapulmonary site of infection can facilitate the ex-
travasation or translocation of an organism, typically bacteria,
into the systemic venous circulation. Once in the bloodstream,
the pathogen can cause damage directly through toxins and
indirectly through inflammatory mediators. Occasionally, this
inflammatory response may promote local thrombosis, which
can serve as an additional site for bacterial proliferation. The
embolization of these thrombi into the pulmonary circulation
can lead to metastatic parenchymal infection of the lungs,
even in the absence of cardiac valvular involvement [7].
In the chest X-ray examination of this case, a well-defined
large opacity was observed in the left hemithorax, accompa-
nied by a hilar overlay sign. Subsequently, a CT scan confirmed
the presence of a lesion with fluid density, indicating a pock-
eted effusion located in the anterior hemithorax. This effusion
was causing compressive atelectasis in certain portions of the
superior and inferior lingula segments of the left superior lung
lobe. These findings could potentially lead to confusion in the
initial chest X-ray examination, where the opacity might be
mistaken for a thoracic mass.
The radiological findings in this case were indicative of sep-
tic pulmonary embolism in a pediatric patient. These find-
ings included diffuse, bilateral nodular consolidations, which
could be accompanied by cavities and feeding vessel signs [4].
Additionally, pleural effusion of left and right hemithorax was
observed.
724 Radiology Case Reports 19 (2024) 721–726

Fig. 3A – A 9-year-old boy with chest pain, fever, and rapid breathing. Findings: Axial slice, lung window, Contrast Enhanced
CT-Scan showed multiple well-defined nonenhancing wedge-shaped opacities lacking cavities (blue arrows) (3A) are
distributed peripherally in both the right and left lung lobes. A large nonenhanced opacite, lenticular-shaped (blue star) (A)
will be explained in Fig. 4. Axial slice lung window showed contrast-enhanced CT-scan few of the lesions had cavities
within (blue arrows) in left lung (B) and right lung (C). Lung window, thick slab, axial slice, maximum intensity projection
(MIP), contrast-enhanced CT-Scan, and feeding vessel sign-in were seen in the left lung (yellow arrows) (D and E).

However, a recent study by Kwon et al. stated that pe-
ripheral wedge-shaped nodular opacity and cavitation in the
nodule were more commonly observed in the gram-positive
group than in the gram-negative patient group with septic pul-
monary embolism. Furthermore, the size of the nodules in the
gram-positive group was larger than that in the gram-negative
group. In contrast, a well-demarcated margin and the ground-
glass attenuation halo (referred to as the “CT halo sign”) of
the nodule, as well as the feeding vessel sign, were more fre-
quently seen in the gram-negative group [6].
There was presentation of septic pulmonary embolism in
this case that corresponds to the characteristics of gram-
negative bacterial etiology. It showed predominantly well-
defined nodular opacity without cavities and the presence of
a feeding vessel sign, although the “CT halo sign” was not ob-
served in this patient. However, a large-sized wedge-shaped
 Radiology Case Reports 19 (2024) 721–726 725

Fig. 4 – A 9-year-old boy with chest pain, fever, and rapid breathing. Findings: Mediastinal window, axial slice, lung window,
sagittal slice, contrast-enhanced CT-scan showed pocketed pleural effusion in left anterior hemithorax (blue star) (A and B
with a smooth, lenticular shape, forming an obtuse angle against the pleural wall, accompanied by compression and
displacement of some portion the adjacent lung tissue of the superior and inferior lingula segment of superior lobe of the
left lung and superior, also seen pleural effusion in right lower posterior hemithorax (red star) (A and C). No mass
appearance was seen.

opacity accompanied by cavities was also observed, which cor-
responds to the characteristic of septic pulmonary embolism
caused by gram-positive bacteria.
Meanwhile, Chang et al. mentioned that the term “feeding
vessel sign” could be a misnomer because it was confirmed
that the vessels were pulmonary veins. Therefore, a more ap-
propriate term might be “draining vessel sign” (DVS). In this
patient, it was observed that the vessels connected to the nod-
ules originated from pulmonary veins [8].
Subsequently, bacterial cultures revealed the growth of
Methicillin Resistant Staphylococcus Aureus (MRSA) in the
pus culture and Acinetobacter Baumannii in the tissue cul-
ture. This confirms the findings from the CT scan, indicating
that both radiological features of septic pulmonary embolism
caused by gram-negative and gram-positive bacterial etiolo-
gies were identified in this patient.
Conclusion
In conclusion, septic pulmonary embolism, though consid-
ered rare in pediatric patients, is an increasingly recognized
condition with potentially serious consequences. This case il-
lustrates the diverse clinical and radiological manifestations
associated with this condition.
726 Radiology Case Reports 19 (2024) 721–726
Our study reaffirms the importance of considering this di-
agnosis, especially when confronted with challenging initial
chest X-ray findings, such as large opacities and hilar overlay
signs that may mimic other thoracic pathologies. These initial
radiological impressions can be misleading and underscore
the necessity of complementary imaging techniques, like CT
scans, for a precise diagnosis.
The presentation of septic pulmonary embolism in this
patient is intriguing due to its dual nature. The radiologi-
cal features displayed characteristics of both gram-negative
and gram-positive bacterial etiologies. The presence of well-
defined nodules without cavities and the positive feeding
vessel sign aligns with gram-negative bacteria, while the
large-sized wedge-shaped opacity with cavities corresponds
to gram-positive bacteria. This duality underscores the com-
plexity of this condition and the need for precise diagnostic
tools.
Further investigations, including bacterial cultures, con-
firmed the presence of MRSA and Acinetobacter baumannii,
validating the radiological findings. This case highlights the
importance of a multidisciplinary approach, combining clin-
ical, radiological, and microbiological assessments to accu-
rately diagnose and treat septic pulmonary embolism.
Patient consent
Written informed consent was obtained from the patient for
the publication of this case report.
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