A 53 years old man with presented with intermittent high fever (body temperature 39.6℃) and chills of 5days. There were no significant past medical history of liver disease or diabetes mellitus. On admission, he had temperature of 37.5°C with a heart rate of 154 beats/min, a blood pressure of 100/68mmHg, dyspneic (RR=38 breaths/min), and an oxygen saturation of 33% on room air. The heart was normal and lungs were clear. Tenderness was elicited on the right upper quadrant. Murphy's sign was not observed. The liver and spleen were not palpable. Skin lesions were absent. Arterial blood gas analysis proved pH 7.31, PaO2 118 mmHg, PaCO2 29.2 mmHg, cGlu 16.6 mmol/L, cLac 2.9mmol/L. A full blood count revealed WBC count was 17.77×109/L with neutrophil predominance (90.1%). C reactive protein (CRP) and procalcitonin (PCT) were elevated to 234.35mg/l and 57.62ng/ml, respectively. His platelet count was 18×109/L. Fibrinogen also was increased to 6.8 g/L. Laboratory results included a prothrombin time of 16.0 seconds, an INR of 1.45, an APTT of 37.6 seconds, and D-dimer of 17.54 mg/L. Creatinine and blood urea nitrogen (URN)were elevated to 128.9umol/l and 9.8umol/l, respectively. His Hba1c was 7.88%. HIV was negative. CT scan of the lung demonstrated that there were multiple nodules and patchy shadows in each lobe of both lungs, the largest of which was located in the lower lobe of the right lung, with a lager cross section of about of a 3x2.2 cm (Fig. 1). CT scan of the liver showed a low- density area in the caudate liver lobe (Fig. 1). For a suspected liver abscess, intravenous imipenem-cilastatin sodium (3g/day) was started. Sepsis treatment was initiated. The patient had an increased oxygen requirement 4 hours after admission. Arterial blood work done revealed an obviously decreased pH of 7.28, PaO2 of 63.5 mmHg, PaCO2 of 31.8 mmHg, cGlu of 18.6 mmol/L, cLac of 2.6mmol/L. Initiation of continuous renal replacement therapy (CRRT) in patients with severe lactic acidosis.
Fig.1 (a b) The lung CT scan on admission showed that there were multiple nodules and patchy shadows in each lobe of both lungs, the largest of which was located in the lower lobe of the right lung, with a lager cross section of about of a 3x2.2 cm (red arrow). (c d) The hepatic CT scan showed that caudate lobe volume increases and a low-density area in the caudate liver lobe (red arrow).
He had a high fever of up to 39.9°C 3 days after admission. Abdominal CT 3 days after admission revealed a 3.3 x 2.1 x2.2 low density area in the caudate lobe (Fig. S1). Chest CT demonstrated that increased local infection (Fig. S1). Combined with the CT imaging, the patient was determined to have metastatic infection in the lungs, in addition to liver, the suspected source of infection. K. pneumoniae was isolated from blood culture, urine and phlegm, which was susceptible to imipenem, meropenem, ceftriaxone, amikacin, and ciprofloxacin.
Eight days after admission, the improved CT examination suggested pulmonary embolism (Fig.2), while cardiac ultrasound suggested pulmonary hypertension. Deep venous thrombosis was not observed by ultrasonography of the lower limbs. With the suspicion of liver abscesses, septic pulmonary embolism. The patient was treated with antibiotics and did not receive anticoagulation. Fifteen days after admission, there were no pulmonary embolism occurred (Fig. S2). The antibiotic therapy was successfully(Fig. S3). The antibiotic regimen included intravenous (IV) Imipenem with cystatin, levofloxacin, cefoperazone- sulbactam sodium and ceftazidime . Patient received antibiotics for 54 days and was hospitalized for 57 days. His data was collected through the follow in the outpatient department. A repeat CT performed in 3 months after he is out of hospital revealed resolution of the lung and liver infection (Fig.3)
Fig.2 Eight days after admission, (a b) Contrast-enhanced Chest CT demonstrated that increased local infection (red arrow). (c d) the improved CT examination suggested pulmonary embolism. (e f) Abdominal CT scan demonstrating an area of abnormal attenuation measuring 3.3 cm × 2.1 cm ×2.2cm in the caudate lobe of the liver.
Fig.3 (a-d) A repeat CT performed in 3 months after he is out of hospital revealed resolution of the lung and liver infection.