Septic Pulmonary Emboli With Feeding Vessel Sign.

Submitted August 5, 2020; revision received August 17, 2020; accepted August 21, 2020. A 42-year-old woman with emphysema and a history of intravenous drug abuse and smoking presented to the emergency department for shortness of breath. She had a 2-week duration of dyspnea at rest, a left foot wound, and fevers. Initial vital signs were 103.8 ̊F, 139 bpm, and 60 rpm. She required supplemental oxygen. Physical examination revealed diffuse bilateral wheezes and a left foot abscess. Blood cultures and polymerase chain reaction revealed methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Chest computed tomography angiography demonstrated diffuse bilateral pulmonary cavitation with the dominant lesion having a feeding vessel sign (image). The patient was diagnosed with MRSA endocarditis on echocardiogram with septic pulmonary emboli. Vancomycin was administered; however, the patient needed to be intubated. Lymphatic drainage was contraindicated in the patient because of the risk of systemic infection, bacteremia, and possible further dislodging emboli. Due to further decompensation, the family chose to pursue comfort care measures. A septic pulmonary embolism is a blood vessel that is obstructed, usually by an infected thrombus. The pathogenesis consists of an embolic or ischemic event followed by an infection causing inflammation, which may form an abscess. Abscesses are most commonly caused by staphylococcal species, especially from infective endocarditis. On imaging, the “feeding vessel sign,” also known as “fruits on the branch sign,” is a combination of a distinct vessel leading directly to a nodular or mass. This finding can indicate one of the following: hematogenous origin near the small pulmonary vessels, a lung metastasis, or arteriovenous malformation. (doi:10.7556/jaoa.2020.130)