Septic Pulmonary Embolism Secondary to Klebsiella pneumoniae Epididymitis

Case Reports in Radiology
22 Mar, 2019 ,

 A 74-year-old male with a history of diabetes mellitus experienced Septic pulmonary embolism secondary to epididymitis, with isolation of K. pneumoniae in blood and presence of lung nodules, with a chest computed tomography showing the halo and reversed halo signs. He was treated with a 14-day antibiotic course post which there was marked reduction of symptoms. 

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A 74-year-old male patient was admitted to our institution with a one-month left-sided testicular pain and occasional dry cough, unquantified fever, asthenia, adynamia, and decreased appetite in the last four days. His history included insulin-requiring type 2 diabetes mellitus, arterial hypertension, stage 3 chronic renal disease, and chronic obstructive pulmonary disease. On physical examination, the patient was febrile and tachycardic and had left testicular edema with pain on epididymal palpation.

An initial evaluation consisted of laboratory tests that showed neutrophilic leukocytosis (WBC 24.2 x103/uL, neutrophils 87%). Chest X-ray evidenced thickening of the bronchial walls with no concomitant parenchymal abnormalities and urinalysis showed an increase in white blood cells and few Gram-negative bacteria. The testicular ultrasound showed an abscess in the tail of the left epididymis; oral doxycycline therapy was administrated.

On the fourth day, the patient developed clinical deterioration with worsening of respiratory symptoms and inadequate metabolic control (HbA1c 8.7% and central glycemia 510 mg/dL) requiring transfer to the intermediate-care unit for management of hyperosmolar hyperglycemic state. The computerized tomography (CT) of the abdomen and pelvis was normal but a follow-up chest X-ray evidenced multiple bilateral nodular lesions and left pleural effusion and positive blood and urine cultures yielding K. pneumoniaesensitive to penicillin, quinolone, and carbapenem.

The CT of the chest confirmed the presence of multiple bilateral nodules with halo sign and reversed halo sign. Presence of an extrapulmonary infective focus along with respiratory symptoms, isolation of bacteria in blood, and multiple bilateral nodules in the chest CT scan led to considering the diagnosis of SPE secondary to epididymitis. Therefore, it was decided to suspend the doxycycline and start intravenous ciprofloxacin.

Clinical evolution after a 14-day antibiotic course was satisfactory with an improvement of the respiratory symptoms and marked decrease in pain and testicular edema, the chest X-ray at day 14th showed a disappearance of the consolidations, and the testicular ultrasound of follow-up at day 16th showed a decrease in local inflammatory signs and resolution of the abscess in the tail of the epididymis.