Abstract Introduction Septic pulmonary emboli (SPE) arise from infected thrombi, whereas bland pulmonary emboli (PE) are thrombotic. Mixed septic and bland emboli are rare and diagnostically challenging, particularly in patients with malignancy or chronic pelvic infection. We describe a case of combined bland PE, septic emboli, cavitary lung lesions, and Staphylococcus lugdunensis bacteremia originating from a chronic presacral abscess and enterocutaneous fistula. Case Report A 63-year-old man with rectal adenocarcinoma treated with neoadjuvant chemoradiation and resection had a complicated postoperative course including delayed anastomotic leak, chronic presacral abscess, and enterocutaneous fistula requiring multiple drain procedures and TPN. He presented with a month of cough, chills, and progressive dyspnea. CT angiography showed nearly occlusive and nonocclusive pulmonary emboli with borderline right ventricular strain. CT chest revealed multiple bilateral cavitary and non-cavitary nodules, concerning for septic emboli versus infarction or metastases. Bilateral lower extremity DVTs were present. Blood cultures grew Staphylococcus lugdunensis from a PICC-associated infection; catheter tip and urine cultures grew the same organism. Repeat cultures cleared after line removal. Echocardiography showed preserved ventricular function without vegetations. CT head showed no intracranial abscess, permitting initiation of full-dose heparin after multidisciplinary discussion. He was diagnosed with mixed bland and septic pulmonary emboli secondary to chronic pelvic infection and bacteremia. Management included prolonged IV vancomycin, anticoagulation, and meropenem. Due to persistent fistulous output, he underwent fistula takedown and end-colostomy, with improvement in inflammatory markers and drain output. Serial CT imaging showed partial resolution of thrombi and progressive improvement of cavitary lesions. He remained clinically stable and transitioned to inpatient rehabilitation. Discussion Mixed septic and bland pulmonary emboli are uncommon and often misdiagnosed in patients with malignancy and chronic infection. In this case, S. lugdunensis bacteremia from a pelvic source produced septic emboli, while concurrent bilateral DVTs contributed bland emboli. Cavitary pulmonary lesions mimicked metastases, complicating diagnosis. Exclusion of intracranial abscess enabled safe anticoagulation, highlighting the importance of coordinated multidisciplinary management. Optimal therapy requires both prolonged intravenous antibiotics and therapeutic anticoagulation, crucial for recovery in mixed embolic disease. This abstract is funded by: None
Worku et al. (Fri,) studied this question.