Multiple peripheral nodules of different sizes, many cavitating, with feeding vessels — in an IV drug user, a patient with a line or right-sided endocarditis, or Lemierre syndrome — the chest CT should prompt echocardiography and a search for the source.
Orient first
- Sources: tricuspid endocarditis, infected lines or pacing leads, septic thrombophlebitis (Lemierre — internal jugular vein).
- Nodules are peripheral and basal, of different ages; some wedge-shaped (infarcts).
- Feeding vessel sign: a vessel leading to the nodule.
Acquire the study
- Contrast-enhanced CT chest (include the neck when Lemierre is suspected), lung and soft-tissue windows.
The manoeuvre
- Lung window: number and size of nodules in mm; cavitation; peripheral distribution.
- Feeding vessel sign on axial slices.
- Wedge-shaped subpleural opacities (septic infarcts).
- Post-contrast series: thrombus in the SVC, lines, internal jugular vein; empyema.
What confirms it
- Multiple cavitating peripheral nodules with a source of bacteraemia.
What licenses you to exclude it
- Stable non-cavitating nodules without sepsis argue against septic emboli.
The classic misread
- Calling them metastases in a febrile patient.