Sepsis other imaging findings
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2] Jason Le, B.S.[3]
Synonyms and keywords: sepsis syndrome; septic shock; septicemia
Sepsis other imaging findings
Overview
No imaging finding establishes the diagnosis of sepsis itself. Imaging in sepsis serves to identify the infectious source, characterize organ dysfunction, and detect complications amenable to source control. This microchapter focuses on the cross-modality source-identification strategy and imaging applications not primarily covered by dedicated chest radiograph, CT, MRI, and echocardiography/ultrasound microchapters, particularly nuclear/molecular imaging, image-guided source control, and characteristic cross-sectional complications.[1][2]
Multimodality source identification
When no infectious source is clinically apparent, obtain a chest radiograph and evaluate for urinary infection, followed by targeted imaging based on the clinical assessment. Contrast-enhanced CT of the chest, abdomen, and pelvis is a high-yield conventional cross-sectional study when a source remains unclear; in an emergency department cohort, a septic focus was identified in approximately 76.5% of CT examinations, including chest/pneumonia (38.6%), abdomen (22.0%), and pelvis/genitourinary tract (20.5%), with a positive predictive value of approximately 82%. The negative predictive value was low (approximately 22%), so a negative CT does not exclude an infectious source.[1]
Targeted CT is preferred over untargeted whole-body scanning and should be selected according to the suspected source and clinical findings. Intravenous contrast improves detection and characterization of abdominal infectious sources; noncontrast CT may be used when intravenous contrast is contraindicated.[1][2]
Detailed modality-specific findings are addressed in the dedicated chest radiograph, CT, MRI, and echocardiography/ultrasound microchapters.
Nuclear and molecular imaging
For an occult infectious source or fever of unknown origin after an unrevealing or inconclusive conventional evaluation, 18F-FDG PET/CT is the principal molecular imaging modality. Reported pooled diagnostic performance is approximately 84.4% sensitivity and 61.8% specificity, with higher sensitivity than radiolabeled leukocyte scintigraphy and gallium-67 scintigraphy in this setting.[3][4]
For suspected cardiovascular infection or endovascular infection, 18F-FDG PET/CT is an important primary molecular imaging modality. Radiolabeled-leukocyte SPECT/CT has higher specificity but lower sensitivity in selected cardiovascular infections and has limited utility for gram-negative or fungal infection.[5]
Image-guided source control
The Surviving Sepsis Campaign 2026 guideline conditionally recommends early source control, typically within approximately 6 hours, when a source requiring source control is identified. Evidence certainty is very low; pooled evidence cited by the guideline showed lower mortality with early source control (RR 0.70; 95% CI 0.51-0.95).[6]
When anatomically feasible, ultrasound- or CT-guided percutaneous catheter drainage provides a minimally invasive method of source control for accessible infected collections. Surgical source control is used when percutaneous drainage is not feasible, inadequate, or otherwise inappropriate.[6]
Imaging of characteristic complications
Bilateral adrenal hemorrhage/Waterhouse-Friderichsen syndrome: CT may demonstrate bilateral hyperattenuating adrenal enlargement, approximately 50-90 HU, with associated periadrenal stranding. Extensive bilateral adrenal hemorrhage can cause acute adrenal insufficiency and should be recognized as a potentially life-threatening complication.[7]
Non-occlusive mesenteric ischemia: CT angiography may demonstrate reduced or absent bowel-wall enhancement. Increased unenhanced bowel-wall attenuation is also among the more specific CT findings. This complication should be considered in septic patients with clinical features suggesting intestinal ischemia despite the absence of an arterial occlusion.[8]
References
- ↑ 1.0 1.1 1.2 Brixey AG, Fung A, De Leon AD; et al. (2024). "ACR Appropriateness Criteria® Sepsis". Journal of the American College of Radiology. 21 (6S): S292–S309. doi:10.1016/j.jacr.2024.02.029.
- ↑ 2.0 2.1 Yealy DM, Mohr NM, Shapiro NI; et al. (2021). "Early Care of Adults With Suspected Sepsis in The Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report". Annals of Emergency Medicine. 78 (1): 1–19. doi:10.1016/j.annemergmed.2021.02.006.
- ↑ van Rijsewijk ND, IJpma FFA, Wouthuyzen-Bakker M, Glaudemans AWJM. (2023). "Molecular Imaging of Fever of Unknown Origin: An Update". Seminars in Nuclear Medicine. 53 (1): 4–17. doi:10.1053/j.semnuclmed.2022.07.002. PMID 35902280 Check
|pmid=value (help). - ↑ Hess S, Noriega-Álvarez E, Leccisotti L; et al. (2024). "EANM consensus document on the use of [18F]FDG PET/CT in fever and inflammation of unknown origin". European Journal of Nuclear Medicine and Molecular Imaging. 51 (9): 2597–2613. doi:10.1007/s00259-024-06732-8.
- ↑ Bourque JM, Birgersdotter-Green U, Bravo PE; et al. (2024). "18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations From ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS". JACC: Cardiovascular Imaging. 17 (6): 669–701. doi:10.1016/j.jcmg.2024.01.004. PMID 38466252 Check
|pmid=value (help). - ↑ 6.0 6.1 Prescott HC, Antonelli M, Alhazzani W; et al. (2026). "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026". Critical Care Medicine. 54 (4): 725–812. doi:10.1097/CCM.0000000000007075.
- ↑ Alshahrani MA, Bin Saeedan M, Alkhunaizan T, Aljohani IM, Azzumeea FM. (2019). "Bilateral adrenal abnormalities: imaging review of different entities". Abdominal Radiology. 44 (1): 154–179. doi:10.1007/s00261-018-1670-5.
- ↑ Pinto A, Lanzetta MM, Addeo G; et al. (2022). "Errors in MDCT diagnosis of acute mesenteric ischemia". Abdominal Radiology. 47 (5): 1699–1713. doi:10.1007/s00261-020-02732-y.