The incidence of acute pulmonary thromboembolism (PTE) is increasing in Japan; however, recent studies have reported that acute PTE associated with pulmonary infarction is easily overlooked. Hence, to facilitate the early diagnosis of acute PTE with pulmonary infarction, we retrospectively investigated and compared the clinical and radiologic findings between acute PTE patients with and without pulmonary infarction. Patients with pulmonary infarction were significantly younger (median: 42.0 vs 70.5 years, p < 0.01), and the frequencies of chest or back pain and hemoptysis were significantly higher than patients without pulmonary infarction (p < 0.01). Regarding chest computed tomography (CT) findings, central lucencies were noted in 69% of patients with pulmonary infarction and occurred predominantly in the lower lobes. Of note, patients with pulmonary infarction were frequently (69%) treated with antibiotics before definite diagnoses, based on high C-reactive protein levels and infiltrations visible on chest radiographs and CT scans. In the diagnosis of acute respiratory failure, the clinical symptoms of chest or back pain and hemoptysis, and chest CT findings such as central lucencies and wedge-shaped peripheral consolidations in the lower lobes should be carefully considered.