History of Present Illness
A 58-year-old man arrived at the emergency room with high fever, dyspnea, anorexia with loss of weight, weakness, and confusion.
Past Medical History
The patient was a current smoker of 15 to 20 cigarettes a day (40 pack-year). He had a history of long-term alcohol abuse, with consequent psychosis, ataxia, and fatty liver.
Physical Examination and Early Clinical Findings
The patient was alert but confused and disoriented. He was pale, had poor fat and muscle mass, and had a body mass index of 19 kg/m 2 . Blood pressure was low (90/60 mm Hg). Arterial blood gas analyses in room air showed acute respiratory failure without hypercapnia: pH 7.42; partial pressure of oxygen (Pa O 2 54.3 mm Hg); partial pressure of carbon dioxide (Pa CO 2 ) 41.6 mm Hg; and bicarbonate (HCO 3− ) 24.5. Blood tests showed marked leukocytosis (37,000/μL) and high inflammation indexes (C-reactive protein (CRP) 324 mg/dL; procalcitonin 10.9 ng/mL).
Chest examination revealed absence of vesicular murmur in the lower field of left hemithorax. Rare fine crackles were appreciated in the middle and upper fields of the same side. No pathological findings were observed on the left hemithorax. No peripheral edema was present. Chest radiography performed in the emergency room showed multiple opacities, with tapering obtuse margins along the right lateral chest wall and at the right lung base, suggestive of loculated pleural effusion ( Fig. 9.1 ). The patient was admitted to the internal medicine department.
Clinical Course
The patient was given supplemental 50% oxygen via a Venturi mask and intravenous fluids (continuous 0.9% saline at 60 mL/h). Empiric antibiotic therapy was started with oral levofloxacin 750 mg a day and intravenous piperacillin/tazobactam 4.5 g three times a day. Chest ultrasonography showed organized pleural effusion with multiple adhesions and loculations in lower-posterior, lateral, lower-anterior, and upper-anterior zones, with an underlying partially consolidated lung ( Fig. 9.2 , A and B ). Despite the therapy, in the subsequent 72 hours, the patient showed persistent signs of dysventilation of the right lung and further episodes of fever.
Chest computed tomography (CT) ( Fig. 9.3 , A and B ) showed multiloculated pleural fluid collections, confirming the ultrasonographic and radiographic findings. A 20-French (Fr) chest tube was inserted through the fifth intercostal space and connected to a water seal chamber. About 600 mL of dull yellow fluid highly suggestive for pus was drained ( Fig. 9.4 ). Physical–chemical examination of pleural fluid was coherent with empyema: low pH (7.12); high level of lactate dehydrogenase (LDH; 2,200 units/L); and low glucose concentration (2.0 mmol/L). Microscopic examination for acid-fast bacilli (AFB) yielded a negative result.
Paracetamol 1 g three times a day was needed to control pain at the chest tube insertion site. After 2 days, the fever disappeared, and the inflammatory indices begun to decrease.
However, bedside ultrasonography showed incomplete lung expansion and persistence of extensive fibrin net with multiple pleural locules. The corresponding chest radiograph is shown in Fig. 9.5 .
