History of Present Illness
A 50-year-old Caucasian man presented to the emergency room with fever of 7 days’ duration, shortness of breath, palpitations, and occasional cough with reddish brown, blood-stained sputum. He had been taking paracetamol, as needed. Chest radiography revealed abundant right hydropneumothorax ( Fig. 11.1 ).
Past Medical History
The patient was a bartender, a current smoker of about 20 cigarettes a day (30 pack-year), with a history of alcohol abuse and fatty liver. He had undergone tonsillectomy in childhood.
Physical Examination and Early Clinical Findings
The patient was alert, breathless at rest, and febrile (body temperature 38.4° C [101.12° F]). He had tachyarrhythmia, with heart rate 150 beats/min, and respiratory failure, with oxygen saturation measured by pulse oximetry (SpO 2 ) of 87% on room air. Respiratory rate was 25 breaths/min, and blood pressure was 170/85 mm Hg. Physical examination revealed absence of breath sounds to the right hemithorax. No pallor, clubbing, and peripheral edema were observed. Electrocardiography (ECG) revealed atrial fibrillation, with a high mean ventricular response.
Promptly 50% oxygen supplement was given via a Venturi mask. Arterial blood gas (ABG) analysis with this supplement resulted in sufficient correction of the partial pressure of oxygen (Pa O 2 75 mm Hg); normal partial pressure of carbon dioxide (Pa C O 2 38 mm Hg); normal blood pH (7.39); and a slight increase in lactate (1.9 mmol/L). To reduce heart rate, a beta-blocker (metoprolol 5 mg intravenously over 5 minutes) was given, followed by a calcium channel blocker (diltiazem 20 mg intravenously over 2 minutes). Paracetamol 1 g was also administrated intravenously for the fever.
Blood tests showed elevated white blood cell (WBC) count (16,400 cells/mm 3 ) and high inflammatory indices (C-reactive protein [CRP] 234 mg/L). Hemoglobin was 12.7 g/dL, the platelet count was 122,000 cells/μL, and the international normalized ratio (INR) was 1.09. An anticoagulant (subcutaneous enoxaparin 6000 units, corresponding to 100 units anti-Xa activity/kg bodyweight, twice daily) and a broad-spectrum antibiotic (intravenous piperacillin/tazobactam 4 g/0.5 g, three times a day) were started as well. Blood cultures were performed.
After the initial treatment, heart rate dropped to around 100 beats/min. Chest ultrasonography showed pleural fluid that was not uniformly anechoic, with numerous floating hyperechoic pinpoints suggestive of empyemic hydropneumothorax ( Fig. 11.2 ). Cardiac ultrasonography showed no abnormalities except for minimal mitral regurgitation. The ejection fraction of the left ventricle was normal (60%), and estimated systolic pulmonary pressure was not increased (30 mm Hg). There was no pericardial effusion.
The patient received information regarding the insertion of a chest tube, and he gave his consent for the procedure. The thoracic surgeon waited 12 hours after enoxaparin administration. With the use of a small-gauge needle, the surgeon injected a local anesthetic (20 mL of lidocaine 200 mg/mL) into the fifth right intercostal space along the midaxillary line. Then a 2.5-cm incision was made along the superior edge of the inferior rib. A curved clamp was used to bluntly dissect through the subcutaneous tissues. Then a 24-French (Fr) pleural drainage was introduced by using the trocar technique. Abundant, creamy, foul-smelling pus (about 1500 mL) flowed out from the pleural space upon entry, together with many air bubbles. The drained pus was sent for microbiological tests. The patient experienced rapid subjective improvement and partial reappearance of breath sounds in the right hemithorax. Subsequently the patient was admitted to the pulmonology department.
Clinical Course
As recommended by the cardiologist, the patient received oral digoxin 0.125 mg once a day, oral diltiazem 60 mg twice daily, and subcutaneous enoxaparin 6000 units twice daily.
The pleural cavity was washed with saline two times daily through the double lumen thoracic drain. In about 36 hours, the fever disappeared, and the respiratory symptoms improved. In 48 hours, greater than 3000 mL of fluid was evacuated.
The chemical–physical examination of the pleural fluid was consistent with the diagnosis of empyema: low pH (7.17), low glucose concentration (30 mg/dL [1.66 mmol/L]), and high LDH levels (1800 units/L).
The microbiologist warned the physicians regarding the gram-positive cocci found in pleural fluid cultures, subsequently defined as colonies of methicillin-resistant Staphylococcus aureus (MRSA). Parenteral vancomycin 500 mg four times a day was added. In the following days, vancomycin trough concentrations at steady state were adequate (≥ 15 μg/mL). Blood culture results were negative.
Chest radiography performed 1 week after pleural drain placement showed persistence of hydropneumothorax and incomplete expansion of the right lung ( Fig. 11.3 ).
