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Dx: Chest Tube Reveals Problematic Empyema

After consultation with thoracic surgery, a contrasted CT of the chest was obtained in an attempt to delineate the patient’s underlying thoracic pathology (below).

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alt TOP: Very large fluid collection with an air-fluid level within the right hemithorax with near complete collapse of the right lung. Gas bubbles within the fluid portion of the collection suggests complexity. Differential considerations include an intraparenchymal lung abscess as well as an empyema.
BOTTOM: Chest tube insertion demonstrated projectile thick, yellow, exudative fluid

Based upon the CT findings, a right-sided chest tube was inserted (above).
On placement of the chest tube, 1500 CCs of thick, yellow, exudative fluid was removed from the right chest cavity. The patient acknowledged improvement in respiratory status. The pleural fluid was sent to the lab for analysis, gram stain, and culture. Blood cultures were drawn and sent. Because of the concern for lung abscess or empyema the patient was started on Vancomycin and Zosyn. The patient remained hemodynamically stable in the emergency department and was transferred to a general medical floor for further care.

The patient had a prolonged hospital course after admission from the emergency department. He had persistent collapse of the right lung and a decision was made to take the patient for video-assisted thoracic surgery (VATS). He had three more chest tubes placed in the operating room and was unable to be extubated for several days post-procedure, due to persistent hypoventilation. The patient’s blood and pleural fluid cultures did not grow out any bacteria. Legionella antigen testing, fungal cultures and mycobacterium testing were also performed and negative. The infectious disease team was consulted on the floor and expressed concern for an anaerobic organism as the cause of infection although no organism was ever identified on culture. A PICC line was placed and the patient was discharged to a SNF after 12 days in the hospital with one chest tube still in place. The patient was continued on Unasyn, as an outpatient, and after five weeks his last chest tube was removed.

Discussion:
An empyema is a collection of exudate in the pleural cavity. It is most often caused by pleural extension of pneumonia, but it may also be able to be caused by any seeding of the pleural cavity from penetrating trauma, esophageal rupture, previous thoracic surgery, or previous chest tube placement (1). Empyema is also an under recognized complication of blunt thoracic trauma and may be an occult perpetrator in subsequent respiratory failure and need for mechanical ventilation (2).

In the emergency setting, chest radiography is indicated to differentiate other chest pathology that can present similarly. A CT of the chest may be necessary to assess for underlying pneumonia, lung abscess, tumor, septations, or other pleural disease.

In the absence of trauma or surgery, the diagnosis of empyema would  be very unlikely. Clinically, one might suspect empyema if the patient has fever, productive cough, or clinical sx’s c/w pneumonia. Radiographically and without a known history, it would  be difficult  to differentiate the two entities – the gold standard for differentiating them (after getting an appropriate history) is tube thoracostomy and evaluation of the fluid.

The definitive management of empyema should be made in consultation with thoracic surgery and infectious disease. The gold standard of treatment has been prompt tube thoracostomy and intravenous antibiotics, but recent literature has suggested a benefit in both intrapleural fibrinolytics and early VATS (3, 4). The patient’s pleural fluid should be sent for analysis and they should be admitted to the hospital for continued therapy.

References:
1. Zwanger M, O’Connor R. Empyema and Abscess Pneumonia in Emergency Medicine. Available at : http://emedicine.medscape.com/article/807499-overview. Accessed August 10, 2011
2. Watkins JA, Spain DA, Richardson JD, Polk HC Jr. Empyema and restrictive pleural processes after blunt trauma: an under-recognized cause of respiratory failure. Am Surg. 2000;66:210-4
3. Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev. Apr 16 2008;CD002312
4. Schneider CR, Gauderer MW, Blackhurst D, Chandler JC, Abrams RS. Video-assisted thoracoscopic surgery as a primary intervention in pediatric parapneumonic effusion and empyema. Am Surg. Sep 2010;76(9):957-61

 


 

 

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