A 55-year-old woman with Streptococcal empyema

Kuo-Chiang Lian, MD, Lilit Pogosian, M.D., and Samuel Lada, M.D.
Internal Medicine Residency Program, David Geffen School of Medicine at UCLA
Clinical Presentation
A 55-year-old woman with an extensive smoking history presented with
shortness of breath and dyspnea on exertion. She reported that she had
recently had a severe upper respiratory infection with symptoms of fever,
sinus pressure, runny nose, cough, and chest congestion approximately three
weeks prior to presentation. Her symptoms resolved after several days, with
the exception of persistent shortness of breath to the point where she was
dyspneic with routine activity.
On presentation, the patient was afebrile but was tachypneic unable to
complete full sentences. Chest examination was remarkable for markedly
decreased breath sounds on the left side, with scattered coarse crackles, left
greater than right. Laboratory studies revealed an elevated WBC with
neutrophilic predominance. Chest x-ray (Figure 1) revealed a left upper lobe
consolidation with loculated pleural effusion. Computed tomography (Figure
2) of the chest revealed multiloculated left pleural effusion with pleural
thickening and subpleural consolidation. Empiric antibiotic coverage was
started with ceftriaxone and azithromycin.
Given the loculated effusion, an ultrasound-guided thoracentesis was
performed, which revealed frank pus, and a pigtail chest tube was placed.
Pleural fluid Gram stain revealed Gram-positive cocci in pairs, and culture
grew Streptococcus pneumoniae. The patient was taken for video-assisted
thoracoscopy for decortication of her loculated empyema, with placement of a
large-bore chest tube. She was discharged home on an extended course of
oral antibiotics with a one-way valve chest tube in place. A chest x-ray three
weeks later showed complete re-expansion of her left lung, and the chest tube
was removed.
Discussion
References
1. Light, RW. Parapenumonic effusions and empyema. Proc Am Thorac Soc 2006;3:75-80.
2. Light, RW, Macgregor, MI, Luchsinger, PC, Ball, WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern
Med 1972; 77:507.
3. Waite, RJ, Carbonneau, RJ, Balikian, JP, et al. Parietal pleural changes in empyema: appearances at CT. Radiology 1990; 175:145.
4. Colice, GL, Curtis, A, Deslauriers, J, et al. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline.
Chest 2000; 118:1158.













Figure 1. Chest x-ray from admission with loculated left pleural effusion
and consolidation.
Learning Objectives
Identify the presenting symptoms and signs of
Streptococcal pneumonia with empyema
Review the management of patients with Streptococcal
empyema, including pleural fluid analysis, indications
for chest tube placement, and surgical options
































Figure 2. CT images from admission with left pleural effusion,
consolidation, and cortication of lung pleura with rind formation.
Epidemiology
Of the approximately one million patients hospitalized with pneumonia in
the U.S. yearly, 20-40% have an associated effusion.
1
Pneumococcal
pneumonia and effusion in particular is associated with increased mortality.


Pathophysiology
In the first stage of development, an exudative parapneumonic effusion
rapidly accumulates due to increased pulmonary interstitial fluid. A
fibrinopurulent stage then develops, characterized by persistent bacterial
infection of the pleural fluid. A third stage of fibroblast proliferation finally
occurs, producing a thick pleural peel which requires decortication for re-
expansion of the lung.
1

Diagnosis The sun never sets on a pleural effusion.
In any significant pleural effusion, diagnostic thoracentesis is indicated.
Classically, pleural fluid analysis has been defined by Lights criteria, in exudate
is distinguished from transudate by any of the following: fluid:serum protein
ratio >0.5; fluid:serum LDH ratio >0.6; or fluid LDH greater than 2/3 upper limit
of normal serum LDH. Fluid pH, glucose, amylase, cell count and microbiology
may also yield important diagnostic information. Poor prognostic indicators on
pleural fluid evaluation include frank pus, positive bacterial stain, low glucose,
positive fluid bacterial culture, low pH, and high LDH.
1,2
Radiologic evaluation is invaluable in assessment of pleural effusion. CT
evaluation in particular may reveal pleural thickness and enhancement, character
of empyema, evaluation of abscess or other parenchymal process,
bronchopleural fistula, and imaging of fluid loculation.
3

Treatment
Guidelines recently published on the management of parapneumonic
effusions defined large or loculated effusions, positive microbiology, pus, and
low pH as indicators for drainage with thoracostomy tubes.
4
While fibrinolytic
therapy has been largely abandoned, DNase compounds show promise in
reducing empyema viscosity. In the setting of pleural rind, decortication and
lysis of adhesions is required for the lung to expand, and is increasingly
performed with video-assisted thoracoscopy.
1