45-yo AAM with no significant PMH, presents with a CC: cough of one week duration, initially productive of thick green sputum, now sputum is thicker and unable to produce sputum as efficiently. He also c/o chest pain with cough, DOE and fever. He denies chills but muscle aches. He never had similar symptoms before and does not follow with a regular doctor.
He looks in moderate respiratory distress with mid sentence pauses and tachypnea.
Chest: Crackles and dullness at the right base
CVS: Tachycardic but regular
What do you think is going on?
Pneumonia was suspected with the symptoms of with high fever, tachypnea, and obvious respiratory distress
In ER, patient was started on pneumonia protocol with IV ABx - Claforan 1 gram and Azithromycin 500 mg which were continued during the hospital stay.
What labs would you order?
EKG was done and showed sinus tachycardia
CBCD showed leukocytosis of 11.9 with bandemia
Would you order an ABG?
Yes, you should.
ABG: PaO2 62 mmHg, SpO2 90% on RA
CXR PA view; R Lateral CXR (click to enlarge)
CXR PA and lateral report: There is no previous examination for comparison. The cardiac silhouette shows mild prominence. Both the lungs are in the shallow inspiratory phase; otherwise the left lung is clear. There is consolidation in the right lower lobe with atelectasis in addition to the small amount of pleural effusion.
CT of the chest
CT chest with IV contrast
CT chest with IV contrast - lung windows
CT chest with contrast report: A multiloculated complex hypoattenuating likely pleural based structure with air levels and internal air bubbles is present within the right paramedian lower thorax measuring approximately 13 x 9 x 5 cm in longitudinal, AP and transverse dimensions, respectively. Superiorly, this structure results in a moderately severe compression of the right lower lobe bronchus. A cluster of subcarinal lymph nodes is present, largest measuring approximately 18 mm in short axis diameter. Partially loculated pleural effusion and volume loss and/or pulmonary parenchymal fibrosis are noted on the right in a patchy distribution.
1. Cavitating right empyema in association with partial volume loss of RLL and RLL air space infiltrate
2. Enlarged subcarinal lymph nodes likely represent a reactive infection/inflammatory process.
CXR showed an irregular infiltrate and suspected effusion on the right. The effusion looked somewhat strange in distribution especially on the lateral CXR, located anteriorly and a CT scan was ordered.
The CT scan of the chest revealed a complex loculated pleural effusion with air pockets consistent with empyema. At this point, the ID consultant and the PCP decided that medical management would not be enough and they asked a cardiothoracic surgeon to help.
The cardiothoracic surgeon thought that the abscess is too medial to try VATS, and an open thoracotomy was done. The exact procedure was right thoracotomy with decortication and bronchoscopy and wedge biopsy of the right lower lobe under general anesthesia. The surgeon found an abscess cavity and managed to remove all the infectious debris from it, and then the lung was decorticated. A single chest tube was placed and directed toward where the abscess cavity had been
RLL Pneumonia with empyema and abscess formation.
Acetaminophen 650 mg q4p/prn po
Lisinopril 5 mg qd po
Ipratropium bromide 0.5 mg q4 ih
Albuterol sulf 2.46 mg q4 ih
Triamterene 37.5mg / 1 tab qd po
Guaifenesin 10 ml p/prn po
Guaifenesin 10 ml q8 po
Pantoprazole sod sesq 40 mg qd po
Propoxyphen n 100mg/a 1 ea q4-6p/p po
Premix i.v. 0 mls q6iv iv
Piperacill na/tazob 3.375 gm
Azithromycin 500 mg qd po
What did we learn from this case?
If there is a pulmonary problem, think sequentially:
- If the SpO2 is low, do ABG
- If there are abnormalities on CXR and you are not sure what is behind them, do CT scan of the chest
An empyema and abscess can hide behind what looks like a pneumonia with small parapneumonic effusion.
Do not wait for the antibiotics to take effect for days, do a CT scan of the chest and call a surgeon early if empyema is suspected.
Diagnostic Approach to Pleural Effusion in Adults. Am Fam Phys, Vol. 73 No. 5, April 1, 2006.
Physician, Heal Thyself - DrCharles.blogspot.com
A young physician died from pneumonia in 1920, eight years later Alexander Fleming would discover penicillin
Last updated: 4/2006