70 Pulmonary - highsky

[ArchivalUser]

A 63-year-old man is evaluated for a 2-week history of cough, fever, and increasing shortness of breath. He has a dull ache in his right chest and has lost 2 kg (4.4 lb) in a week. The patient is a smoker with a long history of heavy alcohol consumption; he also has poorly controlled type 2 diabetes mellitus.

On examination, the temperature is 38.9 °C (102 °F), blood pressure is 96/60 mm Hg, pulse rate is 120/min, and respiration rate is 26/min. He has halitosis with poor oral hygiene. The trachea is not deviated. There is decreased respiratory excursion on the right side with decreased breath sounds and egophony. Tubular bronchial breathing is heard in the mid-chest posteriorly. Laboratory examination reveals a peripheral blood leukocyte count of 24,000/μL (24 × 109/L) and the hemoglobin is 8.5 g/dL (85 g/L). Chest radiograph shows a moderate right pleural effusion. A right lateral decubitus film shows the effusion to be large (>3 cm from the chest wall to the lung margin) and free flowing, associated with a right lower lobe infiltrate. Thoracentesis is performed and 1 L of foul smelling turbid fluid is aspirated. Gram stain reveals gram-positive cocci and gram-negative rods. Pleural fluid results are as follows:

Laboratory Studies
Cell count

Erythrocytes 1200/μL (1.2 × 109/L), leukocytes 2495/μL (2.495 × 109/L) with 80% neutrophils, 15% lymphocytes, 2% mesothelial cells, and 3% eosinophils.
Total protein

5.5 mg/dL (55 g/L)
Lactate dehydrogenase

3200 U/L
Glucose

25 mg/dL (1.39 mmol/L)
pH

6.95

Which of the following would be the most appropriate next step in the management of this patient?

A Intravenous ceftriaxone and azithromycin
B Intravenous piperacillin-tazobactam plus gentamicin
C Intravenous piperacillin-tazobactam plus gentamicin plus tube thoracostomy
D Intravenous ciprofloxacin and video-assisted thoracoscopy with decortication
E Intrapleural fibrinolytic therapy

[ArchivalUser]

cc

[ArchivalUser]

CC

[ArchivalUser]

(Correct Answer = C)


* Patients with anaerobic bacterial infection involving the pleural space usually have subacute presentations with weight loss and a history of alcoholism, unresponsiveness, possible aspiration, and poor oral hygiene.
* Fibrinolytic therapy may be considered in patients with empyema who are poor surgical candidates.

This patient has an anaerobic pleural effusion with characteristics that suggest the probability of subsequent loculation if drainage is not accomplished in conjunction with institution of antibiotic therapy directed towards the causative pathogens. Tube thoracostomy is indicated in addition to institution of appropriate antibiotic coverage.

Patients with anaerobic bacterial infection involving the pleural space usually have subacute presentations. The median duration of symptoms is usually 10 days before diagnosis. Patients also usually have significant weight loss and may have history of alcoholism, unresponsiveness, possible aspiration and poor oral hygiene.

Anaerobic organisms are isolated from pleural aspirates less often than aerobic organisms but the yield depends upon the care with which pleural fluid is cultured when anaerobic infection is suspected. The most common anaerobic organisms cultured from pleural fluid are Bacteroides and Peptostreptococcus species.

A decubitus chest radiograph is of value and can help determine if intrapleural loculation is present. With the affected side dependent, free-flowing fluids will occupy the space between the ribcage and the inferior aspect of the lung. Loculated fluid will not œlayer-out on decubitus radiographs and may present as pleural-based masses that lack air bronchograms.

The presence of a multiloculated parapneumonic effusion with or without documentation of empyema by demonstration of organisms within pleural fluid by Gram stain or by pleural fluid culture indicates that pleural drainage should be performed. Early video-assisted thoracoscopy (VATS) or thoracotomy are the generally preferred approaches for operative candidates who have persistent sepsis and loculation. In the above scenario the pleural effusion is free flowing, so a decortication is not indicated at this time.

Antibiotic treatment should include adequate anaerobic coverage which can be provided with piperacillin-tazobactam, metronidazole or clindamycin, or penicillin. Ceftriaxone and azithromycin is the initial choice for community-acquired pneumonia when anaerobic infection is not suspected. Although gram-negative coverage is also required given the initial stain of the pleural fluid, ciprofloxacin alone does not provide adequate anaerobic coverage for use in these circumstances.

A multicenter trial showed that streptokinase did not improve mortality, surgical or length-of-stay outcomes, challenging the use of routine fibrinolytic therapy for empyema. At present, intrapleural use of streptokinase or alternative fibrinolysins including urokinase or tissue plasminogen activator should still be considered for non-surgical candidates.
Bibliography

[ArchivalUser]

thnx

[ArchivalUser]

thanks