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Some images on Figure 1 are so compelling that we want to know more details on presentation, diagnosis, and treatment for an “Expanded Case”. These expanded cases have been written by the healthcare professional who treated the patient and posted the case to Figure 1. 


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Case:

This is the case of a 66 year-old female who was brought to my attention due to her hypoxemia, shortness of breath, and abnormal chest X-Ray.

The patient had a past medical history of untreated COPD, cigarette smoking, and schizoaffective disorder. She took no medications and had no allergies.

She had reported feeling feverish, unwell, and moderately short of breath for a three month period with an acutely worse phase for three days prior to admission. The patient described producing large volumes of purulent sputum over the recent six weeks, and was also experiencing orthopnea, mostly related to sputum production.

On examination, the patient was hypertensive, tachycardic, and tachypneic. Her oxygen saturation was 94% on 80% O2 via high-flow face mask. The patient appeared unkempt – she had several mats in her hair and dark crusts on the soles of her feet. Her pulses were normal, her skin was uniformly warm to touch, and the precordium was hyperdynamic with normal heart sounds. No mottling was present. 

Auscultation of the chest demonstrated coarse crackles bilaterally and markedly reduced air entry to the entire right lung. Bronchial breath sounds were present on the right. Percussion demonstrated stony dullness of the entire right hemithorax and normal resonance on the left.

Noting the “whiteout” of the right hemithorax, a CT of the chest was obtained, which demonstrated compression of the right lung and a massive, complex pleural effusion.

Under ultrasonic guidance, a chest drain was inserted percutaneously to drain the effusion. Immediately, 1.3L of frankly purulent fluid drained from the chest, and the patient’s dyspnea improved markedly. The fluid was sent for Gram stain and culture.

Final diagnosis:

Thoracic empyema

Treatment:

Broad spectrum antibiotics were started, and a regimen of fibrinolytics was administered into the chest tube to facilitate drainage.

Original Case on Figure 1:

Thoracic Empyema

Further reading:

Management of Pleural Effusion, Empyema, and Lung Abscess. Semin Intervent Radiol. Mar 2011; 28(1): 75–86. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140254/pdf/sir28075.pdf (OPEN ACCESS)

Case Written by: JenkinsMD

Original Case on Figure 1: Thoracic Empyema


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