Case In Point: Middle-Aged Man With Worsening Cough and Dyspnea

Case In Point: Middle-Aged Man With Worsening Cough and Dyspnea

A 52-year-old man with hypertension and hyperlipidemia presents to the emergency department with a 5-month history of cough and dyspnea. Despite several courses of oral antibiotics, the patient's dyspnea has worsened; his cough has persisted and now produces foul-smelling brown sputum. He denies fever, chills, and rigors. His appetite is only fair; he lost 8 lb during the month before this evaluation. He is a long-time smoker but has no history of alcohol or substance abuse.

The patient's temperature is normal; his blood pressure is 125/75 mm Hg. He is tachypneic, with a respiration rate of 24 breaths per minute. His heart rate is 93 beats per minute. No lymphadenopathy is detected. Decreased air entry in the left hemithorax and dullness to percussion over the left lower lobe and lingular area are noted. Tactile vocal fremitus (TVF) is decreased in the same areas. The remainder of the physical examination is unremarkable.

The posteroanterior chest radiograph suggests a rounded retrocardiac density in the left hemithorax (Figure 1). This is confirmed by the lateral view, which shows a large posterior lobulated shadow (Figure 2). The differential diagnosis at this point includes loculated pleural effusion, lung abscess without an air-fluid level, and thoracic empyema with or without an underlying malignancy. A chest CT scan delineates a 9 3 8-cm rounded density (Figure 3). The difference in homogeneity suggests a walled-off fluid collection with no evidence of air.

Intravenous levofloxacin and clindamycin are initiated in anticipation of percutaneous chest tube insertion into the lesion in the left hemithorax. The pleura in the left posterior lung base is slightly thickened; however, there is no evidence of an endobronchial obstructing lesion, hilar-mediastinal mass lesion, or pulmonary nodule. After the tube is placed, about 850 mL of foul-smelling brown fluid is evacuated by gravity (Figure 4). Microbiologic culture of the contents reveals Streptococcus intermedius, which is sensitive to levofloxacin. Cytologic analysis of the drainage material reveals no malignancy. Intravenous levofloxacin is continued for 10 days, followed by oral levofloxacin for another 2 weeks. Chest radiography and chest CT are repeated just before the chest tube is removed to assess whether surgery is needed. The CT scan shows almost complete resolution of the empyema.


Almost two thirds of cases of pleural empyema result from pneumonia with a complicated parapneumonic effusion. Other causes include chest trauma, tuberculosis, and mediastinal or pulmonary surgery, especially lung resection. In approximately 10% of patients, no cause is apparent.1,2

Mortality from empyema ranges from 1% to 19%.3 The prognosis is worse for elderly patients and for those with comorbid cardiac, pulmonary, or renal disease. The outcome is also likely to be poor in patients with hospital-acquired or culture-positive empyema, especially those with collections of fluid that contain Gram-negative bacteria or multiple pathogens.3


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