Transcript Slide 1

67 year old male was admitted to OSH on 6/30/05 with L-sided
chest pain, shortness of breath, and hypoxia after 2 weeks of
coughing up yellow sputum. CT at OSH showed L pleural
effusion, L hilar fullness, and a 2x3 cm mediastinal LN.
Thoracentesis on 7/1 showed exudative fluid without evidence
for malignancy and no growth. The patient was started on
moxifloxacin, and BAL washings on 7/5 grew MSSA. As of
7/13, patient’s condition had not improved, and he was
transferred to UVA still feeling ill, nauseated, and dyspneic.
PMHx: diabetes mellitus, HTN, chronic kidney disease, R
tib/fib fx 8 months ago.
SHx: quit smoking in 1982 after 30+ pk yrs.
Allergic to augmentin.
History otherwise noncontributory.
On exam, patient was afebrile, O2 sat 94% on 2LNC, and his
breath sounds were decreased over entire L lobe. WBC was 13.2.
Differential Diagnosis of
Nonresolving Pneumonia
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Inappropriate treatment of pathogen
Misdiagnosis of nonbacterial pathogens: mycobacteria, fungi,
Nocardia, and Actinomyces
Resistant bacterial pathogens
Development of complications: empyema, lung abscess
Neoplastic disorders: brochogenic ca, bronchoalveolar cell ca,
lymphoma
Immunologic disorders: vasculitis, BOOP, Eosinophilic
pneumonia syndromes, AIP, pulmonary alveolar proteinosis,
sarcoidosis, SLE
Drug toxicity
Pulmonary vascular abnormalities: CHF, PE
L pleural effusion and L-sided air
space disease.
Minimal layering of left pleural
effusion. Possibly partially
loculated left effusion and/or
airspace disease L base.
Pleural thickening along the posterior aspect of the right lung base and marked left-sided
pleural thickening that includes costal, paravertebral, and mediastinal pleural surfaces.
Circumferential pleural thickening within the left hemithorax may be either infection or
malignancy.
There is a fluid collection with sporadic pockets of gas that appears to be trapped in the
posterior pleural space.
This may represent an empyema.
18 mm short axis
prevascular lymph node.
L hilar mass 27 x 34 mm may represent an enlarged lymph node or primary malignancy.
Hospital Course
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Patient placed on vancomycin and clindamycin.
Thoracentesis on 7/14. 40 cc fluid with glucose < 2 (<40-30),
LDH 5275 (>1000), pH 7.4 (<7.20), 3+PMNs, no bacteria.
Bronchoscopy on 7/14 with biopsy and BAL showed no
evidence of malignancy. Negative for legionella, AFB, viruses,
PCP, fungi. BAL positive for gm+ cocci.
On 7/20, patient went to TCV for drainage of empyema and L
visceral and parietal decortication. As the pleural rind was
elevated, they entered a L apical segment lower lobe abscess.
This was drained. Chest tube was placed. Pathology consistent
with empyema and abscess. No evidence of malignancy.
On 7/25, chest tube removed.
On 7/27, patient was discharged. He was maintaining O2 sat of
96% on 1-2L at rest and ambulating with 3LNC. CXR at time
of discharge showed haziness secondary to decortication but
resolving effusion.
Final diagnosis: MSSA lung abscess and empyema
Student Teaching File Case
Amy Oyler
UVA SOM 06
Period #2: July 23- August 20, 2005
References
 Ost, David, Alan Fein, Steven Feinsilver, Rakesh
Shah, “Nonresolving pneumonia.” UptoDate.
 Strange, Charlie, “Pathogenesis and management
of parapneumonic effusions and empyema in
adults.” UptoDate.