67 year old male was admitted to OSH on 6/30/05 with L-sided 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 chest pain, shortness of breath, and hypoxia after 2 weeks of coughing up yellow sputum. CT at OSH showed L pleural coughing up yellow sputum. CT at OSH showed L pleural effusion, L hilar fullness, and a 2x3 cm mediastinal LN. effusion, L hilar fullness, and a 2x3 cm mediastinal LN. Thoracentesis on 7/1 showed exudative fluid without evidence Thoracentesis on 7/1 showed exudative fluid without evidence for malignancy and no growth. The patient was started on for malignancy and no growth. The patient was started on moxifloxacin, and BAL washings on 7/5 grew MSSA. As of moxifloxacin, and BAL washings on 7/5 grew MSSA. As of 7/13, patient’s condition had not improved, and he was 7/13, patient’s condition had not improved, and he was transferred to UVA still feeling ill, nauseated, and dyspneic. transferred to UVA still feeling ill, nauseated, and dyspneic.

PMHx: diabetes mellitus, HTN, chronic kidney disease, R PMHx: diabetes mellitus, HTN, chronic kidney disease, R tib/fib fx 8 months ago.tib/fib fx 8 months ago.

SHx: quit smoking in 1982 after 30+ pk yrs.SHx: quit smoking in 1982 after 30+ pk yrs. Allergic to augmentin.Allergic to augmentin. History otherwise noncontributory.History otherwise noncontributory.

On exam, patient was afebrile, O2 sat 94% on 2LNC, and his On exam, patient was afebrile, O2 sat 94% on 2LNC, and his breath sounds were decreased over entire L lobe. WBC was breath sounds were decreased over entire L lobe. WBC was 13.2.13.2.

Differential Diagnosis of Differential Diagnosis of Nonresolving PneumoniaNonresolving Pneumonia

Inappropriate treatment of pathogenInappropriate treatment of pathogen Misdiagnosis of nonbacterial pathogens: Misdiagnosis of nonbacterial pathogens:

mycobacteria, fungi, Nocardia, and Actinomycesmycobacteria, fungi, Nocardia, and Actinomyces Resistant bacterial pathogensResistant bacterial pathogens Development of complications: empyema, lung Development of complications: empyema, lung

abscessabscess Neoplastic disorders: brochogenic ca, Neoplastic disorders: brochogenic ca,

bronchoalveolar cell ca, lymphomabronchoalveolar cell ca, lymphoma Immunologic disorders: vasculitis, BOOP, Immunologic disorders: vasculitis, BOOP,

Eosinophilic pneumonia syndromes, AIP, Eosinophilic pneumonia syndromes, AIP, pulmonary alveolar proteinosis, sarcoidosis, SLEpulmonary alveolar proteinosis, sarcoidosis, SLE

Drug toxicityDrug toxicity Pulmonary vascular abnormalities: CHF, PEPulmonary 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.

Circumferential pleural thickening within the left hemithorax may be either infection or malignancy.

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.

This may represent an empyema.

There is a fluid collection with sporadic pockets of gas that appears to be trapped in the posterior pleural space.

L hilar mass 27 x 34 mm may represent an enlarged lymph node or primary malignancy.

18 mm short axis prevascular lymph node.

Hospital CourseHospital Course Patient placed on vancomycin and clindamycin.Patient placed on vancomycin and clindamycin. Thoracentesis on 7/14. 40 cc fluid with glucose < 2 (<40-Thoracentesis on 7/14. 40 cc fluid with glucose < 2 (<40-

30), LDH 5275 (>1000), pH 7.4 (<7.20), 3+PMNs, no 30), LDH 5275 (>1000), pH 7.4 (<7.20), 3+PMNs, no bacteria.bacteria.

Bronchoscopy on 7/14 with biopsy and BAL showed no Bronchoscopy on 7/14 with biopsy and BAL showed no evidence of malignancy. Negative for legionella, AFB, evidence of malignancy. Negative for legionella, AFB, viruses, PCP, fungi. BAL positive for gm+ cocci.viruses, PCP, fungi. BAL positive for gm+ cocci.

On 7/20, patient went to TCV for drainage of empyema and L On 7/20, patient went to TCV for drainage of empyema and L visceral and parietal decortication. As the pleural rind was visceral and parietal decortication. As the pleural rind was elevated, they entered a L apical segment lower lobe elevated, they entered a L apical segment lower lobe abscess. This was drained. Chest tube was placed. abscess. This was drained. Chest tube was placed. Pathology consistent with empyema and abscess. No Pathology consistent with empyema and abscess. No evidence of malignancy.evidence of malignancy.

On 7/25, chest tube removed.On 7/25, chest tube removed. On 7/27, patient was discharged. He was maintaining O2 sat On 7/27, patient was discharged. He was maintaining O2 sat

of 96% on 1-2L at rest and ambulating with 3LNC. CXR at of 96% on 1-2L at rest and ambulating with 3LNC. CXR at time of discharge showed haziness secondary to time of discharge showed haziness secondary to decortication but resolving effusion. decortication but resolving effusion.

Final diagnosis: MSSA lung abscess and empyemaFinal diagnosis: MSSA lung abscess and empyema

Student Teaching File CaseStudent Teaching File CaseAmy OylerAmy OylerUVA SOM 06UVA SOM 06Period #2: July 23- August 20, 2005Period #2: July 23- August 20, 2005

ReferencesReferences Ost, David, Alan Fein, Steven Feinsilver, Ost, David, Alan Fein, Steven Feinsilver,

Rakesh Shah, “Nonresolving Rakesh Shah, “Nonresolving pneumonia.” UptoDate.pneumonia.” UptoDate.

Strange, Charlie, “Pathogenesis and Strange, Charlie, “Pathogenesis and management of parapneumonic effusions management of parapneumonic effusions and empyema in adults.” UptoDate.and empyema in adults.” UptoDate.