An Elderly Man With New Lethargy and Abnormal Chest Radiography Findings

PATIENT FOLLOW-UP

Sputum culture results reported the presence of only normal oral flora, while both blood and pleural fluid specimens had no growth at 24 hours. Thus, the diagnosis was assumed to be community-acquired left lower lobe pneumonia with parapneumonic pleural effusion. Because of his age and infirmity, the patient was considered a borderline surgical candidate at best, and thus a 14F chest tube was placed, and tPA-DNase administered in that way. In the ensuing 8 days, the fever resolved, the leukocytosis resolved, and daily tube drainage diminished. Additionally, the left lower lobe infiltrate gradually improved. The tube was removed, and antibiotics were continued for 2 weeks thereafter. The patient was discharged to home, where he was able to resume his prehospitalization activity level and was in his steady state several months later.

TAKE-HOME MESSAGE

Pleural effusion remains a common and classic condition in medicine. Technical advances such as point-of-care ultrasonography evaluation and guided needle aspiration have markedly enhanced the ability to diagnose the presence of volume, septation, and other pleural effusion characteristics, which are important in judging appropriate therapeutic strategies. Pleural fluid analysis and, of course, bacteriologic and cytologic analysis, remain the key first steps in management. The traditional Light criteria for differentiating transudate from exudate remain unsurpassed. The most common cause for exudate remains empyema/parapneumonic effusions followed by malignant pleural effusions (lung cancer, breast cancer, and lymphoma are the main primaries). Transudative effusions are caused mainly by CHF, cirrhosis, and nephrotic syndrome, all of which will usually be clinically obvious. Management depends on exudate vs transudate etiology, treating the cause of the effusion as appropriate (eg, antibiotics for infection, diuresis for CHF), and correct and timely use of a variety of drainage techniques.

Ronald N. Rubin, MD, is a professor of medicine at the Lewis Katz School of Medicine at Temple University and is chief of clinical hematology in the Department of Medicine at Temple University Hospital in Philadelphia, Pennsylvania.

References:

1. Davies He, Davies RJO, Davies CWH; BTS Pleural Disease Guideline Group. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65 suppl 2:ii41-ii53.

2. Feller-Kopman D, Light R. Pleural disease. N Engl J Med. 2018;378(8):740-751.

3. Rahman NM, Kahan BC, Miller RF, Gleeson FV, Nunn AJ, Maskell NA. A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural effusion. Chest. 2014;145(4):848-855.

4. Rahman NM, Maskell NA, Davies CWH, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;​137(3):536-543.

5. Rahman NM, Maskell NA, West A, et al. Interpleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365(6):​518-526.

6. Tillett WS, Sherry S. The effect in patients of streptococcal fibrinolysin (streptokinase) and streptococcal desoxyribonuclease on fibrinous, purulent, and sanguinous pleural exudations. J Clin Invest. 1949;28(1):173-190.