Why the Worsening Chest Pain?

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A 52-year-old male presented to the emergency department with four weeks of shortness of breath and right sided chest pain. His symptoms had gradually progressed in severity and were worse with exertion. These symptoms started several days after he fell against a counter and struck his right chest wall. He initially had a “small gash and black and blue mark” on his right lateral chest wall but these resolved over the course of the month. He denied similar symptoms in the past or recurrent injury dating from the initial insult.

The patient’s past medical history was significant for hypertension, uncontrolled due to medication non-compliance. He denied any drug allergies and had a long smoking history. The patient did not recall any chronic medical diseases in his family.

On examination, the patient had a low-grade fever of 37.9 C orally. He was mildly hypertensive, 160/95, and had a heart rate of 111. His respiratory rate was 26 and his oxygen saturation was normal on room air. The patient appeared tachypneic with no accessory muscle use and his trachea was mid-line. He had clear breath sounds on the left, but had absent breath sounds on the right chest in all lung segments. The patient had a regular tachycardia on auscultation, with normal S1 and S2, no murmurs, and no muffled sounds. There was no JVD. His chest wall was non-tender throughout palpation without any crepitance. The remainder of his examination was unremarkable.

A PA and lateral chest x-ray was immediately obtained (see images). What is your suspected diagnosis?

  1. Hemothorax
  2. Empyema
  3. Intraparenchymal lung abscess
  4. Unilateral diaphragm perforation

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Dx: Chest Tube Reveals Problematic Empyema

After consultation with thoracic surgery, a contrasted CT of the chest was obtained in an attempt to delineate the patient’s underlying thoracic pathology (below).

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TOP: Very large fluid collection with an air-fluid level within the right hemithorax with near complete collapse of the right lung. Gas bubbles within the fluid portion of the collection suggests complexity. Differential considerations include an intraparenchymal lung abscess as well as an empyema.
BOTTOM: Chest tube insertion demonstrated projectile thick, yellow, exudative fluid

Based upon the CT findings, a right-sided chest tube was inserted (above).
On placement of the chest tube, 1500 CCs of thick, yellow, exudative fluid was removed from the right chest cavity. The patient acknowledged improvement in respiratory status. The pleural fluid was sent to the lab for analysis, gram stain, and culture. Blood cultures were drawn and sent. Because of the concern for lung abscess or empyema the patient was started on Vancomycin and Zosyn. The patient remained hemodynamically stable in the emergency department and was transferred to a general medical floor for further care.

The patient had a prolonged hospital course after admission from the emergency department. He had persistent collapse of the right lung and a decision was made to take the patient for video-assisted thoracic surgery (VATS). He had three more chest tubes placed in the operating room and was unable to be extubated for several days post-procedure, due to persistent hypoventilation. The patient’s blood and pleural fluid cultures did not grow out any bacteria. Legionella antigen testing, fungal cultures and mycobacterium testing were also performed and negative. The infectious disease team was consulted on the floor and expressed concern for an anaerobic organism as the cause of infection although no organism was ever identified on culture. A PICC line was placed and the patient was discharged to a SNF after 12 days in the hospital with one chest tube still in place. The patient was continued on Unasyn, as an outpatient, and after five weeks his last chest tube was removed.

Discussion:
An empyema is a collection of exudate in the pleural cavity. It is most often caused by pleural extension of pneumonia, but it may also be able to be caused by any seeding of the pleural cavity from penetrating trauma, esophageal rupture, previous thoracic surgery, or previous chest tube placement (1). Empyema is also an under recognized complication of blunt thoracic trauma and may be an occult perpetrator in subsequent respiratory failure and need for mechanical ventilation (2).

In the emergency setting, chest radiography is indicated to differentiate other chest pathology that can present similarly. A CT of the chest may be necessary to assess for underlying pneumonia, lung abscess, tumor, septations, or other pleural disease.

In the absence of trauma or surgery, the diagnosis of empyema would  be very unlikely. Clinically, one might suspect empyema if the patient has fever, productive cough, or clinical sx’s c/w pneumonia. Radiographically and without a known history, it would  be difficult  to differentiate the two entities – the gold standard for differentiating them (after getting an appropriate history) is tube thoracostomy and evaluation of the fluid.

The definitive management of empyema should be made in consultation with thoracic surgery and infectious disease. The gold standard of treatment has been prompt tube thoracostomy and intravenous antibiotics, but recent literature has suggested a benefit in both intrapleural fibrinolytics and early VATS (3, 4). The patient’s pleural fluid should be sent for analysis and they should be admitted to the hospital for continued therapy.

References:
1. Zwanger M, O’Connor R. Empyema and Abscess Pneumonia in Emergency Medicine. Available at : http://emedicine.medscape.com/article/807499-overview. Accessed August 10, 2011
2. Watkins JA, Spain DA, Richardson JD, Polk HC Jr. Empyema and restrictive pleural processes after blunt trauma: an under-recognized cause of respiratory failure. Am Surg. 2000;66:210-4
3. Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev. Apr 16 2008;CD002312
4. Schneider CR, Gauderer MW, Blackhurst D, Chandler JC, Abrams RS. Video-assisted thoracoscopic surgery as a primary intervention in pediatric parapneumonic effusion and empyema. Am Surg. Sep 2010;76(9):957-61

ABOUT THE AUTHOR

David Effron, MD is the assistant professor of emergency medicine at Case Western Reserve University and attending physician in the department of emergency medicine at the MetroHealth Medical Center, in Cleveland, Ohio.

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