Pulmonary Report Pearls – 2/12/18 – Pleural Effusions

Thank you to Max for presenting the case of a middle aged woman with history of SLE c/b Evans syndrome on steroids (20 grams x 2 weeks) re-presenting to medicine after treatment strep pneumonia on oral amox with recurrent cough, fevers and pleuritic chest pain. She was found to have a left sided effusion and will be evaluated today for drainage and possible chest tube (incomplete source control!!).

  • 15-20% of patients with Strep Pneumonia will have bacteremia. These patients should be continued on abx for 14 days and it is important to ensure there are no metastatic complications before abx are discontinued.
  • Remember wrong drug, wrong bug or incomplete source control in any patient presents with ongoing fevers. However, as we discussed other causes of ongoing fevers include failed immune system (immunosuppression preventing host from clearing an infection) and/or another problem (such as a rheum flare) driving fevers.
  • Pulmonary complications associated with strep pneumo bacteremia include empyema, necrotizing pneumonia, and lung abscess.
  • The main difference with a high resolution CT vs. standard CT at Moffitt is air dynamics – inspiration and expiration comes with HRCT. We no longer skip lesions with the high resolution CT. This is not true in the community…yet.
  • Effusions related to infection run on a spectrum from simple parapneumonic à complicated à empyema. See more details below on delineation and implications for management.
  • Never let the sunset on a pleural effusion without tapping it! In general, all parapneumonic effusions, EXCEPT those that are free flowing and layer less than 10 mm on a lateral decubitus film, should be sampled by thoracentesis.

 

The Gradient of Pleural Effusions

Stages Macro Appearance Pleural fluid characteristics Management
Simple Parapneumonic Clear Fluid pH > 7.2

LDH < 1000 IU/I

Glucose > 2.2 mmol/l

No organisms on culture or gram stain

Will resolve with abx alone

Chest tube for symptoms only

Complicated Parapneumonic Clear fluid or cloudy/turbid pH < 7.2

LDH > 1000

Glucose < 2.2 mmol/l

May be + organisms on gram stain/culture

Requires chest tube drainage
Empyema Frank pus May be + organisms on gram stain/culture Requires chest tube drainage
  • Other indications for drainage of an effusion include: large + free flowing ( > 1/2 the hemithorax), loculated effusions, or effusions with a thickened parietal pleura.
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