462: PURULENT TEETH AND PURULENT PLEURAL SPACE

Abstract

Introduction: Empyema is a rare but serious complication of pneumonia. Most common causative organisms include streptococcus species, staphylococcus, and anaerobes. We present a case of empyema secondary to Fusobacterium nucleatum and Porphyromonous gingivalis in a patient with periodontitis. Description: A 70-year-old male with a history of Cerebral Palsy presented with 2 weeks of generalized weakness. He was afebrile, heart rate of 160bpm, respiratory rate of 35/min, Oxygen saturation of 87% on room air, and a BP of 113/76. He was ill-appearing with decreased air entry on the right side of the chest on the exam. His labs showed a WBC of 11.2 k/ul, and high Lactic acid and procalcitonin. CXR showed subtotal opacification of the right hemithorax. CT Scan of the chest showed a large loculated right hydropneumothorax with adjacent atelectasis. Vancomycin, cefepime, and metronidazole were started. A chest tube was inserted for source control with immediate drainage of 120 ml of Purulent turbid fluid. Culture from the pleural fluid grew Fusobacterium nucleatum and Porphyromonous gingivalis. Repeat imaging showed multiple sites of undrained pleural effusion and incomplete expansion of the lung. TPA and DNase were instilled in the pleural cavity every 12 hours over a period of 72 hours to help with drainage and lysis of loculations. Follow-up chest CT showed trapped unexpanded lung with loculations, scarring, and pneumothorax around it. The patient underwent a right thoracotomy with complete visceral and parietal pleural decortication that resulted in the gradual expansion of the lungs and removal of his chest tube. Due to the organisms involved, a panorex xray was done and showed periodontitis. The patient underwent extraction of infected teeth to prevent recurrent empyema. He was discharged on ampicillin/ sulbactam for a total course of four weeks. Discussion: Fusobacterium nucleatum and Porphyromonous gingivalis are gram negative oral anaerobes that frequently cause periodontitis. Aspiration of oral and dental secretions containing these organisms resulted in pneumonia and empyema in our patient. Identifying those organisms allowed us to search and treat for the underlying conditions. Treatment strategies include appropriate antibiotic therapy along with pleural space drainage.