A 19-year-old woman with pleuritic chest pain.

Abstract

Case presentation A 19-year-old woman with a medical history significant for poorly controlled diabetes mellitus (DM) (hemoglobin A1C 11.2%) presented with a 12-day history of right-sided pleuritic chest pain. One month earlier, she had developed sudden-onset fever, dry cough and shortness of breath. At the time, she did not have any gastrointestinal symptoms including epigastric pain, heartburn, vomiting or retching. She denied sick contacts and had no preceding symptoms of an upper respiratory tract infection. She was seen at a local emergency department and was released home on a 10-day course of oral doxycycline (100 mg every 12 h) to treat a community-acquired pneumonia (CAP). After an initial two-week improvement, her complaints relapsed, with fevers, dry cough, poor appetite and the above-described chest pain. The patient did not smoke and she denied alcohol abuse or illicit drug use. On presentation to the hospital, she was febrile (temperature 38.2°C), her oxygen saturation was 86% on room air and she was thin. She was awake and oriented but in obvious pain. She had no jugular venous distention. Her heart sounds were regular without murmurs or gallops. The lung examination revealed reduced air entry over the right lung base with bronchial breath sounds and egophony. The abdomen was soft without tenderness or distension and she had no evidence of subcutaneous emphysema or lymphadenopathy. There were no lower limb edema and no joint swelling or deformities. The laboratory tests revealed a white blood cell count of 26.0×109/L and a hemoglobin level of 119 g/L. Blood chemistry showed normal kidney and liver function. Tests for HIV and pregnancy were negative. Chest imaging included a chest x-ray and a contrasted chest computed tomography scan (Figures 1 and 2). The patient was admitted to hospital with severe sepsis due to CAP complicated by an empyema and was started on intravenous broad-spectrum antibiotics, vancomycin (15 mg/kg every 12 h) and piperacillin/tazobactam (3.375 g every 6 h). She underwent computed tomography-guided drainage 48 h afterwards. An interventional radiologist performed the procedure under strict sterile techniques. Cytopathology (Figure 3) and cultures were ordered on the drained fluid. What is your diagnosis?