AN UNUSUAL CAUSE OF PLEURAL EMPYEMA

Abstract

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Empyema usually results as a complication of pneumonia, however trans-diaphragmatic spread of infection into pleural space from a liver abscess is very rare. CASE PRESENTATION: A 54-year-old female presented with 5 days of worsening dyspnea on exertion, decreased appetite and a right sided pleuritic chest pain. Her past medical history was significant for colorectal cancer with liver metastasis, for which she underwent right hepatectomy 3 weeks before presentation. On admission, she was diaphoretic along with hypotension, tachycardia, tachypnea and hypoxia. Blood work revealed neutrophil predominant leukocytosis of 25,000/µl. Computed tomography (CT) of chest showed moderate right sided pleural effusion without loculation. A 6 x7x 8 cm subcapsular fluid collection was also noted in the right posterolateral hepatic lobe, which was the site of her recent hepatic resection. Given these findings, there was a high suspicion for transdiaphragmatic spread of infection causing empyema. A diagnostic right thoracentesis showed an exudative effusion with a ph of 6.78, glucose 2, lactate dehydrogenase of 2213 and grams stain showing gram positive cocci. For optimal source control a 14 Fr chest tube and a percutaneous hepatic drain were placed, along with administration of alteplase and dornase. Fluid culture from both sites speciated as Staphylococcus epidermidis and empiric antibiotics were narrowed down to linezolid. Repeat CT chest imaging showed worsening loculated empyema, and patient underwent video assisted thoracoscopic surgery for adhesion lysis and evacuation. Intraoperatively, bile was found in the pleural space and the hepatic drain was seen coursing through the pleural cavity, which was subsequently removed. Post procedure patient showed marked clinical improvement. DISCUSSION: Empyema caused by transdiaphragmatic spread of infection from a pyogenic liver abscess (PLA) is very rare. Right hepatic resection leading to empyema has a reported incidence of 1%. Such patients also tend to have more biliary leakage and intrabdominal abscesses as studied by Goumard C et al. [1]. PLA themselves usually arises from intra-abdominal or biliary tract infection and are often polymicrobial. When monomicrobial, Klebsiella pneumoniae is the most common primary pathogen while Staphylococcus epidermidis, like in our patient, has been infrequently reported. Risk factors for development of complicated parapneumonic effusion requiring surgical or chest tube drainage include isolation of mixed gram positive and negative species (HR 10.62, p value 0.044, CI 1.069–105.411). Presence of bilateral pleural effusions and biliary tract inflammation are also significant risk factors for development of pleural empyema.[2]. CONCLUSIONS: Liver abscess leading to empyema through trans-diaphragmatic spread is an infrequent cause of empyema, and should be considered in patients who have undergone recent liver surgery. Reference #1: 1.Goumard, C., et al., Pleural Empyema Following Liver Resection: A Rare But Serious Complication. World J Surg, 2016. 40(12): p. 2999-3008. Reference #2: 2.Yi, E., et al., Evaluation of clinical risk factors for developing pleural empyema secondary to liver abscess. BMC Gastroenterol, 2019. 19(1): p. 215. DISCLOSURES: No relevant relationships by Ilya Berim, source=Web Response No relevant relationships by Sidra Raoof, source=Web Response