MASSIVE SPONTANEOUS PLEURAL EFFUSION IN END-STAGE RENAL DISEASE PATIENT WITH VANCOMYCIN RESISTANT ENTEROCOCCUS EMPYEMA AND COVID-19 INFECTION

Abstract

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pleural effusion is one of the most common complications seen in end-stage renal disease (ESRD) patients [1]. Here we report a case of massive spontaneous pleural effusion in an ESRD patient, who tested positive for coronavirus disease 2019 (COVID-19) on hospital admission, and later grew vancomycin resistant enterococcus (VRE) from the pleural space. CASE PRESENTATION: 79-year-old male with past medical history of ESRD on hemodialysis, hypertension, diabetes mellitus and history of prostate cancer presented with abdominal discomfort and progressive nausea and vomiting. COVID-19 test was positive on screening, although vital signs and review of systems were negative except as above. Labs were remarkable for leukocytosis, elevated blood urea nitrogen and creatinine. Chest X-ray showed nearly complete opacification of the left hemithorax associated with dense consolidation of the left lower lobe and the lingula. Computerized tomography scan showed a large complex fluid attenuating lesion involving the left hemithorax, which may represent a large loculated left-sided effusion versus a large left-sided empyema, resulting in mediastinal shift to the right and inferior displacement of the left hemidiaphragm. Pleural fluid was drained via pigtail catheter, and on analysis was found to be exudative with few leukocytes and no microorganisms. Due to septations of the hemithorax and development of hydropneumothorax, chest tube was placed and eventually video-assisted thoracoscopic surgery was performed for further drainage and decortication. Biopsy obtained during surgery showed no malignant cells; tissue culture and subsequent pleural fluid cultures were positive for VRE. DISCUSSION: Pleural effusion is a pathological finding that is often seen in ESRD patients with heart failure, pneumonia, pulmonary embolism, cancer and uremia [1]. Interestingly, our patient received regular hemodialysis, and presented with no signs of heart failure or fluid overload, making ESRD less likely to be a major or direct cause of the massive pleural effusion. Studies show VRE is prevalent in dialysis centers and frequently colonizes ESRD patients [2]. Rarely, VRE can cause empyema, as illustrated by Cotton in an asplenic patient with multiple co-morbidities who presented with pneumonia [3]. Our patient might have VRE colonized in his airway, so pleural cultures were positive after decortication. Additionally, COVID-19 infection has been associated with pleural effusion [4]. Hussein reported an acute accumulation of moderate exudative pleural effusion in a patient with no past medical history except for concurrent COVID-19 infection. As a result, the positive COVID-19 test in our patient might also contribute to his massive effusion. CONCLUSIONS: Factors like ESRD on hemodialysis, positive VRE in pleural tissue culture, as well as COVID-19 infection, may all contribute to the rare massive pleural effusion in our case. REFERENCE #1: Uzan, G. and H. Ikitimur, Pleural Effusion in End Stage Renal Failure Patients. Sisli Etfal Hastan Tip Bul, 2019. 53(1): p. 54-57. REFERENCE #2: Zacharioudakis, I.M., et al., Vancomycin-resistant enterococci colonization among dialysis patients: a meta-analysis of prevalence, risk factors, and significance. Am J Kidney Dis, 2015. 65(1): p. 88-97.Cotton, M.J. and C.D. Packer, Vancomycin-resistant Enterococcus faecium Empyema in an Asplenic Patient. Cureus, 2018. 10(8): p. e3227. REFERENCE #3: Hussein, M., et al., Pleural effusion as an isolated finding in COVID-19 infection. Respir Med Case Rep, 2020. 31: p. 101269. DISCLOSURES: No relevant relationships by Aram Hambardzumyan, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Liyun Liu, source=Web Response Speaker/Speaker's Bureau relationship with GSK Please note: approx 2016 to now Added 05/02/2021 by Michael Mandel, source=Web Response, value=Consulting fee No relevant relationships by Corina Nava, source=Web Response No relevant relationships by ABHISHEK NIMKAR, source=Web Response No relevant relationships by Carlos Romano, source=Web Response