RARE AND RAPID: A CASE OF EXPLOSIVE PLEURITIS

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Parapneumonic effusions (PPE) are pleural effusions associated a bacterial pneumonia or lung abscess. Between 20 to 57% of the 1 million patients hospitalized yearly with pneumonia develop a PPE. We present a rare case of rapidly developing PPE, known as “explosive pleuritis.” CASE PRESENTATION: 56 year old male smoker with mild persistent asthma presented with worsening pleuritic chest pain. Pain was around the right scapula and had been progressively worsening over 5 days. It had no alleviating factor, and worsened with coughing and deep inhalation. He also had intermittent nonproductive coughs as well as a single episode of subjective fever 1 day prior, but no other symptoms. He denied sick contacts and recent travel outside of New York. CT pulmonary embolism protocol was obtained initially, which revealed a mass like structure in the right lower lobe, suspicious for a pneumonia versus an early abscess. He was admitted to the general medical floor and remained hemodynamically stable, required no oxygen supplementation, had no leukocytosis, and was initiated on Ampicillin/Sulbactam therapy. The following day, the patient became more tachypneic needing supplemental oxygen, and developed a leukocytosis of 13.9K/uL. Chest X-ray showed a new right side infiltrate and pleural effusion. Due to his rapidly deteriorating status, he was transferred to the medical ICU. Antibiotics were broadened and a repeat CT scan was obtained. The repeat scan revealed a large loculated right sided pleural effusion. A tube thoracostomy was attempted, however bedside ultrasound exam showed extensive stranding and haziness of the pleural effusion without a safe insertion site. Cardiothoracic surgery was consulted and patient had a video assisted thoracoscopic surgery. Large amount of empyema was evacuated, and the patient had 3 chest tubes inserted. Over the next 4 days, the patient’s respiratory status and leukocytosis had improved, and he had his chest tubes removed without any complications. Patient was discharged on day 8 of admission, and is now completing a 6 week course of antibiotics. Cultures obtained throughout the admission including the pleural peel and rind have unfortunately been negative. DISCUSSION: Explosive pleuritis is a rare entity that develops within 24 hours, involves 90% of the affected hemithorax, and has the tendency to loculate early. Streptococcal infections have been associated with it, owing to the blockage of lymphatics with cellular debris. However, the causative organism often is not isolated. Once identified, prompt initiation of antibiotics and drainage of the effusion is needed. This can be achieved by either tube thoracostomy or by surgical decortication. CONCLUSIONS: Explosive pleuritis should be considered for a rapidly deteriorating patient with pneumonia. It is an emergency that requires prompt investigation and treatment consisting of both medical and surgical treatment. Reference #1: Sharma JK, Marrie TJ. Explosive pleuritis. Can J Infect Dis. 2001;12(2):104-7. Reference #2: Bryant RE, Salmon CJ. Pleural empyema.Clin Infect Dis 1996:22;747-62. Reference #3: Braman SS, Donat WE. Explosive pleuritis.Am J Med 1986;81:723-6. DISCLOSURES: No relevant relationships by Erica Altschul, source=Web Response No relevant relationships by Nader Ishak Gabra, source=Web Response No relevant relationships by Oki Ishikawa, source=Web Response No relevant relationships by Omar Mahmoud, source=Web Response No relevant relationships by Bushra Mina, source=Web Response No relevant relationships by Maly Oron, source=Web Response No relevant relationships by Varun Shah, source=Web Response