Pleural Fluid Culture Research Articles

Chylothorax after chimeric antigen receptor T cell therapy for relapsed and refractory diffuse large B-cell lymphoma: A case report.

Anti-CD19-targeted chimeric antigen receptor (CAR) T cell therapy is effective in treating relapsed/refractory diffuse large B-cell lymphoma (DLBCL). This therapy is associated with several side effects that can be life-threatening such as cytokine release syndrome (CRS). However, chylothorax associated with CRS after CAR-T therapy has not been reported. A 23-year-old male diagnosed with DLBCL relapsing after autologous peripheral blood stem cell transplantation was treated with anti-CD19-targeted CAR-T cell therapy. After CAR-T cell transfusion, he developed grade 3 CRS includes fever, dyspnea, tachycardia and hypotension. The symptoms of CRS persisted and chest plain film revealed bilateral pleural effusion. Chylothorax was confirmed by the pleural effusion analysis that triglyceride level was 1061 mg/dL. Bacterial and fungal culture of pleural fluid reported no pathogen was detected. Cytological examination of pleural effusion revealed no malignant cells. The chylothorax resolved after treatment with intravenous administration of tocilizumab. On 30-day follow-up, the patient was in stable clinical condition with complete remission of DLBCL on whole-body positron emission tomography scan. We reported a rare case of CAR-T associated chylothorax in a patient with relapsed and refractory DLBCL. Grade 3 CRS with high interleukin-6 level was presented in our patient. The symptoms of CRS were improved with tocilizumab treatment and the chylothorax resolved later on. It is suggested that high interleukin-6 releases might induce chyle leakage resulting from activations of endothelium and coagulation. Our finding highlights the occurrence of chylothorax during the course of CAR-T cell therapy and the importance of proper monitoring and prompt management of this life-threatening side effect.

Diagnostic Yield of 16S Ribosomal Ribonucleic Acid Gene-Based Targeted Metagenomic Sequencing for Evaluation of Pleural Space Infection: A Prospective Study

ObjectiveTo better understand the microbial profile of complicated parapneumonic effusions and empyema, and to evaluate whether antimicrobial selection would differ if guided by targeted metagenomic sequencing (tMGS) vs conventional cultures (CCs) alone. Patients and MethodsWe analyzed the pleural fluid of a cohort of 47 patients undergoing thoracentesis from January 1, 2017 to August 31, 2019, to characterize their microbial profile. All samples underwent 16S ribosomal ribonucleic acid gene polymerase chain reaction, followed by tMGS. ResultsPleural space infection was deemed clinically present in 20 of the 47 (43%) participants. Of those, n=7 (35%) had positive pleural fluid cultures and n=14 (70%) had positive tMGS results. The organisms identified by tMGS were concordant with CCs; however, tMGS detected additional bacterial species over CCs alone. Streptococcus and Staphylococcus species were the most common organisms identified, with Streptococcus intermedius/constellatus identified in 5 patients. Polymicrobial infections were found in 6 of the 20 patients, with anaerobes being the most common organisms identified in these cases. ConclusionStreptococci and staphylococci were the most common organisms identified in infected pleural fluid. Anaerobes were common in polymicrobial infections. When compared with CCs, tMGS had higher sensitivity than CCs. Targeted metagenomic sequencing identified additional organisms, not identified by CCs, with associated potential management implications.

Role of thoracoscopy in diagnosis of tubercular pleural effusion in low ADA setting- A prospective, observational study

BackgroundTubercular Pleural effusion (TBPE) is one of most common extrapulmonary tuberculosis. It can be difficult to diagnose due to low sensitivity of pleural fluid smear, culture and CBNAAT. Diagnosis of TBPE is then dependent on the level of pleural fluid Adenosine Deaminase (ADA). Thoracoscopic pleural biopsy gives definite diagnosis specially in Low Pleural fluid ADA setting. Aims and objectiveThis study was planned to find out the prevalence of tubercular etiology in patients of exudative pleural effusion with low ADA (ADA <40 IU/L). Material and methodsA Prospective, observational study was carried out in a tertiary teaching institute in north India. Total 142 patients of pleural effusion with low ADA were enrolled. All patients underwent rigid thoracoscopy for confirmation of their diagnosis. ResultsOut of 142 patients, male were 78 (55%) and female were 64 (45%). Mean age of patients were 57.4 years. Tuberculosis was diagnosed as a cause of effusion in 22 (15.5%) out of 142 patients. Majority of TBPE patients had pleural thickening as thoracoscopic finding. Mean ADA level in TBPE was 27.36 ± 11.6 as compared to 18.55 ± 9.02 in non tubercular pleural effusion patients and this difference was significant statistically (P- 0.002). ConclusionThe diagnosis of patients having exudative, low ADA pleural effusion can be very easily confirmed by thoracoscopy guided pleural biopsy which has a very high diagnostic yield.

Pleural Aspergillosis Complicating Chronic Cavitary Pulmonary Aspergillosis in a Tuberculosis Sequel: About One Case

Introduction: Pleural aspergillosis is a rare pathology; it is defined by an infection of the pleural cavity by an opportunistic fungus of the genus Aspergillus. Observation: We report the case of a 24-year-old female patient treated for pulmonary tuberculosis complicated by a left pyopneumothorax drained for 5 months. The reason for consultation 3 months after stopping the antibacillary treatment was a purulent bronchial syndrome, left chest pain with a tingling sensation and exertional dyspnea. Clinical examination revealed an aerated effusion syndrome in the left hemithorax. Chest imaging showed a left pneumothorax with thickening of the visceral pleura and a left upper lobar alveolar focus with clearing within it. Aspergillus serology was positive. The patient had undergone video-assisted thoracoscopy, which revealed the presence of false membranes and whitish deposits of mycotic appearance. The biopsy of the pseudomembranes was in favor of pleural aspergillosis. The patient was put under antifungal treatment for 6 months with a good clinical and radiological evolution. Conclusion: Aspergillus is a mycelial fungus formed by filaments that penetrate the airways by inhalation of its spores. Pleural localizations are rare. Sequelae of tuberculosis, broncho pleural fistulas, pleural drainage and pulmonary resection are considered the main conditions predisposing to infection of the pleural space by aspergillus. The diagnosis is confirmed by pleural fluid culture or pleural biopsy.

Tension pyopneumothorax caused by Parvimonas micra: a case report

Tension pyopneumothorax is a rare and life-threatening complication of pneumonia, lung abscess, and empyema, and immediate thoracic drainage or surgery is required. A 70-year-old man presented to another hospital 2 weeks after exacerbation of dyspnea and anorexia. Chest X-ray imaging revealed leftward deviation of the mediastinum, pleural effusion, and collapse of the right lung. The patient was referred to our hospital for surgical treatment. He underwent chest drainage immediately after the transfer. The patient’s blood pressure was elevated after drainage. Chest X-ray imaging showed improvement in the mediastinal deviation, but expansion failure of the lung occurred. Debridement and parietal and visceral decortications were performed under thoracotomy. The thoracic cavity was irrigated using a pulse lavage irrigation system with 12,000 mL of saline. The patient underwent fibrinolytic therapy with intrathoracic urokinase postoperatively because of persistent high inflammatory marker levels and multilocular pleural effusion. Parvimonas micra was detected in the preoperative pleural fluid culture. He was discharged on postoperative day 22 and followed up as an outpatient afterwards. Two years have passed since the surgery, and there has been no recurrence of empyema. Decortication of the parietal and visceral pleura and irrigation using a pulse lavage irrigation system were effective.

Parapneumonic effusion in children: Rapid pathogen detection in pleural fluid using multiplex bacterial PCR.

Parapneumonic effusion in children: Rapid pathogen detection in pleural fluid using multiplex bacterial PCR.

An independent prognostic factor in surgical cases of pleural empyema caused by common bacteria is the presence of a fistula.

Some surgical cases of pleural empyema lead to death despite multidisciplinary treatment. The purpose of this study was to identify prognostic factors in cases treated surgically for pneumonia-associated pleural effusions and empyema caused by common bacteria. We conducted a retrospective cohort study of 108 surgical patients of empyema who encountered at our hospital between 2011 and 2021. Patients were divided into surviving and non-surviving cases. Factors on admission (age, sex, body mass index, presence of fistula, performance status, pleural fluid culture results, HbA1c, albumin, leukocytes, hemoglobin, body temperature, heart rate, respiratory rate, systolic blood pressure, prognostic nutritional index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and RAPID score) were compared between the two groups. There were 87 cases of pleural empyema caused by pneumonia due to common bacteria. Variables that differed significantly in univariate analysis between the surviving and non-surviving cases in patients' characteristics on admission were fistula (p value < 0.001, odds ratio 20.000, 95% confidence interval 3.478-115.022), positive pleural fluid culture (0.016, 6.591, 1.190-36.502), body mass index < 18.5 (0.001, 16.857, 1.915-148.349), performance status 0-1 (0.007, 11.778, 1.349-102.858), and hemoglobin (0.024, 1.768, 1.077-2.904). Multivariate analysis showed significant differences in the presence of fistula (p = 0.036, CI 1.174-125.825). The odds ratio was 12.154. The mortality rate was 3.8% for non-fistulous empyema and 44.4% for fistulous empyema. In 6 of 9 cases of fistulous empyema, the fistula could be closed. Fistula was a significant independent prognostic factor for pneumonia-associated pleural effusions and empyema caused by common bacteria.

Refractory Pneumonia in a 12-year-old Girl with Hemoglobin SS Disease

Refractory Pneumonia in a 12-year-old Girl with Hemoglobin SS Disease

Phenotyping empyema by pleural fluid culture results and macroscopic appearance: an 8-year retrospective study.

The clinical impact of phenotyping empyema is poorly described. This study was designed to evaluate clinical characteristics and outcomes based on the two readily available parameters, pleural fluid culture status and macroscopic fluid appearance. A retrospective study was conducted on patients with empyema hospitalised between 2013 and 2020. Empyema was classified into culture-positive empyema (CPE) or culture-negative empyema (CNE) and pus-appearing empyema (PAE) or non-pus-appearing empyema (non-PAE) based on the pleural fluid culture status and macroscopic fluid appearance, respectively. Altogether, 212 patients had confirmed empyema (CPE: n=188, CNE: n=24; PAE: n=118, non-PAE: n=94). The cohort was predominantly male (n=163, 76.9%) with a mean age of 65.0±13.6 years. Most patients (n=180, 84.9%) had at least one comorbidity. Patients with CPE had higher rates of in-hospital mortality (19.1% versus 0.0%, p=0.017) and 90-day mortality (18.6% versus 0.0%, p=0.017) and more extrapulmonary sources of infection (29.8% versus 8.3%, p=0.026) when compared with patients with CNE. No significant difference in mortality rate was found between PAE and non-PAE during the in-hospital stay and at 30 days and 90 days. Patients with PAE had less extrapulmonary sources of infection (20.3% versus 36.2%, p=0.010) and more anaerobic infection (40.9% versus 24.5%, p=0.017) than those with non-PAE. The median RAPID (renal, age, purulence, infection source, and dietary factors) scores were higher in the CPE and non-PAE groups. After adjusting for covariates, culture positivity was not independently associated with mortality on multivariable analysis. Empyema is a heterogeneous disease with different clinical characteristics. Phenotyping empyema into different subclasses based on pleural fluid microbiological results and macroscopic fluid appearance provides insight into the underlying bacteriology, source of infection and subsequent clinical outcomes.

Rare Presentation of Pleural Empyema due to Non Typhoidal Salmonella-A Case Report

Non typhoidal Salmonella usually causes bacteraemia, enterocolitis, and endovascular infection, but pleuro-pulmonary illness is uncommon, mainly observed in patients with a background of malignancy, underlying pulmonary diseases. Localisation of the infection has been witnessed at various sites following a bacteraemia but case reports on pulmonary focus are minimal. Here, we report a case of a 36 year old male patient who presented to Emergency Department with an underlying non Hodgkin’s Lymphoma along with a left sided pleural effusion. Pleural fluid tapping was done and the sample was sent for microbiological analysis. The pleural fluid culture along with serotyping confirmed the organism as Salmonella enterica serovar Typhimurium. The patient was discharged after parenteral Ceftriaxone therapy and symptom resolution. This case adds to the growing body of evidence of rare presentation of non typhoidal Salmonella as a probable etiological agent of infection in exudative pleural effusions.

Nil Intervention is at Times the Best Intervention

A sudden drop of air-fluid level in the pneumonectomy space in the absence of a bronchopleural fistula and pleural infection is termed benign emptying of the post pneumonectomy space (BEPS). We herein report a case of benign emptying of pneumonectomy space, briefly review the literature and enumerate possible mechanisms for the same. It is an extremely rare entity and follows a benign course. Patients with BEPS are clinically stable, afebrile with no fluid expectoration, and have a normal white blood cell count. Bronchoscopy reveals an intact bronchial stump and pleural fluid cultures are often sterile. Close monitoring and early detection of a bronchopleural fistula is the management. Clinicians should keep BEPS among the differential diagnosis in case of a drop in the air-fluid level of the post pneumonectomy space. Awareness of this entity is crucial as it helps prevent unnecessary and morbid surgical interventions.&#x0D; Keywords: Pneumonectomy; BEPS; Bronchopleural Fistula; India.

332. Broad range PCR of pleural fluid improves diagnosis of bacterial pneumonia complicated by parapneumonic effusion

Abstract Background Bacterial pneumonia complicated by a para pneumonic effusion is frequently encountered in hospitalized patients. However, identifying the etiology of pneumonia remains elusive. Published data report rates of bacteremia ranging from 13-26% among patients with pneumonia complicated by parapneumonic effusion. Good quality sputum samples are difficult to obtain in children. Culture of pleural fluid is helpful, but most patients are already pretreated before a specimen is obtained limiting utility. Nucleic acid assays of pleural fluid have reported sensitivities from 40-80%. We wanted to review our experience with pleural fluid nucleic acid assay at Akron childrens hospital Methods Using help from our laboratory data support team, we retrospectively reviewed the records of all pleural fluid isolates that were sent out to Washington University Medical Center for 16 S rRNA sequencing (broad range polymerase chain reaction assay). The review covered a 8-year time period ranging from January 2014 to March 2022. Negative blood and pleural fluid cultures were a prerequisite before the send out for nucleic acid assay. Results A total of 29 pleural fluid samples were sent out for 16S rRNA sequencing. 22 of these had a detectable target. This translated into a yield of about 75%. The following table summarizes our findings. Conclusion In our experience, nucleic acid assay of the pleural fluid is valuable in making a bacteriological diagnosis of pneumonia with para pneumonic effusion. Its benefit remains in patients pretreated with antibiotics. For the individual patient it may help narrow antibiotic therapy. At an institutional level it would allow for developing guidelines for empiric antibiotic management. However, in most institutions’ nucleic acid assay of pleural fluid remains a send out test and optimizing workflows to reduce turnaround time remains a challenge. Disclosures All Authors: No reported disclosures.

Pleuropulmonary Aspergillosis Presenting as Hydropneumothorax in Second Trimester Pregnancy

Pleuropulmonary aspergillosis is a rare entity and usually occurs in a patient with preexisting lung disease or surgery. A 29-year-old pregnant woman with 16 weeks of gestation presented with shortness of breath, right-sided chest pain, and productive cough of 2 weeks' duration. A chest radiograph done with abdominal shield revealed right hydropneumothorax. Intercostal drainage insertion was done under ultrasound guidance. Pleural fluid was exudative with high adenosine deaminase levels, and GeneXpert test was negative for Mycobacterium tuberculosis. Pleural fluid and sputum culture revealed significant growth of Aspergillus fumigatus. She was treated with voriconazole intravenously followed by oral route. The patient improved clinically with good lung expansion, and she delivered a normal live baby by elective cesarean section. We report this case in view of the rarity of pleuropulmonary aspergillosis occurring in a young pregnant female with no evidence of prior lung pathology.

Empyema Thoracis in children: A Five-Year Analysis from a Tertiary Care Center in Eastern Nepal

Introduction: Complicated community-acquired pneumonia resulting in empyema thoracis remains the largest single cause of morbidity and mortality worldwide in children. This study was carried out to evaluate the clinical profile, associated complications and outcome of empyema thoracis in children. Methods: A retrospective study was conducted in the Department of Paediatrics at a tertiary care center in Eastern Nepal. A total of 106 children were managed with the diagnosis of complicated pneumonia with effusion or empyema thoracis from March 2017 to February 2021 (Five years). Only those patients who had clinico-radiological evidence of pleural effusion or empyema thoracis and received treatment with or without intercostal chest tube drainage (ICD) as the initial procedure were enrolled in the study. Besides supportive treatments and antibiotics; streptokinase was instilled intrapleurally in all the patients for three days. Patients who did not respond underwent VATS / decortication. Results: Majority of the children (60.19%) were below five years of age and were males (73.58%). Majority (55.67%) had a right-sided pleural effusion and fever was the predominant symptom (55.66%) at presentation. The pleural fluid culture was sterile in more than half (55.66%) of the patients with Staphylococcus aureus grown in 33.96%. The three most common complications were subcutaneous emphysema, thickened pleura, and pyo-pneumothorax. The success rate of medical management was 83.96% and the mortality was low (2.84%). Conclusions: The success rate of conservative management with antimicrobial therapy, intercostal drainage and fibrinolytics in this study was high (83.96%) with no major adverse effects of fibrinolytic therapy in empyema thoracis.

AN UNUSUAL COMPLICATION OF ACUTE APPENDICITIS

AN UNUSUAL COMPLICATION OF ACUTE APPENDICITIS

IATROGENIC ESOPHAGEAL PLEURAL FISTULA POST-TRANSESOPHAGEAL ECHOCARDIOGRAM: A CASE REPORT

IATROGENIC ESOPHAGEAL PLEURAL FISTULA POST-TRANSESOPHAGEAL ECHOCARDIOGRAM: A CASE REPORT

S3270 A Rare Case of Disseminated Cryptococcosis Presenting as a Pleural Effusion in a Patient With Cirrhosis

Introduction: Cryptococcus neoformans is an encapsulated yeast classically know as an opportunistic infection notorious for affecting patients with acquired immunodeficiency syndrome (AIDS) and other immunosuppressed patients. Over the last few decades, there have been very few cases of pleural effusions as the initial presentation of disseminated cryptococcosis, particularly with cirrhosis as the only risk factor for an immunocompromised state. Here we present and discuss this unique case. Case Description/Methods: A 48 y/o male with a past medical history of alcoholic cirrhosis presented to the ED with shortness of breath. His past medical history is significant for multiple hospitalizations for decompensated hepatic cirrhosis, ascites, pleural effusions, portal hypertension, gastropathy, and s/p TIPS. MELD-Na score of 31. He presents with a 3-day history of worsening shortness of breath. Chest x-ray on admission showed a right sided pleural effusion concerning for hepatic hydrothorax and pleural fluid eventually grew yeast. Pleural fluid and blood cultures later grew cryptococcus neoformans. Respiratory culture His hospital course was complicated by worsening respiratory failure requiring a short period of intubation, acute kidney injury secondary to hepatorenal syndrome and amphotericin B toxicity, and eventually his demise. (Figure) Discussion: C. neoformans is an encapsulated yeast typically known for infecting immunocompromised hosts, classically patients with AIDS or patient’s receiving immunosuppression therapy [1]. The pathophysiology normally involves inhalation causing primary lung lesion then dissemination, usually to the meninges and brain. While AIDS and patients receiving immunosuppression therapy are predisposing factors for disseminated cryptococcosis, cirrhosis appears to be an increasingly more common risk factor. Interestingly, this patient presented initially with a large pleural effusion that later grew C. neoformans with eventual disseminated cryptococcosis with fungemia. In a 2015 case report by Wang et al, they reported only 5 documented cases of pleural effusion as the initial clinical presentation of disseminated cryptococcosis in the English language literature [2]. The 5 patients studied all had an obvious cause of immunosuppression, making our patient with cirrhosis an even more unique case.Figure 1.: AP chest X-ray from admission showing right-sided pleural effusion with associated passive atelectasis and near complete opacification of the right hemithorax.

PET PEEVE: DYSPNEA FROM UNDIAGNOSED PASTEURELLA MULTOCIDA EMPYEMA

PET PEEVE: DYSPNEA FROM UNDIAGNOSED PASTEURELLA MULTOCIDA EMPYEMA

WHEN FLU LEADS THE WAY: A CASE OF PARVIMONAS MICRA POLYMICROBIAL EMPYEMA IN A PATIENT WITH INFLUENZA A INFECTION

WHEN FLU LEADS THE WAY: A CASE OF PARVIMONAS MICRA POLYMICROBIAL EMPYEMA IN A PATIENT WITH INFLUENZA A INFECTION

A RARE CASE OF ACTINOMYCES EMPYEMA

A RARE CASE OF ACTINOMYCES EMPYEMA