Pleural Culture Research Articles

Epigallocatechin-3-gallate (EGCG) reduced expression of Signal peptide-CUB-EGF domain-containing protein 3 (SCUBE3) and Transforming Growth Factor-β1 (TGF-β1) in visceral pleural tissue cultures of patients with empyema

Abstract* Background Increased expression of signal peptide-CUB-EGF domain-containing protein 3 (SCUBE3) and Transforming Growth Factor-β1 (TGF-β1) has been thought to influence the fibrosis process in many tissues. However, increased expression of these two factors has never been assessed in pleural fibrosis. Pleural fibrosis is a disease that usually results from various infectious processes, such as empyema. Fibrosis formation is recently known to be prevented by Epigallocatechin-3-gallate (EGCG), which is the most potent active substance found in Gambir (Uncaria gambir Roxb) leaves. Thus, further research is needed to determine the potential of EGCG to inhibit the process of pleural fibrosis caused by empyema. Methods An in vitro experimental study with post test-only controlled group was conducted on the pleural tissue of all patients who underwent decortication surgery due to empyema at Dr. M. Djamil Hospital, Padang, Indonesia between March 1st and April 30, 2024. Case samples were obtained by consecutive sampling, and three patients who met the inclusion criteria were obtained. Pleural tissue in each patient was then divided into several groups based on the treatment, namely the control group, 50 μg EGCG administration group, and 100 μg EGCG administration group. We used to determine SCUBE3 and TGF-β1 genes expression. Data were tested using ANOVA and Least Significant Difference (LSD) tests. Results There were significant differences in the SCUBE3 and TGF-β1 genes expression of 50 μg and 100 μg EGCG administration groups and the control groups in the 2 × 2 cm sample preparation (p=0.002) (p=0.014, respectively). Significant differences in TGF-β1 expression were also found between the groups treated with EGCG 50 μg and 100 μg and the control group in the 1 × 1 cm preparation (p=0.019). Conclusion EGCG can potentially decrease SCUBE3 and TGF-β1 expression in patients with pleural empyema.

Epigallocatechin-3-gallate (EGCG) reduced expression of Signal peptide-CUB-EGF domain-containing protein 3 (SCUBE3) and Transforming Growth Factor-β1 (TGF-β1) in visceral pleural tissue cultures of patients with empyema

Abstract* Background Increased expression of signal peptide-CUB-EGF domain-containing protein 3 (SCUBE3) and Transforming Growth Factor-β1 (TGF-β1) has been thought to influence the fibrosis process in many tissues. However, increased expression of these two factors has never been assessed in pleural fibrosis. Pleural fibrosis is a disease that usually results from various infectious processes, such as empyema. Fibrosis formation is recently known to be prevented by Epigallocatechin-3-gallate (EGCG), which is the most potent active substance found in Gambir (Uncaria gambir Roxb) leaves. Thus, further research is needed to determine the potential of EGCG to inhibit the process of pleural fibrosis caused by empyema. Methods An in vitro experimental study with post test-only controlled group was conducted on the pleural tissue of all patients who underwent decortication surgery due to empyema at Dr. M. Djamil Hospital, Padang, Indonesia between March 1st and April 30, 2024. Case samples were obtained by consecutive sampling, and three patients who met the inclusion criteria were obtained. Pleural tissue in each patient was then divided into several groups based on the treatment, namely the control group, 50 μg EGCG administration group, and 100 μg EGCG administration group. We used to determine SCUBE3 and TGF-β1 genes expression. Data were tested using ANOVA and Least Significant Difference (LSD) tests. Results There were significant differences in the SCUBE3 and TGF-β1 genes expression of 50 μg and 100 μg EGCG administration groups and the control groups in the 2 × 2 cm sample preparation (p=0.002) (p=0.014, respectively). Significant differences in TGF-β1 expression were also found between the groups treated with EGCG 50 μg and 100 μg and the control group in the 1 × 1 cm preparation (p=0.019). Conclusion EGCG can potentially decrease SCUBE3 and TGF-β1 expression in patients with pleural empyema.

Community-Acquired Candida albicans Empyema Leading to Tension Physiology: A Case Report.

A tension empyema, in which purulent material accumulates in the chest cavity and leads to cardiopulmonary dysfunction, is a rare complication of empyemas. Moreover, fungal empyemas that grow Candida albicans and cause tension physiology have not yet been previously described. In this report, we present an immunocompetent 30-year-old male who presented to the emergency department with worsening shortness of breath and was found to have a left-sided fungal empyema causing tension physiology. Left chest thoracostomy yielded approximately 4 liters of purulent fluid. Pleural cultures eventually grew C albicans, and after antifungal therapy, surgical decortication of the lung, and a prolonged intensive care unit stay, the patient was discharged home in stable condition. While mortality from C albicans empyemas that cause respiratory compromise is exceedingly high, our case highlights that aggressive management with rapid chest thoracostomy and antifungal therapy can lead to a favorable outcome.

Inoculation of pleural fluid in blood culture bottles could be a routine practice in pleural infection

Background Worldwide, pleural infections are becoming more common. Overuse of empirical antibiotics has been linked to longer hospital stays and higher death rates, causing the emergence of antibiotic-resistant pathogens. So, proper care requires the identification of the pathogenic bacteria using pleural fluid culture. In addition to normal culture, pleural fluid inoculation in blood culture bottles enhances the proportion of patients with detectable infections in less time. Aim To assess whether inoculating pleural fluid into a blood culture bottle will increase the yield of isolated pathogens compared to routine culture techniques in evaluating pleural infection. Also, to compare the time of pathogen detection when comparing the detection by blood culture bottle versus the routine microbiological culture technique. Recognize the distribution of isolated bacteria from our center and their susceptibility profile to different antibiotics and predict the most effective empirical antibiotics. Patients and methods Cross-sectional analytical prospective study conducted at the Department of Pulmonology and Clinical Pathology in Cairo University Hospitals. It included 70 patients with infected pleural effusion. Under ultrasound supervision, pleural fluid was extracted and transported to the laboratory for routine microbiological culture. At the same time, an automated blood culture bottle was inoculated with 5–10 ml to be incubated. All the detected pathogens were identified and tested for antimicrobial susceptibility according to CLSI. Results The mean age of our patients was 47.1 ± 15.6 years. Empyema was documented in 16 (22.9%) of our patients, whereas 54 (77.1%) had exudative pleural effusion. Positive aerobic infection in blood culture bottle was seen in 37 patients, compared to 21 patients in direct pleural culture. A statistically significant difference was found between the culture positive rate in aerobic blood culture bottles and direct pleural culture (P=0.001). Conclusion Blood culture bottle inoculation of infected pleural fluid increases the sensitivity of microbial yield in a shorter time than standard culture.

Retrospective review of empyema and parapneumonic effusions in hospitalized children in Ghana

Objectives: Empyema and parapneumonic effusions (PPEs) are common complications of community-acquired pneumonia in children. Both contribute to prolonged hospital stay, increased morbidity, and less frequent mortality. This study aimed to describe the demographics, immunization status, clinical profile, etiology, and outcomes in children admitted with empyema and PPE to the Komfo Anokye Teaching Hospital. Materials and Methods: This was a retrospective cross-sectional study that reviewed folders and electronic records of children admitted from January 2016 to December 2020. Information on demographic characteristics, immunization status, clinical profile, date of admission, and discharge or death were documented. Information was extracted using Microsoft Excel. Data was then analysed with Stata statistical software package version 16. Results: Records were available for 51 out of 65 children, the median age was 42 months interquartile range (IQR) (22.5–96) and 68.6% (n = 35) of the children were males. Three of the children 5.9% did not have a chest drain inserted. In all, 60.8% (n = 31) of the children had received all doses of the pneumococcal conjugate vaccine (PCV) up-to-date for age. Four children (7.8%) had oxygen saturation <90%, whereas 43.9% (n = 18) had axillary temperature >38°C. Blood cultures were done for 72.6% (n = 37) of patients, Staphylococcus aureus was isolated in 5 patients (13.5%, n = 5/37) and Streptococcus pneumoniae was isolated in 1 patient (2.7%, n = 1/37). While the rest, 83.8% (n = 31) had no bacterial growth. The pleural aspirate culture was done in 64.7% (n = 33) of the patients and 6 (18.1%) had S. aureus isolated. Common antibiotics administered were amoxicillin clavulanic acid in 33.3% (n = 17) of the patients, and ceftriaxone in 31.4% (n = 16) of the patients. Three (5.9%) children died. The median length of hospital stay was 9 days IQR (7–14). Conclusion: Empyema and PPE occurred more commonly in children older than 1 year, with a low mortality rate among the children. Most children with empyema were full immunised with PCV-13.

Retrospective evaluation of etiologic causes and pleural culture results in patients with pleural effusion

Amaç: Plevral efüzyon, birçok farklı hastalığın komplikasyonu olarak gelişebilir. Bu çalışmada, hastanemize plevral efüzyon nedeni ile yatırılan veya incelemeler sırasında plevral efüzyon saptanan hastaların efüzyon nedenlerinin, özelliklerinin ve plevral sıvı kültürlerinin değerlendirilmesi amaçlandı.
 Gereç ve Yöntemler: Çalışmada Nisan 2020-Haziran 2022 tarihleri arasında hastanede yatan plevral efüzyon saptanan ve torasentez işlemi uygulanan 18 yaşın üzerindeki hastalar retrospektif olarak değerlendirildi. Çalışmaya 84 hasta dahil edildi. Hastalara ait bulgular konsültasyon notları ve hastane otomasyon sisteminden elde edildi. Plevral sıvının yerleşimi unilateral (sağ veya sol) veya bilateral olarak kaydedildi. Plevral sıvının görünümü (seröz, hemorajik ve püy), biyokimyasal analizler ve plevra sıvısı kültürleri incelendi. Plevral efüzyonun eksüda-transüda ayrımı için Light kriterleri kullanıldı. 
 Bulgular: Hastaların yaş ortalaması 64,31 ± 16,99 yıl ve 48'i (%57,1) erkek cinsiyette idi. 52 (%61,9) hastada sağda, 19 (%22,62) hastada solda, 13 (%15,48) hastada bilateral plevral efüzyon saptandı. Plevral sıvı, en sık olarak 59 (%70,23) hastada seröz görünümde, 14 (%16,68) hastada hemorajik, 11 (%13,09) hastada pürülan görünümündeydi. 58 (%69,04) hastada eksüda, 26 (%30,96) hastada transüda saptandı. Olguların 16’sında (%19,04) malign plevral efüzyon saptandı. Malign plevral efüzyonu olanların yaş ortalaması 70,11± 10,09 yıl olup, genel ortalamadan daha yüksekti. Transüdası olan 26 hastanın 18’i (%69,23) erkek cinsiyette idi. Eksüdası olanların ise 30’u (%51,72) erkek cinsiyette idi.
 Sonuçlar: Plevral efüzyonun en sık nedenleri olarak sırasıyla kalp yetmzliği, malign hastalıklar, parapnömonik efüzyon ve ampiyem olarak tespit edildi. Bu hastalardan alınan plevra sıvı incelemeleri tedaviye yol göstermesi açısından faydalıdır.

Evaluation and outcome of parapneumonic effusion among children attending Assiut University Pediatric Hospital

BackgroundEmpyema is the most frequent suppurative complication of bacterial pneumonia in childhood. As parapneumonic effusion (PPE) progresses, fibrin and cellular debris accumulate, the purulent fluid becomes septated, and a thick peel forms over the pleura.AimTo describe and compare clinical, laboratory, microbiological findings in patients with PPE and to verify the prognostic accuracy of pleural fluid C-reactive protein in disease progression.Patients and methodsIn all, 25 children aged from 1 month to 16 years, with PPE and empyema were enrolled in this prospective study, which was carried out at Assiut University Children Hospital, from January 1, 2019 to June 30, 2019.ResultsFever and dyspnea occurred in 88 and 64% of patients, respectively. Right effusion occurred in 64% of patients. Hemoglobin was less than 10 g/dl in 72% of patients. Pleural fluid C-reactive protein after 1 week, decreased significantly (15.21 ± 9.45 vs. 50.70 ± 20.85 mg/dl). Blood culture showed no growth in 11 (44%) patients while six (24%) patients had Staphylococcus aureus. Pleural culture revealed no growth in 13 (52%) patients while S. aureus was found in seven (28%) patients.ConclusionS. aureus is the most common isolated organism in both blood and pleural fluid positive cultures. All children received the recommended antibiotics for the treatment of empyema and empyema drainage with an intercostal tube without using fibrinolytic therapy and only 12% of the children were advised for surgical treatment in the form of open thoracotomy with decortication.

A Retrospective Chart Review of Pediatric Complicated Community-Acquired Pneumonia: An Experience in the Al Qassimi Women and Children Hospital.

Background Community-acquired pneumonia (CAP) is one of the most common global health issues. Even though many vaccinations and new diagnostic tools are available, CAP has a higher mortality rate, especially in children less than five years of age. Complicated CAP (CCAP) in a healthy child is a severe disease characterized by a combination of local complications, such as parapneumonic effusion (PPE), empyema (EMP), necrotizing pneumonia (NP), abscess, pneumothorax, and bronchopleural fistula, and systemic complications, such as bacteremia, metastatic infection, multiorgan failure, acute respiratory distress syndrome, disseminated intravascular coagulation, and, rarely, death. This study describes the demographic features, clinical presentation, management, and outcomes of patients diagnosed with CCAP at the Al Qassimi Women's and Children's Hospital (AQWCH). Methodology This retrospective chart review aims to collect and explore the data of all previously healthy children admitted with CCAP between the ages of one month and 13 years at AQWCH from January 2018 to December 2020. The primary study outcome measure is to provide clinicians with the diagnostics, evaluation, and management required to treat complicated pneumonia. Results A total of 195 patients were diagnosed with CAP, of whom 30 (15.3%) were diagnosed with CCAP. Of these, 14 (46.6%) patients had NP, eight (26.7%) had PPE, and eight (26.7%) had EMP. The median age of patients was 2.5 years, with 13 (43%) males and 17 (57%) females. The median duration of their stay in the hospital was 16 days. All patients were vaccinated with Hib, PCV13, or PCV7, and 57% of the patients received antibiotics before admission. The most common findings were consolidation and pleural effusion. Blood culture was negative in all cases, and pleural culture was positive only in three cases. A total of 17 (57%) patients underwent video-assisted thoracoscopic surgery (VATS), and post-VATS surgical emphysema was found to be the most common complication. Chest X-rays normalized after three months in 65% of patients. On comparing patients who were admitted to the Pediatric Intensive Care Unit (PICU) before any surgical intervention with those who were not, it was found that patients who required PICU admission were young (median = 2 years; interquartile range (IQR) = 1-4.5; p = 0.044) and had higher respiratory rate (mean = 49 breaths/per minute, standard deviation (SD) = 11; p = 0.000). In addition, they had lower median albumin (median = 2 g/L; IQR = 1.8-2.23; p = 0.004). On comparing patients who required VATS and those who did not require VATS, it was found that the former had a higher median respiratory rate (48 per min; range = 42-54; p = 0.01). A cavity in the chest computed tomography (CT) was found in 86% of patients with VATS (p = 0.017), and they had lower median albumin (median = 2 g/L; IQR = 1.92-2.24; p = 0.012), as well as longer median duration of using oral antibiotics (median = 21 days; IQR = 19-26; p = 0.025). Patients with complicated NP had a higher respiratory rate and higher PICU admission, and more cavity in the chest was found in the CT study. Most NP patients also underwent VATS and had longer median days of using oral antibiotics. One patient developed a bronchopleural fistula, and one patient diagnosed with NP died. Conclusions CCAP is a major cause of hospitalization in children. It is important to suspect CCAP in all CAP patients not responding to treatment after 48-72 hours.

Donor Derived Coccidioides in a Lung Transplant Recipient

<h3>Introduction</h3> There are no universal guidelines on screening donors for coccidioides. We describe a fatal case of coccidioides empyema from a donor previously residing in an endemic region. <h3>Case Report</h3> This is a 72 year old male, status post right single lung transplantation 3 weeks prior for chronic hypersensitivity pneumonitis, who presents to clinic with a productive cough. The donor was a 31 year old male with no medical history from the southern inland region of California. A chest X-ray in clinic demonstrated a right pleural effusion. He underwent thoracentesis and bronchoscopy on post-operative day (POD) 22. Pleural fluid was lymphocytic and exudative with negative cultures, and transbronchial biopsies showed mild acute cellular rejection. He was treated with pulse dose steroids. His symptoms worsened one week later when he was seen in the emergency department. Chest CT showed a large right loculated pleural effusion. The patient was started on broad spectrum antibiotics, and a thoracostomy tube was placed, demonstrating a neutrophil predominant exudate. Repeat chest CT showed the effusion extending through the chest wall, and an additional thoracostomy tube was placed. The patient became more hypoxemic requiring mechanical ventilation and VV-ECMO. Pleural cultures taken two-days prior demonstrated mold and the patient underwent irrigation with amphotericin in the operating room, along with intravenous amphotericin. Ultimately, the patient had multi-organ failure and cardiac arrest. Following his passing, pleural fluid cultures confirmed growth of Coccidioides immitis. <h3>Summary</h3> This case describes a patient with initial negative serologies to coccidioides and a donor from the southern inland region of California, where the incidence of coccidioides is increasing. Transmission of donor-derived coccidioides has been shown to be 43% within 30 days post-transplant, with a 29% mortality. Given the high mortality and treatment availability, screening donors in endemic areas with serologies may prevent post-transplant complications.

Empyema and Parapneumonic effusions in children admitted to a teaching hospital in Ghana. -A retrospective review

Background&#x0D; Parapneumonic effusions (PPE) and Empyema are serious complications of pneumonia in children that are associated with higher morbidity and prolonged hospital stay. The introduction of the pneumococcal conjugate vaccines (PCV 13) have led to a reported decline in the episodes of complicated pneumonia in children. The organisms commonly associated with PPE and Empyema are Streptococcus pneumoniae and Staphylococcus aureus though Mycobacterium tuberculosis has also been reported. There is paucity of data on children with PPE and Empyema in Ghana. We aimed to describe the profile, mode of presentation and outcomes in children admitted with PPE and Empyema to the Komfo Anokye Teaching Hospital.&#x0D; Methods&#x0D; A retrospective review of medical records (folders) and electronic data on children with PPE and Empyema admitted to the pulmonology unit from January 2018 to December 2020 were retrieved. Demographic records, immunization status, clinical presentation, length of hospital stay and outcome of admission were extracted using a Microsoft Excel. Data was then analysed with STATA version 16.&#x0D; Results&#x0D; Records were available for 51 children; the median age was 42 months IQR (22.5-96) and 68.6% (n=35) were males. In all 84.2% (n=38), had received all immunisations up to date for age. At presentation, 9.5% (n=4/42) had oxygen saturation &lt;90%, whilst 43.9% (n=18/41) had axillary temperature &gt; 38oC. The median respiratory rate was 47.5 IQR (32.8-57). The Median white cell count was 15.84 X10 9/l IQR (11.9-24.73) and median hemoglobin was 9.6 g/dl IQR (8.6-11.7). Pleural aspirate culture isolated Staphylococcus aureus for 6 patients. The rest were either not available or had no bacterial growth. Amoxicillin clavulanic acid and ceftriaxone were the most commonly used antibiotics. The median length of hospital stay was 9 days IQR (7-12) while the median length of chest tube insertion was 7 days IQR (5.5-9). In all 7.8 (n-4/51) patients died.&#x0D; Conclusion&#x0D; Both young and older children are affected with PPE/empyema. There is a good uptake of vaccines among children admitted for PPE/empyema, Staphylococcus aureus is the most common bacterial isolated from pleural aspirate culture. Most children admitted with complicated PPE/Empyema survived.

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

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

FIBROTHORAX DUE TO STREPTOCOCCUS INTERMEDIUS INFECTION IN A 24-YEAR-OLD PATIENT WITH DOWN SYNDROME

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Fibrothorax occurs as a long-term complication of untreated pleural infections. Well-known causes of fibrothorax include recurrent parapneumonic effusions, empyema, and frank hemorrhage in the pleural space. Here we present a case of massive fibrothorax secondary to silent aspiration pneumonias in a patient with Down's syndrome. CASE PRESENTATION: A 24-year-old male with Down's syndrome and autism presents with a complaint of right-sided back pain and fever for two days. The patient is non-verbal at baseline but is able to communicate with his mother, who is the primary caregiver. He has a fixed routine throughout the day, owing to his autism, and his mother takes excessive precautions in tracking his symptoms and keeping his healthcare appointments.In the ER, the patient was hypoxic and tachypneic; initially requiring non-invasive ventilation, and subsequently mechanical ventilation with admission to the ICU. Work-up including chest radiograph revealed complete opacification of the right hemithorax, while the CT chest revealed a large right-sided pleural effusion, consolidation, and a thick pleural peel. Broad-spectrum antibiotics were initiated, and the patient subsequently underwent a right-sided VATS and lung decortication. Intraoperative findings revealed massive fibrothorax without frank pus. Blood and respiratory cultures were negative, surgical culture from pleural peel, however, grew Streptococcus intermedius (S. intermedius). Pathology demonstrated granulation tissue with abundant adherent fibrin and fibrinopurulent exudate, compatible with empyema. On day 7, he was transferred out of the ICU after showing marked clinical improvement. DISCUSSION: Diffuse pleural thickening or fibrothorax occurs due to severe pleural space inflammation. The development of empyema is an uncommon complication, with a reported incidence of 2-3% of all pneumonias. We hypothesize the etiology in our patient to be attributed to recurrent silent aspirations in a patient with Downs syndrome. Anatomical and functional abnormalities including macroglossia, poor neuromotor control, and gastroesophageal reflux make these patients aspiration-prone, which quite often are silent. This is further supported by the presence of S. intermedius in the pleural culture. This bacterium is commonly found in the oral flora but has been associated with brain, liver and thoracic empyema. Recent literature review revealed a limited number of reported cases of pneumonia caused by S. intermedius. Decortication is an effective strategy for treating symptomatic patients, regardless of cause, when significant underlying parenchymal disease has been excluded, as was done in our patient. CONCLUSIONS: It is important for clinicians to be aware of uncommon causes of fibrothorax, such as seen in this case of recurrent silent aspirations, without recurrent pleural effusions, leading to strep intermedius-associated pleural fibrosis. REFERENCE #1: Hannoodi F, Ali I, Sabbagh H, Kumar S. Streptococcus intermedius Causing Necrotizing Pneumonia in an Immune Competent Female: A Case Report and Literature Review. Case Rep Pulmonol. 2016;2016:7452161. doi:10.1155/2016/7452161 REFERENCE #2: Huggins JT, Sahn SA. Causes and management of pleural fibrosis. Respirology. 2004 Nov;9(4):441-7. doi: 10.1111/j.1440-1843.2004.00630.x. PMID: 15612954 REFERENCE #3: Jackson A, Maybee J, Moran MK, Wolter-Warmerdam K, Hickey F. Clinical Characteristics of Dysphagia in Children with Down Syndrome. Dysphagia. 2016 Oct;31(5):663-71. doi: 10.1007/s00455-016-9725-7. Epub 2016 Jul 12. PMID: 27405422 DISCLOSURES: No relevant relationships by Timothy Barreiro, source=Web Response No relevant relationships by Rishanki Jha, source=Web Response No relevant relationships by Oyidiya Osoka, source=Web Response

RARE BACTERIAL EMPYEMA AFTER A BLUNT TRAUMA

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pleural effusion (PE) is an accumulation of excess fluid in the pleural space. PE is classified as transudative or exudative. Transudative pleural effusion can result from: increased hydrostatic pressure, decreased oncotic forces or increased negative intrapleural pressure. On the other hand, exudative pleural effusion result from increased capillary permeability and impaired lymphatic drainage caused by inflammatory processes. Parapneumonic effusions such as empyema are related to pneumonia in 20-40%. ß hemolytic Lancefield group A streptococcus pyogenes (GAS) is a common cause of upper respiratory tract and cutaneous infections which commonly is related to streptococcal toxic shock syndrome. GAS is an uncommon pathogen with 1.14 per 100,000 habitants associated to bacterial pneumonia, however the prevalence of GAS associated to empyema is only 0.7%. CASE PRESENTATION: Case of 46-year-old man with history of IVDA who arrived to urgency room due to shortness of breath, dry cough and left pleuritic chest pain of 3 weeks of evolution. He had a chest trauma as a pedestrian 2 weeks prior arrival. He denied fever, night sweats, hemoptysis, palpitations, or weight changes. Vitals signs were remarkable for tachycardia, tachypnea and decreased peripheral oxygen saturation. Physical examination was remarkable for bilateral decreased breath sounds and left side dullness to percussion. ABG's with oxygen supplementation revealed hypercapnia 57.3 mmHg with elevated A-a gradient 66.3 mmHg. CBC showed leukocytosis with left shifting. Chemistry panel was remarkable for metabolic alkalosis 31 mmol/L and lactate dehydrogenase was elevated 615 IU/L. Chest X-Ray showed left sided white lung, followed by a chest CT with bilateral pleuro-parenchyma fibrotic changes, bullae formation, centrilobular emphysema, patchy ground glass appearance at both lung fields and decreased right lung volume with ipsilateral displacement of the heart and mediastinal structures with large, multiloculated left pleural effusion with increased density. Left side thoracentesis performed collecting 120ml of purulent fluid, elevated WBC 150,000 with PMN 65% and gram stain positive. Chest tube was placed and drain 1400ml of brown-yellow purulent fluid and pleural culture showed growth of streptococcus pyogenes group A. Patient started on directed IV antibiotic therapy. DISCUSSION: Empyema is an accumulation of excess pus in pleural space. The M protein, the major virulence factor, is a macromolecule incorporated in fimbriae present on the cell membrane projecting on the bacterial cell wall. It is the primary cause of antigenic shift and antigenic drift among GAS. CONCLUSIONS: We expect to contribute awareness and knowledge to the medical field to always include empyema in the working diagnosis of all patients with progressive dyspnea after blunt trauma. REFERENCE #1: Sakai T, Taniyama D, Takahashi S, Nakamura M, Takahashi T. Pleural empyema and streptococcal toxic shock syndrome due to Streptococcus pyogenes in a healthy Spanish traveler in Japan. IDCases. 2017;9:85-88. Published 2017 Jun 27. doi:10.1016/j.idcr.2017.06.006 REFERENCE #2: Shebl E, Paul M. Parapneumonic Pleural Effusions And Empyema Thoracis. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534297/ REFERENCE #3: Tamayo E, Montes M, Vicente D, Pérez-Trallero E. Streptococcus pyogenes Pneumonia in Adults: Clinical Presentation and Molecular Characterization of Isolates 2006-2015. PLoS One. 2016;11(3):e0152640. Published 2016 Mar 30. doi:10.1371/journal.pone.0152640 DISCLOSURES: No relevant relationships by Maria Betancourt, source=Web Response No relevant relationships by Marlene Farinacci Vilaro, source=Web Response No relevant relationships by Kyomara Hernandez-Moya, source=Web Response No relevant relationships by Arnaldo Nieves-Ortiz, source=Web Response No relevant relationships by Ivanisse Ortiz Velez, source=Web Response No relevant relationships by Neshma Roman-Velez, source=Web Response

Microbiological profile and antibiotic resistance pattern of empyema thoracis in Calabar, Nigeria.

Targeted empirical antibiotic therapy based on local microbiology and antibiotic resistance patterns is essential for the treatment of empyema thoracis. Our retrospective review of 105 pleural empyema culture and sensitivity reports aimed at determining the causative microorganisms and their antimicrobial resistance pattern. Of 105 pleural aspirate samples, 46 (43.8%) were positive on culture. Gram-negative organisms (n = 43) were the predominant isolates, the commonest of which was Klebsiella pneumoniae. It was concluded that empyema thoracis is predominantly caused by Gram-negative organisms in our locality. This should guide protocols on the initiation of empirical therapy.

Profile of Patients With Tuberculous Pleural Effusion in Qatar: A Retrospective Study.

IntroductionTuberculosis (TB) remains one of the top 10 causes of death globally. Around 1.7 billion people are infected with mycobacterium TB worldwide, and almost 90% of cases each year are found in 30 high TB burden countries. Due to the influx of a large expatriate population mainly from the high TB burden countries, there is an increased number of pulmonary TB as well as tuberculous pleural effusion cases reported in Qatar.ObjectivesThe demographic, clinical, laboratory, and histopathological parameters of patients with tuberculous pleural effusion were assessed.MethodsA single-center study was conducted at Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar. Adults diagnosed to have tuberculous pleural effusion were included, and those with clinical suspicion of tuberculous pleural effusion with positive sputum acid-fast bacillus (AFB) but negative AFB in pleural samples were excluded.ResultsA total of 106 patients were reviewed, of whom 100 were included for the final analysis, with 86% being men. Majority were from the Asian subcontinent, and the mean age was 33.8 years (SD ± 10.3). Main symptoms in decreasing order were cough (77%), fever (56%), and chest pain (54%). Of the patients, 72% had normal BMI, and rest were above the normal range. Anemia and hypoalbuminemia were found in 36.7% and 89.8% of the patients, respectively. Positive AFB culture was observed in pleural biopsy (79%), pleural fluid (13%), and sputum (16%). Positive AFB by polymerase chain reaction (PCR) was observed in pleural biopsy (57%), pleural fluid (3%), and sputum (2.2%), whereas AFB smear was positive in 2% of pleural biopsy samples. Caseating granuloma was seen in 80% of patients. All the three Light's criteria were met by 30% of the patients whereas 52% had two criteria fulfilled. No association between the number of Light's criteria and AFB yield was observed.ConclusionsTPE was more common in healthy young adults. The AFB yield on pleural biopsy, PCR, and culture was significantly higher than that on all other samples. The number of positive Light's criteria did not have any association with positive AFB yield.

Abstract 14814: By Stanza or Story, the Structure of a Poem

A 63-year-old male with recent diagnosis of idiopathic pericarditis presented to the hospital with atrial fibrillation and rapid ventricular rates. He reported one week of palpitations and subacute lower extremity weakness. On exam he was hemodynamically stable with evidence of intra- and extravascular fluid overload. Lab analysis showed elevated creatinine, inflammatory markers, and serum protein gap. Chest radiograph showed bilateral pleural effusions and a focal sclerotic thoracic vertebra. TTE revealed mildly reduced biventricular function, elevated RVSP, and moderate pericardial effusion. The presence of pericardial and pleural effusions with elevated inflammatory markers suggest serositis, and a differential of malignant, autoimmune, and infectious etiologies were considered. Hepatosplenomegaly was noted on CT imaging. Blood, pleural, and pericardial cultures revealed no growth and autoimmune serologies were negative. Given these findings- the differential was narrowed to lymphoma, myeloma with or without amyloidosis, and paraneoplastic syndromes. Electrophoresis revealed presence of an M protein, fat pad biopsy was negative for amyloid fibrils. Bone marrow biopsy revealed an abnormal plasma cell population and biopsy of sclerotic vertebra showed no malignancy. Whole body FDG PET showed no focal uptake in the heart nor elsewhere. VEGF levels were significantly elevated. On the basis of the plasma cell dyscrasia, polyneuropathy, sclerotic bone lesion, elevated VEGF level, hepatosplenomegaly, and pericardial effusion the patient was diagnosed with POEMS syndrome- an extremely rare paraneoplastic syndrome with multisystemic end-organ effects. Cardiac manifestations are infrequent, but include pericardial effusion, myocardial edema and dysfunction, pulmonary hypertension, and volume overload. No specific cardiac therapy exists, but involvement may regress with chemotherapy for treatment of the underlying malignancy. This case demonstrates the importance of recognizing cardiac manifestations as the initial or cardinal presentation of underlying systemic disease, where accurate diagnosis may rely on identification of subtle non-cardiac symptoms, laboratory, and imaging findings as demonstrated here.

PARAPNEUMONIC PLEURAL EFFUSION AND EMPYEMA: MICROBIOLOGICAL ASSESSMENT AND TREATMENT STRATEGIES IN A HIGH-VOLUME PLEURAL CENTER

SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Parapneumonic effusion refers to the accumulation of fluid in the pleural space in the setting of an adjacent pneumonia. Furthermore, empyema refers to a collection of pus within the pleural space, which can develop when bacteria's, fungi, parasites, or mycobacteria invade the pleural space, either from an adjacent pneumonia, from direct inoculation or another source. We aim to characterize the pleural culture from patients with parapneumonic pleural effusions in terms of isolated microorganisms, antibiotic treatment and source of infection. METHODS: Retrospective medical records review of patients diagnosed with parapneumonic pleural effusion and empyema between 1998 and 2019 at Beth Israel Deaconess Medical Center were included. Patients were identified from our institutional database using the International Classification of Diseases 9th revision (ICD-9, codes 510.9 and 510.10) as well as the 10th revision (ICD-10, codes J86.0 and J86.9). RESULTS: Total of 598 subjects were included. Pleural fluid culture was obtained in 535 (89.5%) patients. Of those, 41.3% had a negative result, followed by polymicrobial etiology (9.5%), MSSA (8.2%), and Streptococcus viridans (8.2%). The most common antibiotics used were Vancomycin in 70.07% of patients, followed by Metronidazole (43.4%), Levofloxacin (36.0%), and Ceftriaxone (35.0%). The median total antibiotic duration was 31 days (IQR 20-44), the IV duration was 10 days (IQR 7-16), and further antibiotic treatment was required in 13.4% due to patient unresponsiveness to initial treatment. Regarding the source of infection, 54.4% of cases were community acquired followed by hospital acquired (32.4%) and post-surgical (8.2%). A total of 321 (53.68%) subjects had VATS. Thoracostomy was performed in 182 (30.43%) patients with 26% of those having a tube size <14 Fr. TPA/DNase therapy was used in 116 (19.4%) subjects and the median number of doses was 2 (IQR 1-3). All-cause mortality during the timeline of the study was 18.56% (n=111). CONCLUSIONS: Our large cohort of patients evidenced the high rate of negative results after pleural fluid culture, followed by polymicrobial etiology, supporting the use of broad-spectrum antibiotic therapy to cover gram positive, gram negative and anaerobic bacteria as a first line strategy. Furthermore, we found a high rate of patients requiring further antibiotic therapy due to initial unresponsiveness to treatment.Our large cohort of patients adds further evidence to the existing literature and helps to elucidate and optimize the antibiotic therapy and reduce failure rate. CLINICAL IMPLICATIONS: Microbiologic characterization of empyema and parapneumonic effusion is necessary for optimizing antibiotic therapy and reducing failure rate. DISCLOSURES: No relevant relationships by Ramsy Abdelghani, source=Web Response No relevant relationships by Alvaro Ayala, source=Web Response No relevant relationships by Alex Chee, source=Web Response No relevant relationships by Fayez Kheir, source=Web Response Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Rachel Martinez, source=Web Response No relevant relationships by Mihir Parikh, source=Web Response No relevant relationships by Priya Patel, source=Web Response No relevant relationships by Alichia Paton, source=Web Response No relevant relationships by Juan Pablo Uribe, source=Web Response

Antibiotic Resistance Is Associated With Morbidity and Mortality After Decortication for Empyema

Previous studies of decortication for empyema demonstrated that patient characteristics are associated with mortality, but the relationship of infectious pathogen to outcome has not been described. Our objective was to analyze the association of microbiology and antibiotic resistance with postoperative mortality after decortication for empyema. We hypothesized that bacterial pathogens, antibiotic resistance, and patient characteristics would all contribute to perioperative morbidity and mortality. Patients undergoing pulmonary decortication for empyema from January 1, 2010 to October 1, 2017 were reviewed retrospectively. Cases were matched with microbiology cultures. Outcomes of interest were a composite of death, tracheostomy, initial ventilator support greater than 48 hours, or unexpected intensive care unit readmission. Antibiotic resistance was categorized as present or absent, and the number of antibiotics with resistance was counted for each patient. We describe the relationship of patient characteristics, antibiotic resistance, and microbiology to mortality. During the study period, 185 patients underwent decortication, 118 of whom had a diagnosis of primary empyema (63.8%). Positive culture results were present in 79 of 185 patients (43%). The most common isolate was Streptococcus, which was present in 29 of 79 (37%), followed by Staphylococcus in 19 of 79 (24%). Of 79 patients, 11 had fungal infections (13.9%). In addition, 16 of 79 patients had polymicrobial empyema (20%). Of 185 patients, 30 experienced the composite adverse outcome (16.2%). In multivariable regression, the composite adverse outcome was associated with emphysema, Candida in pleural culture, and antibiotic resistance count. Perioperative mortality and morbidity after decortication for empyema is considerable. In this cohort, infections with increasing antibiotic resistance are associated with morbidity and mortality among patients with empyema.

MON-689 Diabetes Mellitus---Hypoglycemic Response---Empyema

Diabetes mellitus---hypoglycemic response---empyemaCase reportA 65-year-old woman was admitted to our department due to high blood glucose for two days on February 29, 2016. Fasting blood glucose was 12.53mmol/L on February 28 without polydipsia, polyuria, polyphagia and weight loss.In the past medical history, she started to cough in January 2016. On February 2, the routine blood examination showed that white blood cells and neutrophils were higher than normal. Chest X-ray was normal. Moxifloxacin was given and symptoms were relieved slightly.On examination, the temperature was 36.9℃. Auscultation of the chest was normal. On the evening of admission, body temperature rose to 37.8 C. On March 1st, white cell, neutrophil, erythrocyte sedimentation rate and C-reactive protein were increased. FBG was 10.5mmol/L, and HbA1c was 10.5%. Chest CT was normal. Piperacillin Tazobactam Sodium and Moxifloxacin were given, and insulin was used to lower blood glucose.On March 2, body temperature was normal. And palpitation, tremor, sweating, fatigue and cold extremities appeared several times. Blood glucose test ruled out hypoglycemia. The above symptoms appeared again at around 4 pm, more serious than before. Gas analysis at 5:12pm showed PH 7.403 and lactic acid 19.27mmol/L. At 6:00pm, blood pressure started to drop. Vasoactive drug was given. In gas analysis at 6:27pm, PH was 7.237, lactic acid 21.05mmol/L. 5% NaHCO3 solution was given to buffer acidosis. Cardiac and respiratory arrested during transferring to ICU. Undergoing cardiopulmonary resuscitation, vasoactive drugs and ventilator-assisted breathing were applied. Hemodialysis was used to counteract lactate acidosis. The bedside chest radiograph showed that the transmittance of left lung was decreased. On March 3, the transmittance of left lung was lower. Doctors prescribed Tylenol and Vancomycin. On March 4, left thoracic puncture and catheterization were performed. The pus was drained out and bacterial cultures were made. Klebsiella pneumoniae was cultured. Sensitive antibiotics therapy was chosen according to pleural cultures. On March 9, left empyema was removed and pericardial fenestration was performed by thoracoscope under general anesthesia. Nutritional support had been given. The patient gradually recovered and was discharged on April 9.DiscussionPalpitation, tremor, sweating and fatigue were the first manifestations of the condition change in this diabetic patient. The condition rapidly developed into septic shock and empyema. After active treatment, she was cured and discharged from hospital. Besides hypoglycemia, other diseases such as septic shock also may cause the symptoms of sympathetic excitation, which should be considered in order to avoid delaying the time of treatment. Furthermore, diabetic patients complicating with infection should be actively treated with effective antibiotics.

A RARE CASE OF HISTOPLASMOSIS PRESENTING WITH PLEURAL EFFUSION IN A NORMAL HOST

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Histoplasmosis is an endemic mycosis that is usually asymptomatic in healthy hosts. We present a rare case of pulmonary histoplasmosis presenting with pleural effusion in an immunocompetent patient. CASE PRESENTATION: A 44 year old male smoker presented to the emergency department with progressive left-sided pleuritic pain, cough, night sweats, and weight loss. Chest x-ray was unremarkable and he was released to follow-up with primary care. His symptoms persisted and chest CT obtained three weeks later revealed a 2.5 cm left lower lobe pleural-based nodule, left hilar lymphadenopathy, and a small left-sided pleural effusion. Thoracentesis yielded 520 ml of exudative pleural fluid with 43% lymphocytes and 16% eosinophils. Testing for histoplasmosis including urine and serum antigens as well as serology were negative. However, pleural fungal culture grew Histoplasma capsulatum. Fluid reaccumulated within a week and repeat thoracentesis again grew H. capsulatum. In the interim, the patient was initiated on itraconazole and pleural effusion resolved. DISCUSSION: Histoplasmosis is a mycosis caused by H. capsulatum which is transmitted via inhalation of microconidia and associated with environments containing bird or bat guano. Infection is generally asymptomatic in healthy hosts and resolves through cell-mediated immunity. However, with large inoculum pulmonary histoplasmosis can manifest in an acute, subacute, or chronic illness. Acute pulmonary histoplasmosis is characterized by fever, dyspnea, and cough with chest imaging showing bilateral patchy opacities, nodules, and lymphadenopathy. In contrast, subacute pulmonary histoplasmosis progresses over several months and imaging reveals more focal opacities. Chronic histoplasmosis is characterized by exacerbations of cough, dyspnea, fever, chest pain, night sweats, and weight loss with radiographic features of cavitation, fibrosis, pleural thickening, and calcified lymph nodes. Pleural effusion secondary to any form of histoplasmosis is exceedingly rare. Diagnosis of histoplasmosis is made via identification of ovoid yeast cells in tissue or body fluid, cultures of blood, sputum, or bronchoscopy specimens, serum and urine antigen, or antibody testing. Antigen testing provides highest yield in acute pulmonary and disseminated histoplasmosis. Combined serum and urine antigen is reportedly 81% sensitive and 99% specific, and therefore negative antigen does not rule out infection as was the case with our patient who had positive pleural culture despite negative antigen testing. CONCLUSIONS: Pulmonary histoplasmosis can present with a variety of clinical and radiographic findings depending upon size of inoculum and immune status of the host. Diagnosis can be challenging and relies on a combination of culture, pathology, antigen, and serologic testing. Our patient is a very rare case of histoplasmosis presenting with culture positive pleural effusion. Reference #1: Wheat, L.J.; Azar, M.M.; Bahr, N.C.; Spec, A.; Relich, R.F.; Hage, C. Histoplasmosis. Infect Dis Clin N Am 30. 2016; 207-227. https://doi.org/10.1016/j..idc.2015.10.009. Reference #2: Di Mango, A.L.; Zanetti, G.; Penha, D.; Mebba Barreto, M.; Marchiori, E. Endemic pulmonary fungal diseases in immunocompetent patients: an emphasis on thoracic imaging. Exper Rev Respir Med. 2019; 13(3): 263-277. https://doi.org/10.1080/17476348.2019.1571914. Reference #3: Patterson, J.; Graham, D.; George, A.; Will, M.; Sutter, D. Right Middle Lobe Collapse and Pleural Effusion in an 18-Year-Old-Man. Chest. 2017; 152(2):e33-e38. DISCLOSURES: No relevant relationships by Brian Boer, source=Web Response No relevant relationships by Amber Johnson, source=Web Response