Case history
Case history
A 65-year-old man re-presents to his physician, following treatment for pneumonia, with fever, increasing breathlessness, and right-sided chest pain. He feels lethargic and has lost 4 kg in weight. He initially presented 3 weeks earlier with a productive cough and breathlessness. At that time, he was diagnosed with community-acquired pneumonia and treated with a course of oral antibiotics. He has a past medical history of poorly controlled type 2 diabetes mellitus. On examination, he is septic, with a temperature of 101.3°F (38.5°C), BP 90/60 mmHg, pulse rate 110 beats/minute, and respiratory rate 28 breaths/minute. He has dullness to percussion and decreased breath sounds at the right lung base. Chest radiograph demonstrates a loculated right pleural effusion, which is confirmed on point-of-care ultrasound. Laboratory examination reveals WBC count 20 × 10⁹/L. He undergoes ultrasound-guided thoracentesis (pleural aspiration) that shows a septated pleural effusion, and frank pus is aspirated.
Other presentations
Empyema may present following iatrogenic intervention in the pleural space, thoracic surgery, thoracic trauma, hospital-acquired pneumonia, or de novo in a patient without a history of pneumonia. Immunocompromised patients, or patients who are already taking antibiotics, may present with few clinical signs of infection. Patients with anaerobic empyemas can present with a more indolent illness characterized by weight loss, constitutional upset, and fatigue.
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