Pleural Infections

Case Presentation
Background
Mr P, 68 Indian Gentleman Presented with

Chest pain x1/52

Smoking history: Passive smoker
- Left sided
Occupational History
- Pleuritic nature
Previously working in plastic
manufacturing industry SOB
Post retirement working in real estate Fever
industry

Comorbids Cough

1/ DM

2/ Hypertension

3/ Depression

4/ Heart Failure
In ED
Admission 16/8/23 (D1)
BP 115/73, PR 86, spo2 94%, temp 36.8
CRP 321
Left chest wall tenderness on palpation
Urea 5.6
Documented Lungs clear, no rhonchi,
Na 135 K 5.3 Cr 111
no crepitations
Alb 34
Admitted to medical for CAP
Hb 10 WCC 21 Plt 350

HbA1c 7.6%
Respi 1st review - referred for complex left pleural effusion
In the ward, Bedside usg done by Respi plan: continue
medical team, noted complex antibiotics as per primary
pleural effusion, thus referred to
team
respi team
send tb workup

Bedside US thorax done by respi Suggest for us guided

team: pigtail insertion
- Complex multiseptated Left To inform once pleural
Parapneumonic Effusion
analysis available
Timeline
16/8/23 Patient admission

17/8/23 USG by medical team - multiloculated, multiseptated pleural effusion

Referred to respiratory team

18/8/23 USG Guided pigtail insertion not done as minimal effusion on USG scan

Require APS referral for pain control

Timeline
19/8/23

Repeat CXR 19/9/23 D4 Repeat CXR 23/8/23 D8

23/8/23 USG guided pigtail insertion (Was given early date)

Timeline
25/8/23 D10 Referred back to respi team as noted pleural fluid
ix exudative (Friday evening)

26/8/23 D11 Dislodged pigtail (Total drainage for only 4 days)

28/8/23 CT Thorax done on 28/8/23 (was given early date)

Referred to CTC KIV for decortication

29/8/23 Patient requested for AOR discharge

Discharge plan:
- Complete Augmentin 6/52
- tca respi clinic 1/12 to review with CXR 26/8/23 D3 post pigtail insertion
- blood taking prior to TCA - FBC RP CA MG CXR when pigtail dislodged
PO4 LFT
- tca ctc clinic 1/12 to review
Blood Ix
Admission 16/8/23 (D1) 18/8/23 D3

CRP 321 CRP 363

Urea 5.6 Na 135 K 5.3 Cr 111 Urea 6.1 Na 131 K 3.70 Cr 92

Alb 34 Alb 34

Hb 10 WCC 21 Plt 350 Hb 9.7 WCC 19 Plt 260

HbA1c 7.6%
Blood Ix
24/8/23 (D9) - d1 post pigtail insertion 27/8/23

CRP 267 Hb 8.0 WCC 12.41 Plt 627

Urea 7.8 Na 137 K 5.2 Cr 105

Alb 34

Hb 8.3 WCC 14 Plt 487

Pleural Fluid Investigation
- Fungal C+S 23/8/23 - NG
- Pleural fluid CS 23/8/23 - NG
- CYTO 23/8/23 - Acute inflammatory process, no atypical cells seen
- TB CS 23/8/23 - IP
- AFB DS 23/8/23 - No AFB
- BIOCHEM 25/8/23 - yellowish, Cl 102, Glucose 0
- TP 40
- pH 7.0
- LDH 25/8/23 - 7211
- ADA 25/8/23 - In Process
CT THORAX
(28/8/23)
CT THORAX
(28/8/23)
CT THORAX
(28/8/23)
CT THORAX
(28/8/23)
CT THORAX
(28/8/23)
 PLEURAL
EFFUSIONS
Light Criteria
Etiology
 PLEURAL
INFECTION
Parapneumonic effusion
Parapneumonic effusion - Pleural effusion that forms in the pleural space adjacent
to a pneumonia.

When bacteria or other pathogens infect the pleural space, a complicated

parapneumonic effusion or empyema may result
 Development of parapneumonic effusions and empyema
Sta Stage 1 Stage 2 Stage 3
Exudative stage (Complicated / (Complicated / organizing
(Uncomplicated / Simple) fibropurulent stage) / empyema thoracis)

Timing Early (Days) Late (Days to Weeeks) Late (Weeks to Months)

Pathophysiology Accumulation of fluid in Progress from Stage 1 if Fibrin membranes

pleural space due to not treated transformed by fibroblast
increased capillary Deposition of fibrin clots into thick nonelastic
permeability from and fibrin membranes in pleural peel > trapped
proinflammatory cytokines pleural cavity - loculations lung with restrictive
respiratory dysfunction

PF Characteristics Exudative Exudative Fluid difficult to obtain

Low to moderately Pleural fluid typically
elevated WCC cloudy
LDH <1000 High WCC, LDH >1000
Normal pH and Glucose pH <7.2, Glu <2.2
No bacterial organisms
Bacterial organisms may
be present
Bacterial organisms may
or may not be present
May see frank pus / thick /
viscous / opaque pleural
fluid
 Development of parapneumonic effusions and empyema
Stage Stage 1 Stage 2 Stage 3
(Uncomplicated / (Complicated / (Complicated / organizing)
Simple) fibropurulent)

Imaging Small to moderate Large and free flowing,
Free flowing loculated, associated
pleural thickening with
contrast enhancement
Large, loculated, and / or
pleural thickening (may be
extensive and
demonstrate a pleural
rind)

Pleural calcification may

be evident

Treatment Typically resolve with Abx + drainage Abx + Drainage

antibiotics alone May require Fibrinolytics / Fibrinolytics / DNase /
DNase VATS may be required
68 year old gentleman
RAPID SCORE?

Community acquired infection Answer: 3

Admission bloods 16/8/23 (D1)

CRP 321

Urea 5.6

Na 135 K 5.3 Cr 111

Alb 34

Hb 10 WCC 21 Plt 350

HbA1c 7.6%
When
encountering a
suspected pleural
infection, when do
we insert a chest
drain?
CPPE - complicated
parapneumonic
effusion
WHAT IF NO PLEURAL FLUID PH AVAILABLE?
Initial pleural fluid glucose of <3.3 may be used as indicator of high probability of
CPPE / Pleural infection - can be used to inform decision to insert intercostal drain
in appropriate context
TPA - tissue plasminogen
activator
DNase -
deoxyribonuclease