A 70-year-old man comes to the emergency department due to a 4-day history of fever, shortness of breath, and right-sided pleuritic chest pain. Medical history is significant for type 2 diabetes mellitus and hypercholesterolemia. Temperature is 38.7 C (101.7 F), blood pressure is 128/78 mm Hg, pulse is 98/min, and respirations are 20/min. Decreased breath sounds and dullness to percussion are noted in the right lower lung field. Chest x-ray reveals a right lower lobe infiltrate and a pleural effusion. Ultrasound examination reveals the pleural effusion is free flowing without loculation. Thoracentesis is performed, and Gram stain of the fluid shows segmented neutrophils and gram-positive cocci in pairs. Cultures of the fluid, blood, and sputum are pending. In addition to systemic antibiotic therapy, which of the following is the most appropriate next step in management?

Question

A 70-year-old man comes to the emergency department due to a 4-day history of fever, shortness of breath, and right-sided pleuritic chest pain.  Medical history is significant for type 2 diabetes mellitus and hypercholesterolemia.  Temperature is 38.7 C (101.7 F), blood pressure is 128/78 mm Hg, pulse is 98/min, and respirations are 20/min.  Decreased breath sounds and dullness to percussion are noted in the right lower lung field.  Chest x-ray reveals a right lower lobe infiltrate and a pleural effusion.  Ultrasound examination reveals the pleural effusion is free flowing without loculation.  Thoracentesis is performed, and Gram stain of the fluid shows segmented neutrophils and gram-positive cocci in pairs.  Cultures of the fluid, blood, and sputum are pending.  In addition to systemic antibiotic therapy, which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d88c_dd8d_bc81_0368bc7080fd_MD0003_00 This patient's clinical presentation is consistent with community-acquired pneumonia, with chest x-ray revealing a parapneumonic effusion. Most parapneumonic effusions are uncomplicated, resulting from increased flow of sterile exudate into the intrapleural space. These effusions typically resolve with antibiotic therapy for pneumonia and require no additional treatment. Complicated parapneumonic effusion (and empyemas, which represent the advanced stage of complicated parapneumonic effusions) must be recognized because they involve bacterial invasion into the pleural space. In addition to antibiotics, drainage of the effusion via chest tube is typically required. This patient's positive pleural fluid Gram stain showing gram-positive cocci in pairs (consistent with Streptococcus pneumoniae) is diagnostic of a complicated effusion, and chest tube placement is indicated. Oftentimes, pleural fluid bacterial counts are low in a complicated effusion, and Gram stain and bacterial culture are falsely negative. In such cases, additional pleural fluid studies can confirm a complicated effusion. Because bacteria in the pleural space metabolize glucose and generate acidic waste, low pleural fluid glucose levels (eg, <60 mg/dL) or pH <7.2 is diagnostic of a complicated effusion and is an indication for drainage. Significantly elevated leukocytes (eg, >50,000/mm³) and lactate dehydrogenase levels >1,000 U/L also suggest bacterial invasion of the pleural space and may be indications for drainage. (Choice A) Bronchoscopy can be helpful in the diagnosis of pneumonia with an atypical presentation (eg, chronic symptoms, unresponsive to antibiotics), but it is not indicated in this patient with a typical presentation of community-acquired pneumonia. (Choice B) Chest physiotherapy may help dislodge pulmonary mucus and is used in patients with cystic fibrosis, but it has not shown benefit in the management of acute pneumonia. (Choice D) Serial chest x-rays (to ensure resolution of the effusion) without additional therapy are appropriate for an uncomplicated parapneumonic effusion. (Choice E) Systemic corticosteroid therapy is used for an acute exacerbation of chronic obstructive pulmonary disease, but it does not have a role in the management of parapneumonic effusions. (Choice F) Video-assisted thoracoscopic surgery (VATS) is sometimes needed to debride and remove loculated and fibrotic fluid collections that develop with an advanced complicated effusion (ie, empyema). However, this patient's complicated effusion is free flowing and amenable to chest tube drainage. Educational objective: Complicated parapneumonic effusions involve bacterial invasion into the pleural space and require drainage in addition to antibiotic therapy. Positive pleural fluid Gram stain or culture is diagnostic of a complicated effusion and is an indication for chest tube placement. References: Diagnostic approach to pleural effusion in adults. (http://www.ncbi.nlm.nih.gov/pubmed/16623208)

A 70-Year-Old Man Comes to the Emergency Department Due to a 4-Day