A 45-year-old man with HIV comes to the emergency department due to increasing shortness of breath, left-sided chest pain, chills, and productive cough. The symptoms began 7 days ago. At first, the patient thought he had the flu, but after 3 days he began coughing up green phlegm and developed left-sided chest pain. The pain is worse with deep breaths or cough. CD4 count is unknown. He smokes cigarettes and drinks alcohol regularly. Temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 26/min. Physical examination shows poor dentition and decreased breath sounds over the left lung base. Chest x-ray is shown below. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 45-year-old man with HIV comes to the emergency department due to increasing shortness of breath, left-sided chest pain, chills, and productive cough.  The symptoms began 7 days ago.  At first, the patient thought he had the flu, but after 3 days he began coughing up green phlegm and developed left-sided chest pain.  The pain is worse with deep breaths or cough.  CD4 count is unknown.  He smokes cigarettes and drinks alcohol regularly.  Temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 26/min.  Physical examination shows poor dentition and decreased breath sounds over the left lung base.  Chest x-ray is shown below.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d94a_af6f_bc81_2d15ba313592_MD0003_00 Approximately 40% of pneumonias are associated with pleural effusions. Most are small, free-flowing, sterile, and resolve with antibiotics (ie, uncomplicated parapneumonic effusion). However, if bacteria persistently cross from the infected pulmonary parenchyma into the pleural space, a complicated parapneumonic effusion or an empyema can develop. Both empyemas and complicated parapneumonic effusions are marked by large, (often) loculated effusions and typical thoracentesis abnormalities (low pH, low glucose); unlike complicated parapneumonic effusions, empyemas also have frank pus or bacteria (by Gram stain) in the pleural space. This patient likely has pneumonia (fever, productive cough), and the presence of pleuritic chest pain and a large left-sided pleural effusion suggests the pneumonia is likely complicated by an empyema. Risk for pneumonia complications such as empyema is greater in patients who are immunocompromised (eg, HIV, post-transplant). All empyemas (and many complicated parapneumonic effusions) require prolonged antibiotics (2-4 weeks) and drainage (usually with a chest tube). pleural effusion (Choices A and G) Acute pericarditis presents with sharp, anterior chest pain. Viral myocarditis can cause chest pain and could be associated with upper respiratory symptoms. However, a cough productive of green phlegm would be unusual, and chest x-ray is typically normal. (Choice B) Bronchopleural fistulas often occur with malignancy or trauma, or after surgical procedures involving the bronchi (eg, pneumonectomy). They can cause empyemas, but there is usually radiographic evidence of air in the pleural space as well. (Choice D) A lung abscess is marked by a cavity with air fluid level on chest x-ray. Aspiration pneumonia commonly causes lung abscesses and is frequently associated with foul-smelling sputum and symptoms that develop over days or weeks. cavity (Choice E) Pneumocystis jiroveci pneumonia is common in patients with HIV with a CD4 count <200/mm³. Symptoms (eg, shortness of breath, nonproductive cough, fever) typically arise over several weeks. Chest x-ray can be normal but often reveals diffuse bilateral interstitial or alveolar infiltrates, not a large, unilateral effusion. interstitial or alveolar infiltrates (Choice F) Pneumothorax typically presents with sudden pleuritic chest pain and shortness of breath. Chest x-ray reveals a radiolucent (black) region of extrapulmonary air. This patient has fever and upper respiratory symptoms that developed over days (and an effusion). radiolucent (black) region Educational objective: Bacterial pneumonia commonly causes a pleural effusion. Often the effusion is small, sterile, and resolves with antibiotics (uncomplicated). However, if bacteria persistently cross into the pleural space, a complicated parapneumonic effusion or empyema can develop. Empyemas have frank pus or bacteria (by Gram stain) in the pleural space and require drainage (chest tube) in addition to prolonged antibiotics.

A 45-Year-Old Man with HIV Comes to the Emergency Department