INTRODUCTION: Community acquired pneumonia (CAP) can result in significant morbidity and mortality. Among the patients admitted with CAP, a rare complication is a parapneumonic or post pneumonic empyema thoracis. Although the course may vary patient to patient, these complications can lead to a prolonged treatment course thus leading to a longer hospital stay and increased mortality. Early detection of CAP is key to avoiding these fatal complications. CASE PRESENTATION:We describe a 36 year-old-male with a past medical history of asthma, tobacco and heroin abuse who presented with a chief complaint of shortness of breath. The patient was previously admitted to the hospital two months prior and he was treated for an asthma exacerbation and community acquired pneumonia. Upon discharge, the patient did not complete the antibiotic course he was prescribed. He also reportedly developed worsening dyspnea on exertion with associated fever, chills, unintentional weight loss and pleuritic chest pain. Due to his worsening dyspnea, he subsequently returned to the hospital to seek emergency treatment. On this presentation, a CT chest was ordered and demonstrated a 17 x 15 x 23.5 cm cystic structure. Along with this, a right middle and lower lobe collapse and leftward mediastinal shift were also noted. CT surgery was consulted and the patient underwent a right thoracoscopy that converted to a right thoracotomy, pulmonary decortication, and parietal pleurectomy with eventual chest tube placement. Per the operative report, three liters of purulent foul smelling material was drained from the lung during the procedure. The purulent material was sent for cultures and grew pan-sensitive Streptococcus intermedius. The patient was then treated with antibiotics and he was discharged home with close follow-up. DISCUSSION: Pneumonia is the leading cause of empyema thoracis, therefore, it is important to recognize this serious complication. Early intervention is crucial as mortality significantly rises the longer patients are without treatment. A subset of patients require urgent exploratory thoracotomy within 24 to 48 hour with indications including: parenchymal, multiple loculations or a trapped lung.CONCLUSIONS: Although empyema thoracis does not have any age preference, pneumonia is typically more common in the elderly population with comorbidities. Interestingly, our patient was younger than the expected age range and he demonstrated a rare complication of pneumonia that resulted from early termination of antibiotic therapy.

Figure 1. Orogastric tube lies to the right of the trachea and has its tip adjacent to the right side of the heart. Orogastric tube may have perforated the esophagus and is positioned in the right side of the mediastinum.

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INTRODUCTION: Cerebral palsy (CP) is a complex disorder that involves progressive permanent central motor dysfunction. Although patients with CP often survive up to adulthood, it is often not without multiple hospitalization for various different disease processes throughout their lifetime. Patients with CP not only suffer from intellectual disabilities but also their disease manifests in many different organ systems. Although autonomic dysfunction has been associated with CP here we aim to describe a series of cases involving a group of patients from a group home for cerebral palsy patients. Who on numerous occasions are hospitalized in undifferentiated shock from suspected autonomic dysfunction. CASE PRESENTATION:We describe multiple patients with CP from a local group home who are brought to the emergency room multiple times a year with similar symptoms. All initially present with the chief complaint of altered mental status worsening from baseline. The patients are often obtunded on initial presentation and unable to protect their airway requiring mechanical ventilation. All of the patients present with a triad of hypothermia (less than 90 degrees fahrenheit), hypotension requiring vasopressors, and bradycardia with heart rates often less than 40 BPM requiring admission to the intensive care unit (ICU). Throughout their hospitalization these patients are thoroughly assessed for their cause of shock including thyroid dysfunction and adrenal insufficiency. Extensive, imaging, and cultures demonstrate no significant abnormalities or growth. Echocardiograms are interpreted as unremarkable. Ultimately there is no clear source of why the patient presented in shock requiring mechanical ventilation, active rewarming and pressor support. The patients usually require ICU supportive management for a few days before they are back to their baseline. No source of shock is ever isolated.DISCUSSION: According to the CDC, cerebral palsy is the most common motor disability in childhood. These patients do survive into adulthood but not without multiple hospitalizations for various different reasons. Homeostasis dysfunction has been associated with CP possibly related to autonomic dysfunction. However, no data has shown patients in adulthood presenting in undifferentiated shock as a result of autonomic dysfunction. We propose that the patients' shock is possibly part of the autonomic dysfunction that has previously been described in patients with CP, however never fully studied in terms of shock. CONCLUSIONS:Patients with CP who survive to adulthood many times have regression in mobility. These patients also suffer from other comorbid conditions that make it difficult for these patients to live independently. Further research is needed to improve the quality of life for this patient population.

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