A Sizeable Complication of Untreated Pneumonia: A Viridans Streptococci Post Pneumonic Empyema Thoracis

Abstract

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.