Pulmonary and Critical Care Pearls

Pleurisy, Fever, and Rapidly Progressive Pleural Effusion in a Healthy, 29-Year-Old Physician

Explosive pleuritis (EP) is an under-reported condition. Although there is no agreed-upon definition, generally, the term EP denotes a dramatic clinical and radiologic progression of pleural space inflammation in the setting of pneumonia. The pleural space inflammation leads to the formation of loculated complex pleural effusion or empyema, and pleural adhesion within a matter of hours, typically in less than 24 hours. Radiologically, these changes are manifested as opacification of the hemithorax with or without contralateral mediastinal shift. Streptococcal pneumonia is the most common cause of EP. Here we present a case and discuss the clinical, microbiologic, radiologic, and treatment aspects of EP. We also scrutinize the medical literature to compare the previously reported cases.

O derrame parapneumónico caracteriza-se pela ne-cessidade de um processo invasivo para a sua resolu-ção e o empiema pela presença de pus na cavidade pleural. Em ambos os casos, o diagnóstico por TAC e o tratamento precoces resultando em menores morbi-lidade e mortalidade. São indicação para um tratamento invasivo os derrames loculados, os que ocu-pam mais de 50% do tórax, os que revelam coloração por Gram e exame cultural positivos, ou derrames com pH inferior a 7,20, glucose inferior a 60 mg/dl, e nível de DHL superior a três vezes o limite normal no soro. Estas características resultam da evolução através de três estádios dos derrames incorrectamente tratados: 1) exsudativo; 2) fibrino-purulento; 3) fibrótico. Dependendo do estádio evolutivo, a aborda-gem terapêutica varia entra toracentese terapêutica, colocação de drenagem torácica com ou sem instila-ção de fibrinolíticos, cirurgia toracoscópica vídeo-assistida e decorticação pulmonar. Os autores fazem uma revisão do estudo destas situações baseados em três casos clínicos com apresentações muito díspares: uma doente com empiema por Streptococcus pyogenes que faleceu rapidamente por hemoptise maciça; um doente com empiema resultante de pneumonia agu-da ocorrida durante um voo de avião; uma doente com empiema e bacteriemia por Streptococcus pneumoniae conduzindo a diagnóstico até então desco-nhecido de infecção por VIH.

Rev Port Pneumol 2009; XV (3): 507-519

Complicated parapneumonic effusion is one in which an invasive procedure is necessary for its resolution and empyema means pus in the pleural space. An early diagnosis and therapy of these conditions results in less morbidity and mortality. CT of the chest is important to study complex pleural effusions. Loculated effusions, those occupying more than 50% of the thorax, or which show positive Gram stain or bacterial culture, or a purulent effusion with a pH below 7.20, with a glucose level below 60 mg/dl or a LDH level more than three times the upper limit of normal for serum, are indications for an invasive procedure. These characteristics result from the evolution of a not well treated parapneumonic effusion, through the three stages: (1) exsudative; (2) fibri-nopurulent; (3) fibrotic. Depending on the stage therapeutic methods vary from therapeutic thoracentesis, insertion of a chest tube with or without instillation of fibrinolytics, video-assisted thoracoscopic surgery, and lung decortication. A review of all these aspects are done based on a series of three cases reports with very different clinical presentation: one patient with empyema by Streptococcus pyogenes and that died rapidly due to massive hemoptysis; a patient with empyema due to acute pneumonia developing during an airflight; a patient with empyema and bacteraemia by Streptococcus pneumonia leading to the diagnosis of an unknown HIV infection.

Rev Port Pneumol 2009; XV (3): 507-519

St reptococcus pyogenes is an uncommon cause of community-acquired pneumonia in children. Further, its clinical course in comparison to pneumonia caused by Streptococcus pneumonia has not been previously highlighted.

We reviewed medical records of children 0–18 years of age from April 1983 to April 2005, with discharge diagnoses of invasive disease caused by group A streptococcus (GAS) (Streptococcus pyogenes), or Streptococcus pneumonia (SP) or pneumonia. Data were extracted from the charts, and a comparison of clinical characteristics between the 2 etiologies was performed. Confirmed disease required blood or pleural fluid isolates. Patients with single isolates of GAS in tracheobronchial secretions or sputum were classified as having presumed disease caused by GAS. Patients with confirmed disease due to GAS and SP were compared with respect to clinical characteristics.

Of 103 patients with invasive GAS disease, 12 (11.6%) had confirmed GAS lobar pneumonia. In addition 7 patients had presumed GAS pneumonia. There were 54 patients with confirmed SP pneumonia. Most children who had GAS pneumonia were healthy and recovered completely. Compared with patients with confirmed SP pneumonia, those with confirmed GAS pneumonia had more frequent and larger effusions, more culture positive effusions, had prolonged fever, and had longer hospitalizations. There was not an increasing trend to GAS pneumonia over the 22-year period. There was not a predominant serotype responsible for the pneumonias.

Lobar GAS pneumonia represents approximately 11% of all cases of invasive disease in this institution during a 22-year period. Compared with patients with SP pneumonia, it appears to cause more effusions and morbidity. The organism is also more frequently recovered from pleural fluid.