67 year old male was admitted to OSH on 6/30/05 with L-sided chest pain, shortness of breath, and hypoxia after 2 weeks of coughing up yellow sputum. CT at OSH showed L pleural effusion, L hilar fullness, and a 2x3 cm mediastinal LN. Thoracentesis on 7/1 showed exudative fluid without evidence for malignancy and no growth. The patient was started on moxifloxacin, and BAL washings on 7/5 grew MSSA. As of 7/13, patient’s condition had not improved, and he was transferred to UVA still feeling ill, nauseated, and dyspneic. 67 year old male was admitted to OSH on 6/30/05 with L-sided chest pain, shortness of breath, and hypoxia after 2 weeks of coughing up yellow sputum. CT at OSH showed L pleural effusion, L hilar fullness, and a 2x3 cm mediastinal LN. Thoracentesis on 7/1 showed exudative fluid without evidence for malignancy and no growth. The patient was started on moxifloxacin, and BAL washings on 7/5 grew MSSA. As of 7/13, patient’s condition had not improved, and he was transferred to UVA still feeling ill, nauseated, and dyspneic. PMHx: diabetes mellitus, HTN, chronic kidney disease, R tib/fib fx 8 months ago. PMHx: diabetes mellitus, HTN, chronic kidney disease, R tib/fib fx 8 months ago. SHx: quit smoking in 1982 after 30+ pk yrs. SHx: quit smoking in 1982 after 30+ pk yrs. Allergic to augmentin. Allergic to augmentin. History otherwise noncontributory. History otherwise noncontributory. On exam, patient was afebrile, O2 sat 94% on 2LNC, and his breath sounds were decreased over entire L lobe. WBC was On exam, patient was afebrile, O2 sat 94% on 2LNC, and his breath sounds were decreased over entire L lobe. WBC was 13.2.

Differential Diagnosis of Nonresolving Pneumonia Inappropriate treatment of pathogen Inappropriate treatment of pathogen Misdiagnosis of nonbacterial pathogens: mycobacteria, fungi, Nocardia, and Actinomyces Misdiagnosis of nonbacterial pathogens: mycobacteria, fungi, Nocardia, and Actinomyces Resistant bacterial pathogens Resistant bacterial pathogens Development of complications: empyema, lung abscess Development of complications: empyema, lung abscess Neoplastic disorders: brochogenic ca, bronchoalveolar cell ca, lymphoma Neoplastic disorders: brochogenic ca, bronchoalveolar cell ca, lymphoma Immunologic disorders: vasculitis, BOOP, Eosinophilic pneumonia syndromes, AIP, pulmonary alveolar proteinosis, sarcoidosis, SLE Immunologic disorders: vasculitis, BOOP, Eosinophilic pneumonia syndromes, AIP, pulmonary alveolar proteinosis, sarcoidosis, SLE Drug toxicity Drug toxicity Pulmonary vascular abnormalities: CHF, PE Pulmonary vascular abnormalities: CHF, PE

L pleural effusion and L-sided air space disease. Minimal layering of left pleural effusion. Possibly partially loculated left effusion and/or airspace disease L base.

Circumferential pleural thickening within the left hemithorax may be either infection or malignancy. Pleural thickening along the posterior aspect of the right lung base and marked left-sided pleural thickening that includes costal, paravertebral, and mediastinal pleural surfaces.

This may represent an empyema. There is a fluid collection with sporadic pockets of gas that appears to be trapped in the posterior pleural space.

L hilar mass 27 x 34 mm may represent an enlarged lymph node or primary malignancy. 18 mm short axis prevascular lymph node.

Hospital Course Patient placed on vancomycin and clindamycin. Patient placed on vancomycin and clindamycin. Thoracentesis on 7/ cc fluid with glucose 1000), pH 7.4 ( 1000), pH 7.4 (<7.20), 3+PMNs, no bacteria. Bronchoscopy on 7/14 with biopsy and BAL showed no evidence of malignancy. Negative for legionella, AFB, viruses, PCP, fungi. BAL positive for gm+ cocci. Bronchoscopy on 7/14 with biopsy and BAL showed no evidence of malignancy. Negative for legionella, AFB, viruses, PCP, fungi. BAL positive for gm+ cocci. On 7/20, patient went to TCV for drainage of empyema and L visceral and parietal decortication. As the pleural rind was elevated, they entered a L apical segment lower lobe abscess. This was drained. Chest tube was placed. Pathology consistent with empyema and abscess. No evidence of malignancy. On 7/20, patient went to TCV for drainage of empyema and L visceral and parietal decortication. As the pleural rind was elevated, they entered a L apical segment lower lobe abscess. This was drained. Chest tube was placed. Pathology consistent with empyema and abscess. No evidence of malignancy. On 7/25, chest tube removed. On 7/25, chest tube removed. On 7/27, patient was discharged. He was maintaining O2 sat of 96% on 1-2L at rest and ambulating with 3LNC. CXR at time of discharge showed haziness secondary to decortication but resolving effusion. On 7/27, patient was discharged. He was maintaining O2 sat of 96% on 1-2L at rest and ambulating with 3LNC. CXR at time of discharge showed haziness secondary to decortication but resolving effusion. Final diagnosis: MSSA lung abscess and empyema Final diagnosis: MSSA lung abscess and empyema

Student Teaching File Case Amy Oyler UVA SOM 06 Period #2: July 23- August 20, 2005 References Ost, David, Alan Fein, Steven Feinsilver, Rakesh Shah, “Nonresolving pneumonia.” UptoDate. Ost, David, Alan Fein, Steven Feinsilver, Rakesh Shah, “Nonresolving pneumonia.” UptoDate. Strange, Charlie, “Pathogenesis and management of parapneumonic effusions and empyema in adults.” UptoDate. Strange, Charlie, “Pathogenesis and management of parapneumonic effusions and empyema in adults.” UptoDate.