Introduction: Spontaneous bacterial empyema (SBE) is a potentially fatal complication of hepatic hydrothorax (HH). Despite high mortality rate, guidelines do not clearly outline the clinical trajectory and management of SBE. We aim to present a case of SBE to familiarize clinicians with the spectrum of SBE presentations.
Case Description/Methods: A 58-year-old male with a history of alcohol use disorder and alcohol-associated cirrhosis decompensated with ascites and left-sided HH presented with fever of 38.1°C. Physical exam was notable for blood pressure 80/57, tachypnea at 28 breaths/minute, and decreased breath sounds in left lung fields.
Labs were notable for leukocytosis and lactic acidosis (Table). Infectious workup was negative for spontaneous bacterial peritonitis (SBP) or urinary infection. Pleural fluid analysis is shown in Table. Blood and pleural fluid cultures grew Clostridium perfringens. CT chest showed loculated fluid in the left pleural space. 12 French pigtail chest tube was placed. In addition to metronidazole and ceftriaxone, 6 doses of intrapleural fibrinolytics were administered. Chest tube was removed once the output had decreased. He was discharged on oral antibiotics and remained asymptomatic on 10-week follow up.
Discussion: SBE should be regarded as a spectrum where it can present as “simple” pleuritis (akin to peritonitis in SBP), uncomplicated parapneumonic effusion (PE), complicated PE or frank empyema similar to our case. It is important to delineate where your patient lies on that spectrum as treatment modalities will differ.
To diagnose PE, the pleural effusion has to be exudative per Light’s criteria. A complicated PE is diagnosed by the presence of exudative effusion that has one or more of the following characteristics: (i) pH < 7.2, (ii) glucose level < 40 mg/dL, or (iii) LDH >1000 IU/L. In complicated PE, identifying complex septations or loculations by imaging is pertinent, either by bedside ultrasound or CT. Frank empyema is diagnosed when pus is seen on pleural fluid sampling.
Pleuritis and uncomplicated PE, is treated like SBP. Source control of the infection may be warranted in complicated PE/empyema. Chest tube drainage is the least invasive method. Chest tubes are relatively contraindicated in HH but have a role in SBE. Intrapleural fibrinolytics may assist in drainage. Surgical debridement is indicated if recurrence of complicated PE/empyema despite adequate drainage occurs. Figure 1 highlights the SBE spectrum. Secondary prophylaxis is indicated after treatment.
