Empyema is pus collection in the pleural space. It occurs due to bacterial invasion of the pleural space, which leads to an increased number of neutrophils. Anaerobic utilization of glucose by the neutrophils and bacteria results in the development of pleural fluid acidosis. In addition, lysis of neutrophils increases the LDH concentration in the pleural fluid to values often in excess of 1000 IU/L.

A 66-year-old male with a known history of HTN and spinal stenosis presented with complaints of shortness of breath and fever with chills and rigors for 3-4 days. He also complained of cough productive of yellow colored sputum, and left sided pleuritic chest pain. He had been evaluated 2 days earlier, was diagnosed with pneumonia, and was placed on oral doxycycline therapy. He denied recent travel, sick contacts, and any GI or GU complaints. He lived at home with his wife and denied any smoking or alcohol history.

On physical exam, he had a temperature of 102F, Heart rate of 100/min, BP of 120/80mm Hg, respiratory rate of 28/min, with oxygen saturation of 92% on 6litres O2. He appeared very sick and his mucous membranes were dry. His respiratory examination revealed decreased breath sounds on the left side upto 2/3rd of the lung, dullness to percussion and decreased tactile vocal fremitus. Lung findings on the right side were normal. His CBC showed a WBC of 30,070, 4% bands, 84% neutrophils, Hb of 13.7, Hct of 46.9 and normal platelets.
Chest radiograph revealed left sided pleural effusion. The pleural fluid analysis revealed pH-7.02, Glucose-23, LDH-1324, Protein-4.9, 1-4 WBC's and no bacteria. The pleural fluid culture grew Streptococcus Intermedius. The patient was diagnosed with empyema.

The patient was started on IV ceftriaxone. A chest tube placed drained only a small amount of yellow colored fluid. The follow up chest x ray did not show any improvement in the effusion. Hence a CT guided placement of pigtail catheter was performed. However this did not improve the drainage either. At this point a decision was made to use intrapleural tPA.
Following administration of tPA, the patient had drainage of 1000 cc fluid on the first day, and about 500 cc the next day. Subsequent chest x rays showed a marked improvement. His symptoms also improved dramatically and he was discharged home on oral cefpodoxime.

Rekha Nair, M.D.
Sonia Kamath, M.D.