Department of Medicine Grand Rounds Vignette
Stanley Josue, M.D. NYU School of Medicine October 18, 2006
CC: A 39 year old male complains of productive cough, pleuritic chest pain and fever for 3 days. HPI: The patient’s past medical history was significant for AIDS (CD4 = 59 and VL = 2550) on HAART and no prior history of opportunistic infections. He recently completed treatment for a right lower lobe pneumonia 2 months prior. He developed fever and cough productive of brown sputum He denied any sick contacts, travel, or noncompliance with his HAART and PCP prophylaxis.
Physical Exam
General: Cachectic male, appearing older than stated age in no apparent distress. T: 101.6 HR: 98 BP: 112/72 RR: 20 97% on room air Lungs: symmetric chest wall expansion, right lower thoracic area had diminished breath sounds, dullness to percussion, and decreased tactile fremitus.
Imaging
CXR: preliminarily interpreted as a right lower lobe cavitary infiltrate with an airfluid level.
Chest CT was ordered (but was delayed due to technical reasons)
Hospital Course
Diagnostic thoracenthesis: 50cc of yellow thick free-flowing fluid, pH 6.2, LDH 21,000, protein 3 (serum protein 7) 8000 WBC with significant bandemia Therapeutic course: The patient was started on broad-spectrum antibiotics and an emergent thoracostomy tube was placed and drained ~400cc of empyema.
Final Diagnosis
Right-sided multi-drug resistant Pseudomonas aeruginosa empyema.