A 57-year-old female patient was admitted to the Department of Respiratory and Critical Care Medicine at our hospital on August 27, 2020. Her chief complaint was "left side chest pain for 3 months, aggravated for 1 week." The patient had a history of diabetes for more than 10 years, and her blood sugar was well-controlled by oral hypoglycemic drugs. In May 2020, the patient had undergone surgery for a gastric antral malignant tumor and treatment with gimeracil and oteracil potassium capsules after gastric surgery.
The patient presented with left-sided chest pain after gastric surgery 3 months ago. One week before admission, the patient's chest pain was aggravated, accompanied by fever, with a maximum temperature of 40 C. The patient did not respond well to the anti-infective treatment in the local hospital. The patient's blood routine data at the local hospital were as follows: white blood cell count: 13.58*109/L; neutrophil count: 11.88*109/L. Her chest computed tomography (CT) showed left pleural effusion with left atelectasis. There was no enlargement of hilar, no enlarged or calcified mediastinal lymph nodes, no widening of mediastinum and no compression of trachea and large blood vessels (Figure 1A). Next, the patient visited to the emergency department of our hospital, a thoracentesis catheter was inserted for drainage, and the drainage fluid was yellow and purulent. The bacterial culture results of the pleural effusion were positive for Escherichia coli and Streptococcus constellation.
On admission, the patient had a wheezing face, her left rib cage was full, and her intercostal space widened. The patient's left thoracic cavity was solid to percussion, and the left breath sounds disappeared.
The patient's admission diagnosis was purulent pleurisy, postoperative antral malignancy and diabetes mellitus type 2.
The patient's abnormal auxiliary examination results after admission were as follows: hemoglobin: 88 g/L; specific mycobacterium tuberculosis cellular immunoassay (T-SPOT.TB): positive; procalcitonin: 0.11 ng/ml; serum albumin: 22.1 g/l; ESR 44: mm/1 h.
The medical thoracoscopy was performed on the second day after admission. Extensive purulent attachments to the parietal pleura, visceral pleura, and diaphragmatic pleura were observed (Figure 1B). Multiple tissue biopsies were performed during the operation, and the purulent, necrotic tissue and adhesions in the thoracic cavity were partially removed. Postoperatively, the drainage fluid was removed from the patient using a thoracic tube. Routine examination of the pleural effusion showed that it was a grayish-yellow viscous liquid comprising primarily multinucleated cells. The Rivalta test of pleural effusion was positive.
Pleural fluid culture was still positive for Escherichia coli and Streptococcus constellation. The pleural fluid was negative for tuberculosis culture and acid-fast staining, meanwhile, her pleural biopsy tissue was were negative for tuberculosis culture. The lactate dehydrogenase level in the pleural effusion was 8,473 U/L, the carcinoembryonic antigen level was 0.73 ng/ml, and the adenosine deaminase level was 232 U/L. A pathological smear of the pleural effusion showed many neutrophils and a few lymphocytes and plasma cells. The pathological findings of the pleural biopsy showed chronic suppurative inflammation with necrosis and inflammatory granulation tissue formation in the fibrous connective tissue. The biopsy special staining results (Figure 1E) were as follows: hexamine silver (+), PAS (+), acid fast (-). Fungal spores were observed on staining, and the morphology supported Histoplasma. And no malignant cells were found in pleural fluid and pleural biopsy.
The patient was diagnosed with empyema, and the pathogens were Escherichia coli, Streptococcus constellation, and Histoplasma. For Escherichia coli and Streptococcus constellation infections, Cefoperazone sulbactam sodium combined with levofloxacin and ceftriaxone monotherapy were successively administered. Histoplasma infection was treated with intravenous injection of deoxycholate amphotericin B at an initial dose of 3 mg and local thoracic irrigation of deoxycholate amphotericin B at an initial dose of 5 mg. The dose of amphotericin B was increased by 5 mg daily for both intravenous injection and thoracic irrigation to a maximum dose of 25 mg. Intravenous injection was administered for 15 days, and thoracic irrigation was administered for 8 days.
During hospitalization, the patient underwent thoracoscopy 3 times. Each time the necrosis and adhesions were cleaned using biopsy forceps. The necrosis in the thoracic cavity gradually decreased, the pleural thickening and adhesion gradually decreased (Figures 1B-D), and the left lung gradually re-expanded. The histopathological special staining of the last two thoracoscopic pleural biopsies results were as follows: hexamine silver (-), PAS (-), and acid fast (-). No definite fungus was found by histopathological staining and pleural tissue culture showed no bacterial or fungal growth.
The characteristics of pleural effusion drainage fluid were significantly improved; it was a pale yellow and clear liquid, and multiple cultures were negative. During hospitalization, the patient underwent three chest CT scans (Figures 2A-C), which revealed that the left lung was gradually re-expanded, the left pleural effusion was gradually reduced, and the left pleural thickening was gradually decreased. She was discharged after 34 days of hospitalization, and her symptoms had improved significantly upon discharge. She had tolerated amphotericin B treatment well; no obvious adverse reactions occurred. After discharge, the patient's anti-infection regimen was to take cefdinir 0.1 g three times a day for 10 days and itraconazole, 200 mg twice a day, for 18 days. The last re-examination of the chest CT about 1 year later, showed that the left lung was re-expanded, with little pleural effusion and pleural thickening on the left side (Figure 2D).