A 65-year-old man with history of atrial fibrillation, non-ischemic cardiomyopathy, HCV, cirrhosis, COPD, distant pericardial and left pleural TB status post pericardial stripping 10 years prior with a residual pleural rind and complex left pleural space, with persistent loculations seen on chest imaging, was undergoing serial thoracenteses every three months, for dyspnea in the setting of recurrent pleural effusion. He was then referred to our pleural clinic for increasing frequency of left sided thoracentesis and an associated increase in dyspnea on exertion.
On initial evaluation, his pleural studies were notable for an empyema (LDH >2700, Glucose<10, pH 6.89) and repeat cultures ultimately grew Staph epidermidus. He was admitted for chest tube placement, which was done under CT guidance and IV antibiotics. The chest tube was subsequently removed 10 days after insertion. No tPA was instilled given ongoing anticoagulation, mild hemoptysis, and the serosanguinous nature of his pleural fluid. One month later, he had persistent symptoms and recurrence of his pleural effusion, so a new pigtail catheter was placed on admission. Pleural fluid studies at that time demonstrated LDH >2,700, glucose<10, pH 7.12, adenosine deaminase 154, WBCs 19,000. He underwent serial irrigation with 250 cc warmed saline three times at the bedside via pigtail. VATS decortication was initially planned; however, the procedure was subsequently deferred because the patient developed flash pulmonary edema. Eleven days after pigtail placement, three doses of tPA were instilled. He was discharged 25 days after pigtail placement with a pneumostat in place. Three weeks after discharge, he followed up in pleural clinic and the pigtail catheter was removed. At one-month follow-up the patient had persistent dyspnea, with interval re-accumulation of pleural fluid and evidence fibrinous stranding on ultrasound. Given re-accumulation, medical pleuroscopy under moderate sedation with TPC placement was performed (Fig. 5).
Following TPC placement, the patient did well from a respiratory standpoint, with resolution of his dyspnea on exertion, ongoing relief from weekly pleural drainage, and evidence of pleural symphysis on CT scan (Fig. 6).
Following TPC placement he had no further admission for shortness of breath or pleural interventions. His TPC remained in place until his death from hepatocellular carcinoma two years after initial encounter.