A 29-year-old man with no known medical illness presented with prolonged fever, cough and pleuritic chest pain for 3 days. On examination, he had reduced breath sounds and stony dullness over the right lung. He was febrile but otherwise had stable vital signs with oxygen saturation of 95% on 3L of oxygen. He had significant positive contact history with a colleague who was diagnosed with smear positive pulmonary tuberculosis.
Initial chest radiograph showed a right lower zone consolidation with pleural effusion (Fig. 1A). Septic parameters were raised and he had acute kidney injury (Table 1). He was started empirically on ceftriaxone 2g daily which was escalated to tazobactam/piperacillin 4.5g thrice daily in view of persistent fever. Intercostal chest catheter (ICC) was inserted which drained only 100 mls of serosanguinous fluid due to the presence of septations (Fig. 1B). Pleural fluid analysis was exudative in nature. Pleural fluid and bronchoalveolar lavage culture were sterile. The elevated pleural fluid adenosine deaminase of 64.8 U/L with pleural fluid lymphocytosis and positive Xpert  Mycobacterium tuberculosis/rifampicin assay confirmed the diagnosis of tuberculous pleural effusion; hence fixed-dose combination anti-tuberculosis (anti-TB); akurit-4 was started and antibiotic was withheld.
We decided for intrapleural fibrinolytic therapy (IPFT) and he received 3 doses of alteplase 16 mg and DNase 5 mg in 24 hours. There was an increase in daily drainage from 220 mls to 1100 mls and 340 mls. The patient's cough improved and his fever subsided. Both chest radiograph and thoracic ultrasound imaging showed improvement of the effusion(Fig. 1C and D), and he was discharged well and completed 6 months of anti-TB.
A 76-year-man with underlying diabetes and hypertension was referred for further management of a complex pleural effusion and liver abscess. He gave a two-week history of right-sided pleuritic chest pain and hypochondriac pain, lethargy, loss of appetite and weight. On examination, he was febrile with stable vital signs. Oxygen saturation was 95% on 3 L of oxygen. He had reduced breath sound and stony dullness over the right lung and hepatomegaly with liver span of 14 cm.
The infective blood parameters were raised (Table 1). Chest radiograph revealed right-sided loculated effusion (Fig. 1E). Computed tomography (CT) thorax revealed a multi-loculated right pleural collection with collapse consolidation of apicoposterior segment of the right upper lobe with liver abscess (Fig. 1F). As he had completed 10 days of amikacin 750mg daily and meropenem 1g thrice daily at his previous hospital, he was commenced on tazobactam/piperacillin 4.5g thrice daily in our centre.
ICC was inserted which drained only 100 mls purulent fluid overnight. Pleural fluid analysis revealed exudative effusion with pleural LDH of 8665 IU/L (Table 1). Pleural fluid and liver abscess were drained and culture grew Klebsiella pneumoniae. He was treated as invasive Klebsiella syndrome and antibiotic was de-escalated to amoxicillin/clavulanate group based on sensitivity. Three courses of intrapleural alteplase 16 mg with DNase 5 mg were administered as per our protocol to facilitate pleural drainage. Significant drainage was achieved subsequently which led to improvement of infective blood parameters, and imaging (Fig. 1G and H).
In view of the persistent liver abscess, he completed 28 days of intravenous amoxicillin/clavulanate and 6 weeks of oral amoxicillin/clavulanate. He remained well on follow up.