Presentation
Throat-ache, right neck swelling, fever and chills began two weeks previously; treated. Symptoms receded, then relapsed more mildly, this time including chest discomfort.
Patient Data
Lung opacities with lower zone distribution predominance, some of which show cavitation.
Small amount of right-sided loculated pleural fluid.
Thin-walled cavitary lesions in all lung lobes - abscesses, predominantly in the lower lobes. The largest lesion is in the LLL, measuring 5.2 x 4.8 x 4.2 cm and abutting the oblique fissure and costal pleura.
Small amount of partly loculated right pleural effusion, with enhancing margins - empyema. Several of the RLL abscesses are clearly contiguous with the empyema, which contains a tiny air bubble.
No enlarged axillary, mediastinal or hilar lymph nodes.
Thymic remnant.
Neck (not shown) unremarkable - no sign of lymphadenopathy, abscess, or any other infectious pathology.
Partial resolution of lung abscesses.
Small amount of right-sided loculated pleural fluid, virtually unchanged.
Case Discussion
A tourist visiting her mother presented to the ER with milder relapse of throat-ache, more on the right, and fever. She had initially presented with chills and a tender, swollen right neck, for which she was prescribed oral amoxicillin/clavulanate BID for 7 days, and finished the entire course. At the ER, she also complained of chest discomfort, aggravated by deep breaths.
History was unremarkable, except for pneumonia at the age of 10 years.
The initial chest X-ray showed bilateral lung lesions, some with cavitations. Since the preliminary differential diagnosis included septic emboli, trans-esophageal echocardiography (TEE) was performed, which revealed a vegetation on the tricuspid valve. A congenital valvular anomaly was suspected, as infective endocarditis of a native valve is an unusual diagnosis for an otherwise healthy person (i.e. non-drug user). Of note, native valve endocarditis is a life-threatening disease and tends to be missed.
Culturing and serology of sputum, bronchial washings and the empyema for an extensive list of pathogens was carried out, including acid-fast staining and sputum PCR for Mycobacterium tuberculosis (as she was from an area endemic for tuberculosis). The latter two came back negative. Bronchial washings yielded antibiotic-susceptible Acinetobacter baumannii, while Fusobacterium necrophorum, a non-spore forming anaerobic bacterium commonly isolated from inflamed tonsils, grew from the empyema culture. Testing for HIV came back negative. The empiric antibiotics were switched accordingly. She recovered uneventfully and finished her antibiotic course at home.
The follow-up X-ray taken at the hospital 7 days after the first, shows that the abscesses and empyema were slow to resolve.
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