Presentation
Increasing shortness of breath.
Patient Data
Right-sided pleural fluid in moderate to a large amount, intercostal catheter noted. Left lung and pleural space are clear.
Pleural fluid culture:
2+ Streptococcus anginosus group
2+ Anaerobes
Gram Stain Report -
Polymorphs...................... 3+
Squamous epithelial cells....... Nil
Gram-positive cocci............. 2+
Gram-negative rods.............. 3+
Gram-positive rods.............. Nil
Gram-negative cocci............. Nil
Sterile Fluid Microscopy Report -
Polymorphs x 10^6/L............. 40000
Lymphocytes x 10^6/L............ 40
Erythrocytes x 10^6/L........... 1500
Unidentified cells x 10^6/L..... 60
Macroscopic Exam Report - Cloudy
Right pigtail drain in situ with tip within the right mid-posterior hemithorax. Moderate sized loculated right pleural fluid with thin surrounding rim of enhancement. There are a couple of locules of gas within the collection, likely related to drain insertion (inserted today).
Associated compressive atelectasis with a near complete collapse of the right lower lobe and the subtotal collapse of the right middle lobe. No mass within the aerated portions of the right lung identified.
There is a cavitating focus in the left upper lobe anteriorly with irregular thick margins, spiculations, and linear bands extending to the pleura. The cavity communicates with a bronchus. The lesion measures approximately 25 x 25 x 25 mm (excluding linear bands). No evidence of surrounding inflammation or fluid within the cavity.
6 mm subpleural nodule in the left anterior upper lobe.
Mild emphysematous change in the lung apices.
No size significant mediastinal or hilar lymphadenopathy by CT size criteria. Right paratracheal node measuring 10 mm in short axis.
No aggressive osseous lesions identified.
The imaged upper abdominal viscera are unremarkable.
Conclusion:
- Loculated right pleural fluid with thin enhancing rim - these features are suggestive of empyema.
- Left upper lobe focal bronchiectasis with irregular margins and spiculations is suspicious for primary malignancy. Differentials include post-inflammatory cavitatory lesion. Respiratory referral recommended.
Post-VATS imaging showing residual basal atelectasis and intercostal drain on the right.
Case Discussion
Although a drain has been inserted at the admission with drainage of frank pus, the cardiothoracic surgeon was consulted and the patient was offered VATS decortication.