Abstract Background Chronic bronchitis is usually caused by repetitive injury or inflammation from occupational exposures, smoking, recurrent infections, or asthma.1-4 It alters normal lung structure, predisposing patients to recurrent or severe infections.5 When structural abnormalities coexist with other risk factors, infection severity and diagnostic complexity increase.6,7 Case report A 38-year-old man with rheumatoid arthritis (on methotrexate), ulcerative colitis, Marfan syndrome, and a history of recurrent Pseudomonas aeruginosa and MRSA pneumonia presented with two weeks of fever, chills, and progressive left-sided pleuritic pain. Chest CT showed a left pleural effusion with near-complete left lower lobe collapse, bronchial obstruction, mild narrowing of the left upper lobe bronchial tree, fibrotic stranding, and a small right lower lobe bulla with scattered bronchiolar opacities. Prior imaging (1 year earlier) had shown a cavitary lesion with halo sign, ground-glass and reticular opacities, and bronchiectasis. Given leukocytosis and prior MRSA infection, antibiotics were escalated to vancomycin and cefepime. Thoracentesis drained 200 mL of thick, reddish fluid, but the effusion persisted. Insertion of three chest tubes and thoracic decortication were performed. Postoperatively, patient developed hemorrhagic shock, requiring ICU transfer. Pleural cultures grew Streptococcus intermedius, MRSA was detected in sputum and nasal PCR, and histopathology confirmed empyema. The patient completed 12 days of linezolid with gradual improvement and was weaned off oxygen as chest tubes were removed. Discussion CT findings of bronchial narrowing and fibrotic stranding supported chronic bronchitis, but the differential remained broad. Ground-glass opacities raised concern for interstitial lung disease (ILD). Methotrexate may increase infection risk and chronic lung injury even after discontinuation.8-10 Rheumatoid arthritis can also cause ILD, pleural effusion, bronchiectasis, and bronchiolitis, markedly heightening infection susceptibility. RA-associated ILD is a leading cause of mortality in these patients.11-13 Given this patient’s age, comorbidities, and recurrent infections, further evaluation with high-resolution CT, spirometry, and bronchoscopy would be essential to guide management and prevent recurrence. Conclusion Structural lung damage from chronic bronchitis, combined with multiple difference exposures likely predisposed this patient to severe empyema. Early recognition and multidisciplinary management are key to improving outcomes in complex cases. This abstract is funded by: None
Halpern et al. (Fri,) studied this question.