Abstract Introduction Escherichia Coli (E. Coli) is a well-known genitourinary and gastrointestinal pathogen but is rarely identified as the causative agent in pulmonary infections. Presentation A 68-year-old female with history of gastric adenocarcinoma status post gastrectomy and partial omentectomy with positive response after neoadjuvant therapy had been under surveillance for approximately 2 months when she presented to the hospital 2 weeks of cough and 1 day of shortness of breath. At presentation she was afebrile, tachycardic to 103 beats per minute, tachypneic to 29 breaths per minute, and hypoxic requiring 6 liters high flow nasal cannula. Laboratory evaluation showed leukocytosis of 15,100 cells per microliter and lactate of 2.3 millimoles per liter. Computed tomography (CT) angiography chest revealed small bilateral subsegmental pulmonary emboli, large right pleural effusion with areas of necrosis, concern for mass, as well as mild left plural effusion (Figure 1). Bedside point of care ultrasound revealed loculation of right sided effusion. The patient was admitted to the intensive care unit, placed on ceftriaxone, vancomycin, metronidazole, and a right sided pigtail catheter was placed yielding 1.6 liters identified as exudative on fluid analysis. The patient’s oxygen requirement decreased to 4 liters of nasal canula, however imaging revealed ongoing loculated effusion. Cardiothoracic surgery performed a right partial pulmonary decortication with wedge resection and pleural biopsy. Operative pleural fluid cultures revealed E. coli. Blood cultures remained negative. Operative chest tubes were removed after 5 days, and the patient was discharged home with ceftriaxone and metronidazole to complete a 6-week course. CT imaging 6-8 weeks after discharge showed improvement of empyema, however, revealed multiple liver masses. Liver mass biopsy confirmed metastatic adenocarcinoma; however, the patient experienced rapid deterioration with cancer related pain and malnutrition leading to her demise prior to reinitiating chemotherapy. Discussion Gram negative organisms including E. coli are a rare cause of empyema and when present, carry higher rates of morbidity and mortality than the gram-positive or anaerobic organisms in empyema. Risk factors for gram negative empyema include cirrhosis and immunocompromised states due to alterations in intestinal permeability and immune regulation that can result in intestine bacterial translocation to the pleural space increasing risk for this rare empyema. This case not only highlights the diagnosis and treatment of E. coli empyema, but also emphasizes the possible relation between this patient’s metastasis of gastric adenocarcinoma to the liver placing her at risk to acquire this rare infection. This abstract is funded by: None
Kozuch et al. (Fri,) studied this question.