Abstract Empyema is a complication of bacterial pneumonia, but can also result from chest trauma, malignancy, or esophageal rupture. Post-traumatic empyema develops as a result of chest wall injury. Unlike aspiration empyema, in which a parapneumonic effusion develops as a result of aspiration pneumonia, post-traumatic empyema results from direct inoculation of bacteria into the pleural space, most commonly from the skin flora. Empyema has significant morbidity and mortality and always requires drainage in addition to antibiotics, and sometimes surgical intervention. We present a case of post-traumatic empyema complicated by aspiration pneumonia and bacterial parapneumonic effusion that required tissue plasminogen activator and dornase alfa, and ultimately surgical decortication. A 76-year-old white male with a history of hypertension presents with 3 days of progressively worsening pleuritic chest pain and dyspnea after chest wall trauma related to a mechanical fall, followed by an aspiration event. In the emergency department, he was febrile, tachycardic, tachypneic, and required 2L of oxygen. He had an exquisitely tender right chest wall, but no flailing of the chest. Laboratory testing showed elevated WBC, lactic acid, and procalcitonin. Pleural fluid analysis showed elevated WBC, protein, and LDH levels, indicating an exudative process. Imaging revealed multiple rib fractures without hemopneumothorax, but did show a consolidation along with moderate-sized loculated pleural effusion. Pleural culture grew pan-sensitive Streptococcus Intermedius and methacillin-sensitive Staphylococcus Aureus. Antibiotics were tailored, and a chest tube was inserted along with six doses of tissue plasminogen activator and dornase alfa. Unfortunately, repeat CT of the thorax showed residual loculated pleural effusion with right lower lobe pleural thickening, indicating lung entrapment. DaVinci-assisted exploration of the right chest with evacuation of fibrotic septation and decortication was performed. Post-traumatic empyema can occur after chest wall injury. Multiple risk fractures are an independent risk factor for empyema formation. This process involves direct inoculation of skin or environmental flora into the pleural space, leading to secondary bacterial infection. In the case of our patient, not only did he develop empyema from direct foreign inoculation from trauma, but he also had an aspiration event that led to parapneumonic effusion. Streptococcus Intermedius is increasingly becoming more recognized as a significant cause of community-acquired pleural empyema in the setting of aspiration pneumonia. Management includes respiratory culture-guided and thoracentesis-fluid culture-guided antibiotics, drainage of the empyema, and, sometimes, surgical intervention to prevent entrapped lung. This abstract is funded by: None
Yin et al. (Fri,) studied this question.