Abstract Introduction Fusobacterium necrophorum is an invasive organism known to cause severe loculated empyema. Current standard treatment is Video Assisted Thorascopic Surgery (VATS) with decortication and pleurodesis, which creates adhesions between the pleurae to prevent air and fluid reaccumulation, improving lung function to 85-88%. VATS is considered invasive with complications including air leak, bleeding, and worsening empyema, whereas pigtail chest tube drain usage is associated with reduced pain and complications long-term. The effectiveness of such conservative management compared to VATS is not well studied for severe empyema treatment in young adults. Case We present a previously healthy 23-year-old male who reported multiple upper respiratory symptoms minimally improved with supportive treatment. Notable aspects of presentation included HR of 118 and initial lab abnormalities of WBC 19.7, lactic acid 2.4, procalcitonin 37.53. Chest CTA showed bilateral cavitary lesions, consolidations, and septic emboli indicating severe necrotizing pneumonia. Blood cultures were drawn, and the patient received fluid resuscitation and empiric IV Cefepime and Vancomycin. He developed tachypnea and pleuritic pain despite treatment and was transferred to the medical ICU. Repeat chest x-ray showed a large right-sided pleural effusion, so a right-sided pigtail chest tube was placed. Pleural fluid analysis indicated a culture-negative empyema and blood cultures showed Fusobacterium necrophorum and the diagnosis of Fusobacterium necrophorum cavitary pneumonia was made. Cardiothoracic Surgery was consulted for VATS decortication with pleurodesis; however, decision was made to trial conservative treatment to avoid risk of unnecessary trauma given inadequate formation of pleural rind and long-term risks of intentionally scarring a previously healthy person’s lung. Chest tubes with tPA/dornase were placed at areas identified through serial imaging and patient was transitioned to IV Unasyn. A total of four chest tubes were placed with near-complete resolution of pleural effusion on final imaging. Patient was discharged on day 18 with a 3-week course of oral Augmentin. At outpatient follow up, the patient exhibited dramatic improvement in symptoms and repeated imaging. Discussion Invasive Fusobacterium necrophorum can result in significantly reduced lung function and subsequent mortality. Current literature shows treatment of invasive empyema with VATS averages a 7 to 10-day hospitalization compared to month-long conservative management using antibiotics. Many of the cases noted, however, are often of chronically ill, elderly patients with reduced mobility, which increases risk of atelectasis and impaired healing. Our patient’s respiratory recovery in a shorter hospitalization suggests that non-surgical treatment is an effective alternative to VATS in younger patients. This abstract is funded by: None
Mylvaganam et al. (Fri,) studied this question.