A69-25 Fungal Empyema Arising From Hepatic Hydrothorax in an Immunocompromised Post-liver Transplant Patient

Abstract Introduction Fungal empyema thoracis is an uncommon but life-threatening condition, accounting for less than 5% of all empyema cases and occurring primarily in immunocompromised hosts, such as post-organ transplant recipients. Its occurrence as a complication of hepatic hydrothorax in the absence of overt ascites is exceptionally rare and diagnostically challenging. We present a case of hepatic hydrothorax complicated by fungal empyema in a post-liver transplant patient. Case Description A 43-year-old man with cryptogenic cirrhosis status post orthotopic liver transplantation in 2023, prior aortic valve replacement, and on maintenance immunosuppression presented with subacute progressive dyspnea worsened by exertion and orthopnea. Examination revealed bilateral decreased breath sounds. Laboratory studies showed WBC 8.4 × 109/L, hemoglobin 10.3 g/dL, platelets 114 × 109/L, and creatinine 2.1 mg/dL. Chest radiograph demonstrated bilateral pleural effusions without significant ascites. Echocardiogram revealed left ventricular ejection fraction of 42% with grade II diastolic dysfunction. Diagnostic thoracentesis yielded exudative fluid that grew Candida albicans. Despite antifungal therapy and bilateral chest-tube drainage with intrapleural tPA/DNase for three days, the effusions reaccumulated, progressing to bilateral pneumothoraces and trapped-lung physiology. Repeated pleural cultures identified Candida famata and Trichosporon beigelii complex. Given persistent infection refractory to medical and fibrinolytic therapy, the patient underwent sequential bilateral thoracotomies with lung decortication. Postoperatively, he remained hemodynamically stable with re-expanded lungs, decreased chest-tube output, and preserved graft function. Discussion This case represents a rare occurrence of bilateral fungal empyema in an immunosuppressed liver-transplant recipient, likely originating from an infected hepatic hydrothorax, possibly via microscopic diaphragmatic defects, even in the absence of overt ascites. Blood cultures have a diagnostic yield below 20% in fungal empyema, underscoring the need for direct pleural fluid analysis. Failure of medical and fibrinolytic therapy highlights that organized fungal empyemas may require surgical decortication for definitive source control. Conclusion Hepatic hydrothorax, even without overt ascites, can progress to fungal empyema in post-transplant patients. Given the low yield of blood cultures, early pleural sampling, targeted antifungal therapy, and timely multidisciplinary escalation to surgical management are essential for survival. This abstract is funded by: None