Case Study of an Atypical Presentation of a Large Undiagnosed Empyema in the Setting of Hyperglycemia

A 58-year-old man with a history of type 2 diabetes mellitus was hospitalized for hyperglycemia. During a review of systems, the patient reported additional symptoms of mild, right-sided pleuritic chest pain. Further investigation revealed dullness to percussion with decreased breath sounds and slight tachycardia on physical exam. Additional workup revealed a 16 cm pleural effusion on CT, despite no fever, no leukocytosis, and mild clinical presentation. Thoracentesis findings revealed empyema, and laboratory analysis identified Streptococcus intermedius. Chest tubes were placed and antibiotics administered during a 15-day hospital stay until the patient requested to leave against medical advice. No concerns of respiratory infection were indicated during the patient’s initial admission to the emergency department, nor during the patient’s previous hospitalization at a different facility one month prior. The patient remained afebrile (except for one recorded mild fever) with no leukocytosis for the entirety of the admission. This case study serves to increase awareness that even a large empyema can go undiagnosed when clinical presentation deviates from the expected and to inform physicians' response to improve patient health outcomes.