Abstract Candida albicans is a commensal fungus colonizing approximately half of the population. It can be found in the oral cavity, gastrointestinal tract, genital mucosa, and skin. Empyema is an infection of the pleural space, often arising as a complication of bacterial pneumonia as inflamed pleura become increasingly permeable and allow for parapneumonic effusion formation.The patient is a 49-year-old female with a medical history only significant for IV heroin use and smoking who presented for 2 weeks of productive cough with thick brown mucous and pleuritic chest pain. She was transferred after CT chest revealed a right sided empyema with mass effect on the mediastinum. On day one, the patient underwent chest tube placement under anesthesia. However, the pleural cavity was too viscous, and so a small thoracotomy was performed. Due to failed aspiration through the tubing, continuous irrigation was necessary before inspection. Inspection revealed diffuse necrosis with multiple large bronchopleural fistulas. The right upper lobe was adhered to the chest wall, and multiple ruptured abscesses. The patient suddenly became hypoxic and hypotensive, requiring a bronchoscopy with left mainstem intubation. Eventually, she underwent a right pneumonectomy. Another bronchoscopy was performed revealing dehiscence of 20 percent of the bronchial stump staple line with communication to the pleural cavity. Repeat thoracotomy was performed. The patient remained ventilator dependent necessitating a tracheostomy. Cultures from initial thoracotomy pleural fluid grew pan-sensitive streptococcus intermedius and bacteroides species. She was treated with appropriate IV antibiotics. By day 21, the patient continued to decline, and she was found to have a right sided empyema. She underwent repeat washout of the pleural space which included modified Clagett solution (meropenem, gentamicin, and vancomycin). Cultures from this pleural fluid and bronchoalveolar lavage of the left lung returned positive for candida albicans. She completed a course of fluconazole and was discharged to a long-term acute care hospital. This case illustrates a rare and uncommon instance of severe bacterial pneumoempyema which required right pneumonectomy. A post-pneumonectomy candida empyema developed. Many are associated with bronchopleural fistula which complicates management. Preservation of the patient’s left lung was of high importance and a Clagett procedure was required. This procedure has been reported to be effective in 88 percent of patients, with failures most commonly resulting from persistent or recurrent bronchopleural fistulas. Clinicians should maintain suspicion for fungal pathogens in patients with empyema, early intervention and timely antifungal treatment improved outcomes for the patient. This abstract is funded by: None
Thota et al. (Fri,) studied this question.