Abstract Streptococcus intermedius, a member of the Streptococcus anginosus group, is distinguished by its strong propensity for abscess formation in deep tissues such as the brain and liver. Pulmonary involvement is relatively uncommon but can be rapidly destructive, particularly in immunocompromised hosts. We present a case of S. intermedius necrotizing pneumonia complicated by hydropneumothorax and bronchopleural fistula, emphasizing the organism’s virulence and the importance of early surgical intervention. A 63-year-old man with a history of non-Hodgkin lymphoma in remission, hypertension, and diabetes presented with worsening left-sided chest pain, dyspnea, and confusion. On arrival, he was hypotensive and in atrial fibrillation with a ventricular rate of 190 bpm. Hemodynamics improved with intravenous diltiazem and electrical cardioversion. Laboratory evaluation revealed profound leukocytosis, acute kidney injury, and severe metabolic derangements resembling tumor lysis syndrome, including hyperkalemia, hyperphosphatemia, hyperuricemia, and markedly elevated transaminases with coagulopathy. Chest imaging demonstrated a large left pleural effusion with air-fluid levels and dense consolidation of the left lower lobe consistent with necrotizing pneumonia. Thoracentesis drained 1.6 liters of thick, dark, purulent fluid. Pleural analysis showed an exudative, neutrophil-predominant effusion, and cultures grew Streptococcus intermedius. Empiric broad-spectrum antibiotics were narrowed to intravenous ceftriaxone. Despite appropriate antimicrobial therapy and continuous drainage via a pigtail catheter, repeat imaging revealed a persistent hydropneumothorax with incomplete lung re-expansion and multiloculated collections. Intrapleural fibrinolysis with alteplase and dornase alfa improved drainage but failed to achieve full resolution. Follow-up CT imaging demonstrated persistent air-fluid levels and raised concern for a bronchopleural fistula originating from the necrotic left lower lobe. Thoracic surgery was consulted, and the patient underwent video-assisted thoracoscopic surgery (VATS), revealing thickened pleura, purulent debris, and a visible bronchopleural communication. Complete decortication and primary repair of the fistula were performed. Postoperatively, the patient’s respiratory status improved, leukocytosis normalized, and serial imaging demonstrated progressive resolution of pleural collections. He was weaned off supplemental oxygen and discharged with full recovery of renal and hepatic function.This case highlights the aggressive and tissue-destructive potential of S. intermedius pulmonary infection. When medical management with antibiotics and drainage fails to achieve re-expansion or resolution of a hydropneumothorax, persistent air leak should raise suspicion for bronchopleural fistula. Early multidisciplinary involvement combining antimicrobial optimization, intrapleural fibrinolytics, and timely surgical intervention is essential to achieving recovery and preventing irreversible pulmonary sequelae in this rare but life-threatening condition. This abstract is funded by: None
Chaney et al. (Fri,) studied this question.