Case of empyema in 48-year-old male with dyspnoea and productive cough
This article describes the case of a 48-year-old male patient with complaints of dyspnoea and productive cough with a history of 2 weeks. His medical history revealed that he was an ex-smoker, and was recurrently admitted to the hospital because of pneumonia like symptoms in the past 4 years. He could not recall any aspiration event before this period. Doctors initially suspected that he had localised lower right lower lobe bronchiectasis. However, bronchoscopic examination did not reveal any signs of stricture, tumour or foreign body. The patient refused to undergo surgery.
Investigations and treatment
Further physical examination showed fever, dullness over the lower right region of the hemithorax, diminished breath sounds and finger clubbing. Blood tests showed leucocyotosis, an increased eryhtrocyte sedimentation rate, C reactive protein level, normocytic normochromic anaemia and thrombocytosis. Other findings included right-sided pleural effusion on chest radiography. Doctors performed thoracentesis, an invasive medical procedure for removing air from the pleural space – while performing the procedure, pus was also aspirated, which is consistent with the diagnosis of empyema.
CT scan of the chest showed honeycombing bronchiectasis of posterobasal segment of the right lower lobe, in addition to pleural effusion and pleural thickening of the right side. Treatment included intravenous clindamycin and ceftriaxone with tube thoracostomy. On fiberoptic bronchoscopy, a plastic foreign body was retrieved, measuring 3 x 1 cm, from the right lower lobe, lumen of posterobasal segment.
In several cases, an aspirated foreign body can cause unresolved pneumonia or empyema in adult patients. The treatment of choice in majority of the patients is generally bronchoscopy. As stated in the study, “foreign body aspiration should be considered as an uncommon cause of unresolved pneumonia, localised bronchiectasis or localised air trapping in adult patients even in the absence of history of aspiration”. However, a delay in diagnosis can lead to procedure-related complications.