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When Good Pleural Effusions Go Bad

When Good Pleural Effusions Go Bad. Cheryl Pirozzi, M.D. Pulmonary Grand Rounds December 16, 2010. What is the common pathology?. www.bikerumor.com. The Case. CC: Pulmonary consult for right pleural effusion. HPI.

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When Good Pleural Effusions Go Bad

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  1. When Good Pleural Effusions Go Bad Cheryl Pirozzi, M.D. Pulmonary Grand Rounds December 16, 2010

  2. What is the common pathology? www.bikerumor.com

  3. The Case • CC: Pulmonary consult for right pleural effusion

  4. HPI • 71 yo man admitted 2 days previously with 1d h/o RUQ pain and right-sided chest pain. • Pain is increased with deep breaths • Increased SOB from baseline • Dry nonproductive cough • No f/c, orthopnea, no change LE edema • No change with eating. No N/V, diarrhea, BRBPR

  5. PMH ILD • Initially developed dry cough and SOB in Jan 2010. • HRCT 2/25/10 showed ILD most c/w NSIP • Long hospitalization 4/21/10 - 6/2/10: • CAP • AF with RVR • Respiratory failure requiring mechanical ventilation • Progression of ILD • VATS wedge biopsy of RUL and RML 5/7/10 most consistent with mixed cellular/fibrotic NSIP • Treated with steroids  good clinical response • Currently tapered to prednisone 20mg po BID

  6. PMH ILD – HRCT 2/25/10

  7. PMH ILD – HRCT 2/25/10

  8. PMH ILD – HRCT 2/25/10

  9. PMH ILD- CTA 4/16/10

  10. PMH ILD- CTA 4/28/10

  11. PMH • DM2 • HTN • Atrial Fibrillation • Gout • Right upper-extremity DVT • 2003 total hip replacement due to OA • Admission 8/10 with hyperglycemia • Admission 9/10 with non-cardiac CP

  12. SH • From the Congo, emigrated to UT in 2003 • No travel since then • No h/o tobacco, EtOH, drugs • Married with 8 children • Previous work as a security officer. No significant exposures FH • Noncontributory

  13. Home Meds Prednisone 20 mg PO bid Arformoterol nebs BID Budesonide nebs BID Albuterol nebs prn Dapsone 100 mg PO daily Warfarin Sotalol Omeprazole Simvastatin Norvasc Lantus and novolog insulin Allopurinol Glipizide

  14. Current Meds Prednisone 20 mg PO bid Budesonide nebs BID Albuterol nebs prn Dapsone 100 mg PO daily Warfarin Sotalol Omeprazole Simvastatin Norvasc Lantus and novolog insulin Allopurinol Glipizide Miralax Morphine

  15. On presentation • VS t 37.6, p 101, 126/75, R 15, SpO2 > 90%/3L • RUQ TTP on exam • Labs: • WBC 24 (PMN 92%), BUN 18, Cr 0.9 • Lactate 2.5, LFTs nl, lipase 16, INR 3.6

  16. Hospital Course • Admitted to Medicine on 10/18/10 • Pain- negative work up for GI causes • Attributed to constipation • HD 3 patient developed fevers • On review of admission imaging, attending noted a loculated right pleural effusion, pulmonary consult called

  17. Physical exam • VS t 38.6, p90, 130/70, R 16, 96%/4 lpm • Gen: obese, alert, oriented, no respiratory distress • HEENT: Mallampati class III airway, OP clear • CV: RRR, no m/g/r. JVP 3 cm/SA • Lungs: crackles bilat, Egophony at R base, decreased BS R base and laterally mid axillary line. TTP R chest wall on mid axillary line. • Abd: TTP RUQ, neg Murphy’s, mildly distended • Ext: 1+ edema

  18. Labs • WBC 20 (PMN 93%), Hgb 11, hct 34, plt 221 • Na 141, k 4.6, Cl 107, CO2 27, bun 11, Cr 0.8, glc 189 • INR 2.4

  19. CXR 10/18/10

  20. CTA 10/18/10

  21. CTA 10/18/10

  22. CTA 10/18/10

  23. Impresssion • Right loculated pleural effusion in immunosuppressed pt with underlying ILD • Concerning for empyema • Diagnostic thoracentesis recommended

  24. Hospital Course • Started on Zosyn, vancomycin, and azithromycin • FFP given to reverse  INR • Bedside ultrasound guided thoracentesis attempted  no tap done • Pt sent to radiology for ultrasound-guided thoracentesis • Unable to obtain any fluid • Small amount in needle was sent for culture • Patient refused any more procedures • Plans made for discharge with home IV Zosyn.

  25. Hospital Course • Just prior to discharge… • Culture from thoracentesis needle AND blood cultures grew this organism:

  26. Hospital Course What is the pathogen? • A) Mycobacterium tuberculosis • B) Actinomyces israelii • C) Streptococcus pneumoniae • D) Nocardia cyriacigeorgica • E) Aspergillus fumigatus

  27. Hospital Course What is the pathogen? A) Mycobacterium tuberculosis B) Actinomyces israelii C) Streptococcus pneumoniae D) Nocardia cyriacigeorgica E) Aspergillus fumigatus

  28. Pulmonary Nocardiosis • Nocardia spp = genus of aerobic actinomycetes • Gram-positive bacilli, branching, beaded, filamentous, weakly acid-fast • Ubiquitous, soil-dwelling organisms Bronchial wash partial acid fast stain thunderhouse4-yuri.blogspot.com Sputum gram stain www.theaidsreader.com Curr Opin Pulm Med. 2006 May;12(3):228-34

  29. Pulmonary Nocardiosis • Mainly opportunistic infection, but can also affect immunocompetent hosts (~ 1/3) • Uncommon; 500 – 1000 cases per year in USA • Incidence thought to be increasing due to more immunosuppressed pts Curr Opin Pulm Med. 2006 May;12(3):228-34 Respirology. 2007;12(3):394-400 Respir Med 2003; 97:709-717

  30. Pulmonary Nocardiosis • Most common cause of nocardiosis in humans = N. asteroides complex (> 80% in pulm dz). • N. cyriacigeorgica is an “emerging infection” recently identified new species, part of N. asteroides complex • 1st described case of pulmonary dz in USA: PNA in a heart transplant recipient. • Schlaberg et al. Nocardia cyriacigeorgica, an emerging pathogen in the United States. J Clin Microbiol. 2008 Jan;46(1):265-73. Epub 2007 Nov 14 Curr Opin Pulm Med. 2006 May;12(3):228-34

  31. Nocardiosis • Most common site of infection is the lung (>2/3 of cases) • Most infections result from inhalation of bacilli • No person to person spread • ~ 50 % of all pulmonary cases disseminate to sites outside the lungs, most commonly the brain • Can also involve skin, soft tissue, and almost every organ system • Nocardemia seen most often with pulm disease, but + blood cultures are rare Curr Opin Pulm Med. 2006 May;12(3):228-34 Medicine 2004; 83:300-313 Murray and Nadel 5th ed

  32. Risk Factors Which of the following have been identified as risk factors for pulmonary nocardiosis? A) COPD B) alveolar proteinosis C) Steroids D) Female gender E) organ transplant recipients F) pulmonary fibrosis

  33. Risk Factors Which of the following have been identified as risk factors for pulmonary nocardiosis? A) COPD B) alveolar proteinosis C) Steroids D) Female gender E) organ transplant recipients F) pulmonary fibrosis

  34. Risk Factors • Impairment of lung defenses: COPD, pulmonary fibrosis, silicosis, alveolar proteinosis • Systemic immunosuppression due to drug therapy, infection, or malignancy • Corticosteroids (74% of cases) • Cytotoxic therapy • Organ transplant recipients • AIDS with CD4 count <100 • Leukemias and lyphomas • Male gender • Alcoholism a RF for CNS dissemination Respirology. 2007;12(3):394-400, Medicine 2004; 83:300-313; Curr Opin Pulm Med. 2006 May;12(3):228-34

  35. Risk Factors Martinez et al. Pulmonary nocardiosis: risk factors and outcomes. Respirology. 2007;12(3):394-400. Observational study of 31 pts with pulm nocardiosis (11 with disseminated nocardiosis) Insert table of rfs 94% had identifiable RFs Most common RFs were corticosteroids (65%) and other immunosuppressive therapy (36%)

  36. Pulmonary Nocardiosis Clinical presentation- diverse • May be acute, subacute, or chronic • Sxs: fever, chills, night sweats, productive cough, weight loss, anorexia, dyspnea and hemoptysis, pleuritic chest pain • Can present with acute, fulminant PNA • Can be complicated by chest wall invasion, empyema necessitans, mediastinitis, pericarditis, SVC syndrome Curr Opin Pulm Med. 2006 May;12(3):228-34 Murray and Nadel 5th ed

  37. Pulmonary Nocardiosis Clinical presentation • s/sx of other organ involvement: • Neurologic signs of mass lesion • Subcutaneous abscesses with or without sinus tracts Murray and Nadel 5th ed Medicine 2004; 83:300-313

  38. Pulmonary Nocardiosis Radiographic findings- wide variety: • single or multiple nodules • lung masses (with or without cavitation) • reticulonodular infiltrates • lobar consolidation • subpleural plaques • pleural effusions (10-33%) • Upper lobe disease is common Curr Opin Pulm Med. 2006 May;12(3):228-34 Medicine 2004; 83:300-313

  39. Pulmonary Nocardiosis Radiographic findings • Pulmonary nocardiosis re-visited. Respir Med 2003; 97:709-717 • retrospective review of clinical and laboratory features of 35 pts with pulmonary nocardiosis

  40. Pulmonary Nocardiosis • Nodules Actinomycoses and Nocardia pulmonary infections. Curr Opin Pulm Med. 2006 May;12(3):228-34

  41. Pulmonary Nocardiosis • Mass-like consolidation Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717

  42. Pulmonary Nocardiosis • Consolidation Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717

  43. Pulmonary Nocardiosis • Multiple cavitating pulmonary nodules Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717

  44. Pulmonary Nocardiosis • Ground glass opacities Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717

  45. Pulmonary Nocardiosis • Pleural effusion imaging.consult.com jcp.bmj.com

  46. Nocardiosis • CNS dissemination jcp.bmj.com

  47. Diagnosis • Gram stain and a modified acid-fast stain of sputum, pleural fluid, or BAL Modified acid-fast stain of sputum containing Nocardia asteroides shows filamentous branching organisms Murray and Nadel 5th ed Curr Opin Pulm Med. 2006 May;12(3):228-34 Murray and Nadel 5th ed

  48. Diagnosis Actinomycoses and Nocardia pulmonary infections. Curr Opin Pulm Med. 2006 May;12(3):228-34

  49. Diagnosis • Culture: growth usually within 3 to 7 days but may take up to 3 weeks • Although the organism occasionally colonizes the upper respiratory tract, recovery of Nocardia from culture of sputum or BAL usually means Nocardia infection • Often initially misdiagnosed as malignancy or TB Curr Opin Pulm Med. 2006 May;12(3):228-34 Murray and Nadel 5th ed Medicine 2004; 83:300-313

  50. Diagnosis • Lung biopsy: necrotizing PNA Respir Med 2003; 97:709-717

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