Empyema, the development of infection within the pleural space, is a well-known complication of pneumonia. Here, we present a unique case of empyema due to a gram-positive cocci, Sarcina ventriculi, occurring after thoracotomy, and its successful treatment.
A 63 year-old, obese man with Type II diabetes presented with a two-week history of fevers and right-sided chest pain. Four months previously, the patient underwent video-assisted thoracoscopy (VATS) for the evaluation of recurrent pleural effusion of unknown etiology. Pleural biopsy revealed fibrinous pleuritis, and cultures were sterile.Physical exam revealed decreased breath sounds at the right base with a tender, indurated, erythematous area over the right lateral chest wall. A pleural effusion was noted on chest radiograph. White blood count count was 26,000. CT scan of the chest demonstrated a large, loculated, gas-filled, right basal pleural collection, along with a pulmonary infiltrate. Empyema due to staphylocci, Streptococcus or gram negative organisms was our initial concern.A repeat VATS was performed. 500 cc of puss was found in the pleural space which extended into the subcutaneous tissue tracking down the right flank. Gram stain of the puss revealed numerous gram-positive cocci and culture grew Sarcina ventriculi. Following identification of the organism, antibiotic therapy was changed to penicillin and clindamycin. The patient had an uneventful recovery and is well eight months later.DISCUSSION:Sarcina ventriculi is an anaerobic gram-positive cocci, which is part of the normal flora found on the skin of diabetics. While other causes of empyema were considered, this organism was cultured from the pleural space. We speculate that the possible source of infection was the prior surgical intervention with the organism being introduced from the skin to the pleura. Beta-lactam antibiotics and surgical intervention appear to be best approach for treating empyema caused by this organism.
This is the first reported case of empyema secondary to Sarcina ventriculi. Consideration of this organism as a cause for empyema in the appropriate setting can lead to successful diagnosis and treatment.
E.R. Restelli, None.