Disorders of the Pleura |

Empyema Due to Streptococcus pyogenes in an Otherwise Healthy 27-Year-Old Patient FREE TO VIEW

Giezy Sardinas*, MD; Richard Fremont, MD; Matthew King, MD
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Meharry Medical College, Nashville, TN

Chest. 2012;142(4_MeetingAbstracts):513A. doi:10.1378/chest.1388640
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SESSION TYPE: Pleural Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The incidence of Group A Streptococcus (GAS), Streptococcus pyogenes, pneumonia is rising. GAS pneumonia often occurs in healthy, young individuals. Pleuritic chest pain, fever, chills, and dyspnea are common manifestations. Cough is not a prominent symptom. Unlike the sterile effusions seen in other pneumonias, half of patients with GAS have an accompanying empyema which may increase in size rapidly.

CASE PRESENTATION: A 27 year old healthy male, presented with severe right sided pleuritic chest pain, worsening SOB, fever and chills of two days duration. He also reported an intermittent cough productive of yellow sputum. Physical exam showed a well-nourished young male, with tachypnea, decreased breath sounds and dullness to percussion on the right side of his chest, and tachycardia. Chest radiography (CXR) and computed tomography of the chest revealed a large right pleural effusion with compressive atelectasis. Thoracentesis was performed and 900ml of thick, cloudy pleural fluid (yellow-brown colored) was removed. Pleural fluid analysis was consistent with an active infection in the pleural space. Gram Stain showed Gram positive cocci in chains, later identified as streptococcus pyogenes. The patient received antibiotics and a thoracostomy tube. His hospital course was complicated with sepsis and respiratory failure requiring endotracheal intubation for 24 hours. Intrapleural alteplase was administered daily for 3 days. He responded to treatment and was successfully discharged home to complete 6 weeks of oral antibiotic therapy as an outpatient. At two week outpatient follow-up, he had no residual dyspnea; he had some slight pain at the chest tube incision site, but no constitutional symptoms. His CXR demonstrated pleural thickening in the right base, but no residual fluid was seen on ultrasound.

DISCUSSION: Group A streptococcus primarily causes infections of the upper respiratory tract and the skin. The occurrence of pneumonia has increased with the resurgence of invasive GAS disease during the past several decades. This case illustrates that GAS pneumonia is a severe illness of rapid onset, frequently associated with local and systemic complications, particularly empyema. If unrecognized or untreated, it is associated with significant morbidity and mortality.

CONCLUSIONS: The incidence of GAS pneumonia is rising in the community. The evaluation of individuals presenting with suspected GAS pneumonia should involve prompt recognition and treatment in order to prevent severe complications such us empyema, toxic shock, or death.

1) Goldman, L., and A. I. Schafer. Goldman's cecil medicine, expert consult premium edition -- enhanced online features and print, single volume. 24th ed. Philadelphia: W B Saunders Co, 2012. 298:1824-25.

2) Fauci, A. S., E. Braunwald, D. L. Kasper, S. L. Hauser, D. L. Longo, J. L. Jameson, and J. Loscalzo. Harrison's principles of internal medicine. 17th Ed. McGraw-Hill Professional, 2008. 130:881-86.

DISCLOSURE: The following authors have nothing to disclose: Giezy Sardinas, Richard Fremont, Matthew King

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Meharry Medical College, Nashville, TN




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