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Chest Infections |

A Rare Case of Pleural Empyema Secondary to Clostridium difficile

Mubdiul Ali Imtiaz, MD; MANAN PANDYA, DO
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Hackensack University Medical Center at Pascack Valley, Clifton, NJ


Chest. 2015;148(4_MeetingAbstracts):98A. doi:10.1378/chest.2251858
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Abstract

SESSION TITLE: Chest Infections I Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Clostridium difficile is well known as the etiologic agent of pseudomembranous colitis and has been implicated as the cause of 10-25% of cases of antimicrobial drug-associated diarrhea. In contrast, reports on isolation of Clostridum difficile infection (CDI) in body sites other than the intestine have been anecdotal. We present a rare case of extraintestinal CDI presenting as a right lung empyema.

CASE PRESENTATION: A 53-year-old man with a history of gastroesophageal reflux disease (GERD), Hodgkin lymphoma, intra-abdominal desmoid tumor, and chronic kidney disease, presented with two weeks history of shortness of breath. Physical examination was notable for dullness to percussion, and diminished breath sounds on the right lung. Chest x-ray demonstrated right-sided pleural effusion, and video-assisted thoracic surgery revealed evidence of a large right lung empyema. A chest tube was placed for drainage, and pleural biopsies with cultures were sent for microscopic analysis. Multiple sets of cultures were noted to be positive for Clostridium difficile. The patient’s stool however was tested negative for CDI. Patient was started on vancomycin, aztreonam, and intravenous (IV) as well as oral metronidazole. The patient was discharged in stable condition with a right sided pleurovac for continued drainage and both IV and oral metronidazole.

DISCUSSION: Clostridium difficile is very rarely isolated from extraintestinal specimens, especially pleuropulmonary specimens. In our case, aspiration from the gut could be a potential source of infection. Although our patient did not have any evidence of oropharyngeal or esophageal dysphagia, he might have aspirated the bacteria from his gut into the lungs. Patient’s history of chronic proton pump inhibitor (PPI) use for GERD might have played a role as PPI use has been associated with an initial episode and recurrence of CDI.

CONCLUSIONS: A high degree of clinical suspicion is required to acknowledge the pathogenetic role of Clostridium difficile isolated from extraintestinal sites. Though uncommon, pulmonary manifestations of CDI should be considered in patients with history of GERD and chronic use of PPI.

Reference #1: Feldman RJ, Kallich M, Weinstein MP. Bacteremia due to Clostrium Difficile: Case report and review of extra intestinal C.difficile infections. Clinical Infectious Disease. 1995; 20: 1560-2.

Reference #2: Simpson AJH, Tabaqchali S, Das SS. Nosocomial empyema caused by Clostridium Difficile. Journal of clinical pathology. 1996; 49: 172-3.

DISCLOSURE: The following authors have nothing to disclose: Mubdiul Ali Imtiaz, MANAN PANDYA

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