Western Reserve Health Education/NEOMED, Youngstown, OH
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Clostridium baratii is an anaerobic, motile, gram-positive bacterium. It is a rare cause of Infant botulinism. We present a rare case of pleural empyema caused by clostridium baratii.
CASE PRESENTATION: A 74-year-old female presented to ER with chief complaint of right-sided chest pain and shortness of breath. She was discharged from the hospital 10 days ago due to small bowel obstruction caused by internal hernia resulting in laparotomy. On examination, she was afebrile and hypoxic with O2 Saturation of 89%. She had diminished breath sounds on the right lung field throughout. CT chest showed moderate right pleural effusion with compressive atelectasis and right lower lobe infiltrate. She was started on Vancomycin, Levofloxacin and Cefepime for possible Healthcare Assoicated Pneumonia. Ultrasound guided right sided thoracentesis revealed exudative effusion. A 14F pigtail catheter was placed under CT guidance and tissue plasminogen activator (tPA) was infused via catheter to help drain the fluid. Total of 3.5L pleural fluid was drained over 5 days with the tPA infusion. Repeat cultures of pleural fluid came back positive for Clostridium baratii which was sensitive to Penicillin. The catheter was removed and she received a PICC line. She was discharged home with home healthcare on Ampicillin-Sulbactam to complete total of 3 weeks’ treatment. During the course of treatment her symptoms resolved.
DISCUSSION: Clostridial pleuropulmonary infections are rare; most of these infections are attributed to Clostridium perfringens. Clostridium Baratii, usually associated with infant botulinism has not been reported to cause pulmonary infections. Trauma, chest surgery or other invasive procedures and underlying lung disease are often found to precede clostridial Empyema. In our patient, spread of Clostridium Baratii occured after a recent abdominal surgery which is may have resulted from transdiphragmatic lymphatic translocation. Intrapleural infusion of TPA is a controversial treatment for empyema. If combined with DNase may result in better drainage. In our case it proved to be effective in the management and resolution of the empyema.
CONCLUSIONS: Although mostly associated with Infant Botulinism, Clostridium Baratii may be associated with other infections in immunocompetent patients particularly pulmonary infections. Infusion of tPA via catheter is an effective option before considering surgery in cases with pleural empyema.
Reference #1: Bayer, A. S., S. C. Nelson, J. E. Galpin, A. W. Chow, and L. B. Guze. 1975. Necrotizing pneumonia and empyema due to Clostridium perfringens. Report of a case and review of the literature. Am. J. Med.59;851-856
Reference #2: Kwan WC, Lam SC, Chow AW, Lepawski M, Glanzberg MM. 1983. Empyema caused by Clostridium perfringens. Can Med Assoc J. 1983 Jun 15; 128(12): 1420-1422.
Reference #3: Najib M. Rahman, D.Phil., Nicholas A. Maskell, D.M. 2011. Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection. N Engl J Med 2011; 365:518-526
DISCLOSURE: The following authors have nothing to disclose: Arslan Talat, Munir Shah
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