Department of Medicine Grand Rounds Vignette

1
Department of Medicine Grand Rounds Vignette

• Stanley Josue, M.D.
• NYU School of Medicine
• October 18, 2006

2

• CC A 39 year old male complains of productive
  cough, pleuritic chest pain and fever for 3 days.
• HPI The patients past medical history was
  significant for AIDS (CD4 59 and VL 2550) on
  HAART and no prior history of opportunistic
  infections. He recently completed treatment for
  a right lower lobe pneumonia 2 months prior. He
  developed fever and cough productive of brown
  sputum He denied any sick contacts, travel, or
  noncompliance with his HAART and PCP prophylaxis.

3
Physical Exam

• General Cachectic male, appearing older than
  stated age in no apparent distress.
• T 101.6 HR 98 BP 112/72 RR 20 97 on
  room air
• Lungs symmetric chest wall expansion, right
  lower thoracic area had diminished breath sounds,
  dullness to percussion, and decreased tactile
  fremitus.

4
Imaging

• CXR preliminarily interpreted as a right lower
  lobe cavitary infiltrate with an air-fluid level.
• Chest CT was ordered (but was delayed due to
  technical reasons)

5
Hospital Course

• Diagnostic thoracenthesis
• 50cc of yellow thick free-flowing fluid,
• pH 6.2, LDH 21,000, protein 3 (serum protein 7)
• 8000 WBC with significant bandemia
• Therapeutic course
• The patient was started on broad-spectrum
  antibiotics and an emergent thoracostomy tube was
  placed and drained 400cc of empyema.

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Final Diagnosis

• Right-sided multi-drug resistant Pseudomonas
  aeruginosa empyema.