Download - When Good Pleural Effusions Go Bad Cheryl Pirozzi, M.D. Pulmonary Grand Rounds December 16, 2010
When Good Pleural Effusions Go Bad
Cheryl Pirozzi, M.D.
Pulmonary Grand Rounds
December 16, 2010
What is the common pathology?
www.bikerumor.com
The Case
• CC: Pulmonary consult for right pleural effusion
HPI
• 71 yo man admitted 2 days previously with 1d h/o RUQ pain and right-sided chest pain.
• Pain is increased with deep breaths• Increased SOB from baseline• Dry nonproductive cough• No f/c, orthopnea, no change LE edema • No change with eating. No N/V, diarrhea,
BRBPR
PMH
ILD• Initially developed dry cough and SOB in Jan 2010. • HRCT 2/25/10 showed ILD most c/w NSIP• Long hospitalization 4/21/10 - 6/2/10:
– CAP– AF with RVR– Respiratory failure requiring mechanical ventilation – Progression of ILD
• VATS wedge biopsy of RUL and RML 5/7/10 most consistent with mixed cellular/fibrotic NSIP
– Treated with steroids good clinical response– Currently tapered to prednisone 20mg po BID
PMH
ILD – HRCT 2/25/10
PMH
ILD – HRCT 2/25/10
PMH
ILD – HRCT 2/25/10
PMH
ILD- CTA 4/16/10
PMH
ILD- CTA 4/28/10
PMH
• DM2• HTN• Atrial Fibrillation• Gout• Right upper-extremity DVT• 2003 total hip replacement due to OA• Admission 8/10 with hyperglycemia• Admission 9/10 with non-cardiac CP
SH
• From the Congo, emigrated to UT in 2003• No travel since then• No h/o tobacco, EtOH, drugs• Married with 8 children• Previous work as a security officer. No
significant exposures
FH• Noncontributory
Home Meds• Prednisone 20 mg PO bid• Arformoterol nebs BID• Budesonide nebs BID• Albuterol nebs prn• Dapsone 100 mg PO daily • Warfarin• Sotalol• Omeprazole • Simvastatin • Norvasc• Lantus and novolog insulin• Allopurinol• Glipizide
Current Meds• Prednisone 20 mg PO bid• Budesonide nebs BID• Albuterol nebs prn• Dapsone 100 mg PO daily • Warfarin• Sotalol• Omeprazole • Simvastatin • Norvasc• Lantus and novolog insulin• Allopurinol• Glipizide• Miralax • Morphine
On presentation
• VS t 37.6, p 101, 126/75, R 15, SpO2 > 90%/3L• RUQ TTP on exam
• Labs: • WBC 24 (PMN 92%), BUN 18, Cr 0.9 • Lactate 2.5, LFTs nl, lipase 16, INR 3.6
Hospital Course
• Admitted to Medicine on 10/18/10• Pain- negative work up for GI causes• Attributed to constipation• HD 3 patient developed fevers
• On review of admission imaging, attending noted a loculated right pleural effusion, pulmonary consult called
Physical exam
• VS t 38.6, p90, 130/70, R 16, 96%/4 lpm• Gen: obese, alert, oriented, no respiratory distress• HEENT: Mallampati class III airway, OP clear• CV: RRR, no m/g/r. JVP 3 cm/SA• Lungs: crackles bilat, Egophony at R base,
decreased BS R base and laterally mid axillary line. TTP R chest wall on mid axillary line.
• Abd: TTP RUQ, neg Murphy’s, mildly distended• Ext: 1+ edema
Labs
• WBC 20 (PMN 93%), Hgb 11, hct 34, plt 221• Na 141, k 4.6, Cl 107, CO2 27, bun 11, Cr 0.8,
glc 189• INR 2.4
CXR 10/18/10
CTA 10/18/10
CTA 10/18/10
CTA 10/18/10
Impresssion
• Right loculated pleural effusion in immunosuppressed pt with underlying ILD
• Concerning for empyema
• Diagnostic thoracentesis recommended
Hospital Course
• Started on Zosyn, vancomycin, and azithromycin• FFP given to reverse INR• Bedside ultrasound guided thoracentesis
attempted no tap done• Pt sent to radiology for ultrasound-guided
thoracentesis– Unable to obtain any fluid
– Small amount in needle was sent for culture
• Patient refused any more procedures• Plans made for discharge with home IV Zosyn.
Hospital Course
• Just prior to discharge…• Culture from thoracentesis needle AND blood
cultures grew this organism:
Hospital Course
What is the pathogen?• A) Mycobacterium tuberculosis• B) Actinomyces israelii• C) Streptococcus pneumoniae • D) Nocardia cyriacigeorgica• E) Aspergillus fumigatus
Hospital Course
What is the pathogen?• A) Mycobacterium tuberculosis• B) Actinomyces israelii• C) Streptococcus pneumoniae • D) Nocardia cyriacigeorgica• E) Aspergillus fumigatus
Pulmonary Nocardiosis• Nocardia spp = genus of aerobic actinomycetes • Gram-positive bacilli, branching, beaded,
filamentous, weakly acid-fast• Ubiquitous, soil-dwelling organisms
Curr Opin Pulm Med. 2006 May;12(3):228-34
Sputum gram stainwww.theaidsreader.com
Bronchial wash partial acid fast stainthunderhouse4-yuri.blogspot.com
Pulmonary Nocardiosis
• Mainly opportunistic infection, but can also affect immunocompetent hosts (~ 1/3)
• Uncommon; 500 – 1000 cases per year in USA– Incidence thought to be increasing due to more
immunosuppressed pts
Curr Opin Pulm Med. 2006 May;12(3):228-34 Respirology. 2007;12(3):394-400Respir Med 2003; 97:709-717
Pulmonary Nocardiosis
• Most common cause of nocardiosis in humans = N. asteroides complex (> 80% in pulm dz). – N. cyriacigeorgica is an “emerging infection” recently
identified new species, part of N. asteroides complex– 1st described case of pulmonary dz in USA: PNA in a
heart transplant recipient.– Schlaberg et al. Nocardia cyriacigeorgica, an emerging pathogen in the
United States. J Clin Microbiol. 2008 Jan;46(1):265-73. Epub 2007 Nov 14
Curr Opin Pulm Med. 2006 May;12(3):228-34
Nocardiosis
• Most common site of infection is the lung (>2/3 of cases)• Most infections result from inhalation of bacilli• No person to person spread
• ~ 50 % of all pulmonary cases disseminate to sites outside the lungs, most commonly the brain
• Can also involve skin, soft tissue, and almost every organ system
• Nocardemia seen most often with pulm disease, but + blood cultures are rare
Curr Opin Pulm Med. 2006 May;12(3):228-34Medicine 2004; 83:300-313Murray and Nadel 5th ed
Risk Factors
• Which of the following have been identified as risk factors for pulmonary nocardiosis?
• A) COPD• B) alveolar proteinosis • C) Steroids• D) Female gender• E) organ transplant recipients• F) pulmonary fibrosis
Risk Factors
• Which of the following have been identified as risk factors for pulmonary nocardiosis?
• A) COPD• B) alveolar proteinosis • C) Steroids• D) Female gender• E) organ transplant recipients• F) pulmonary fibrosis
Risk Factors
• Impairment of lung defenses: COPD, pulmonary fibrosis, silicosis, alveolar proteinosis
• Systemic immunosuppression due to drug therapy, infection, or malignancy– Corticosteroids (74% of cases)– Cytotoxic therapy– Organ transplant recipients– AIDS with CD4 count <100– Leukemias and lyphomas
• Male gender• Alcoholism a RF for CNS dissemination
Respirology. 2007;12(3):394-400, Medicine 2004; 83:300-313; Curr Opin Pulm Med. 2006 May;12(3):228-34
Risk Factors• Martinez et al. Pulmonary nocardiosis: risk factors and outcomes.
Respirology. 2007;12(3):394-400.• Observational study of 31 pts with pulm nocardiosis (11 with disseminated
nocardiosis)
• Insert table of rfs
• 94% had identifiable RFs• Most common RFs were corticosteroids (65%) and other
immunosuppressive therapy (36%)
Pulmonary Nocardiosis
Clinical presentation- diverse• May be acute, subacute, or chronic • Sxs: fever, chills, night sweats, productive
cough, weight loss, anorexia, dyspnea and hemoptysis, pleuritic chest pain
• Can present with acute, fulminant PNA• Can be complicated by chest wall invasion,
empyema necessitans, mediastinitis, pericarditis, SVC syndrome
Curr Opin Pulm Med. 2006 May;12(3):228-34Murray and Nadel 5th ed
Pulmonary Nocardiosis
Clinical presentation• s/sx of other organ involvement:
– Neurologic signs of mass lesion– Subcutaneous abscesses with or without sinus tracts
Murray and Nadel 5th edMedicine 2004; 83:300-313
Pulmonary Nocardiosis
Radiographic findings- wide variety:• single or multiple nodules • lung masses (with or without cavitation)• reticulonodular infiltrates • lobar consolidation • subpleural plaques • pleural effusions (10-33%) • Upper lobe disease is common
Curr Opin Pulm Med. 2006 May;12(3):228-34Medicine 2004; 83:300-313
Pulmonary NocardiosisRadiographic findings• Pulmonary nocardiosis re-visited. Respir Med 2003; 97:709-717
• retrospective review of clinical and laboratory features of 35 pts with pulmonary nocardiosis
Pulmonary Nocardiosis
• Nodules
Actinomycoses and Nocardia pulmonary infections. Curr Opin Pulm Med. 2006 May;12(3):228-34
Pulmonary Nocardiosis
• Mass-like consolidation
Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717
Pulmonary Nocardiosis
• Consolidation
Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717
Pulmonary Nocardiosis
• Multiple cavitating pulmonary nodules
Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717
Pulmonary Nocardiosis
• Ground glass opacities
Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717
Pulmonary Nocardiosis
• Pleural effusion
imaging.consult.com jcp.bmj.com
Nocardiosis
• CNS dissemination
jcp.bmj.com
Diagnosis
• Gram stain and a modified acid-fast stain of sputum, pleural fluid, or BAL
Curr Opin Pulm Med. 2006 May;12(3):228-34 Murray and Nadel 5th ed
Modified acid-fast stain of sputum containing Nocardia asteroides shows filamentous branching organismsMurray and Nadel 5th ed
Diagnosis
Actinomycoses and Nocardia pulmonary infections. Curr Opin Pulm Med. 2006 May;12(3):228-34
Diagnosis
• Culture: growth usually within 3 to 7 days but may take up to 3 weeks
• Although the organism occasionally colonizes the upper respiratory tract, recovery of Nocardia from culture of sputum or BAL usually means Nocardia infection
• Often initially misdiagnosed as malignancy or TB
Curr Opin Pulm Med. 2006 May;12(3):228-34Murray and Nadel 5th ed Medicine 2004; 83:300-313
Diagnosis
• Lung biopsy: necrotizing PNA
Respir Med 2003; 97:709-717
Treatment
• Which antibiotic(s) would you use to treat this patient?
• A) Imipenem• B) Zosyn• C) azithromycin• D) Bactrim• E) ceftriaxone• F) clindamycin • G) doxycycline
Treatment
• Which antibiotic(s) would you use to treat this patient?
• A) Imipenem• B) Zosyn• C) azithromycin• D) Bactrim• E) ceftriaxone• F) clindamycin • G) doxycycline
Treatment
• Tends to relapse or progress despite appropriate therapy
• Adequate drainage or excision of abscesses and empyema is crucial
• Duration:– Immunocompetent patients without CNS dz 6–12
months. – Immunosuppressed patients1 year + if possible
dose of immunosuppressant drug– CNS involvement at least 1 year
Murray and Nadel 5th ed Respirology. 2007;12(3):394-400
Treatment
Abx choice• Martinez et al. Pulmonary
nocardiosis: risk factors and outcomes. Respirology. 2007;12(3):394-400.
• Observational study of 31 pts with pulm nocardiosis– 65% N. asteroides
• Most were sensitive to:– amikacin (100%)– TMP-SMZ (95%)– imipenem (93%)– 3rd gen cephalosporins
(90%)
Treatment
Abx choice• Much resistance and treatment failure• No prospective randomized trials• Most recommend empiric treatment with 2 or 3 abx in
severe infection– (pulmonary, CNS, disseminated, and all infections in
immunocompromised pts)
• IV x 3-6 weeks, then can change to PO if improving• 1st line TMP-SMX• Other options: carbapenems, amikacin, 3rd gen
cephalosporins, doxycycline, linezolid, minocycline• Tailor therapy based on susceptibilities Medicine 2004; 83:300-313Curr Opin Pulm Med. 2006 May;12(3):228-34UpToDate.com
Prognosis
• Mortality – Pulmonary dz: 15 – 30%– Higher mortality for acute presentations (~ 66%)– CNS disease 40% to 87%– Nocardemia 44%–85%
• Treatment failure in disseminated disease up to 20%
Murray and Nadel 5th ed Medicine 2004; 83:300-313 Respirology. 2007;12(3):394-400
Our patient
• Initially refused surgery. Treatment started with Bactrim IV, imipenem IV, and doxycycline IV.
• Eventually pt agreed to surgery, and underwent right thoracotomy, decortication, and evacuation of empyema on 10/28/10.
• OR noted empyema “gross purulence” and fibrothorax
• OR Tissue gram stain + nocardia• MRI brain negative for nocardia abscesses• Uncomplicated surgery, recovered well.
Our patient
• Based on sensitivities imipenem changed to ceftriaxone
• At time of discharge doing well, on 1-2 LPM O2• Discharged to SNF on bactrim DS 2 tab PO tid x
at least 12 months, ceftriaxone 1g IV q12 x at least 6 weeks, and doxycycline 100mg PO BID
• Prednisone decreased to 20 mg po daily• ID and pulm follow up
What is the common pathology?
A: NOCARDIOSIS
References• Martinez Tomas R, Menendez Villanueva R, Reyes Calzada S, et al.
Pulmonary nocardiosis: risk factors and outcomes. Respirology. 2007;12(3):394-400.
• Hui CH, Au VW, Rowland K, et al. Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med 2003; 97:709-717
• Menendez R, Cordero PJ, Santos M, et al. Pulmonary infection with Nocardia species: a report of 10 cases and review. Eur Respir J 1997; 10:1542-1546
• Uttamchandani RB, Daikos GL, Reyes RR, et al. Nocardiosis in 30 patients with advanced human immunodeficiency virus infection: clinical features and outcome. Clin Infect Dis. 1994;18(3):348-53.
• Lederman ER, Crum NF. A case series and focused review of nocardiosis: clinical and microbiologic aspects. Medicine 2004; 83:300-313
• Yildiz O, Doganay M. Actinomycoses and Nocardia pulmonary infections. Curr Opin Pulm Med. 2006 May;12(3):228-34.
• Schlaberg R, Huard RC, Della-Latta P. Nocardia cyriacigeorgica, an emerging pathogen in the United States. J Clin Microbiol. 2008 Jan;46(1):265-73. Epub 2007 Nov 14.
• Nocardiosis. Murray and Nadel 5th ed• Chapman S. Treatment of Nocardiosis. UpToDate.com 2010