Fungal Empyema Thoracis in an Immunocompetent Patient: An Account of Presentation, Evaluation and Treatment
American Journal of Respiratory and Critical Care Medicine
Introduction: Fungal empyema thoraces (FET) is a rare presentation, defined as at least one fungal isolate recovered from the pleural fluid in the setting of an exudative pleural effusion. The most frequent pathogens implicated in this presentation are Candida spp. and Aspergillus spp. Here, we present a case of a 57 year-old female with pancreatic cancer that developed a candida albicans empyema, successfully treated with systemic antifungals, drainage and decortication and provide a brief discussion of the presentation, evaluation and treatment of FET. Case: A 57- year-old female with a past medical history significant for alcoholic pancreatitis with pseudocysts presented with obstructive jaundice. Her initial presentation was complicated by new-onset atrial fibrillation with rapid ventricular rate, hypoxia requiring intubation and septic shock. MRCP revealed dilated intrahepatic and extrahepatic ducts and liver function tests were concerning for ascending cholangitis. She underwent an endoscopic ultrasound with biopsy of a pancreatic head mass, later revealed to be stage II pancreatic adenocarcinoma with invasion of the portal vein. Chest radiograph on presentation revealed bilateral pleural effusions thought to be secondary to third spacing of fluids due to sepsis induced by cholangitis. She was treated with systemic antibiotics and vasopressors for hemodynamic support. Thoracentesis was preformed yielding purulent fluid and culture demonstrated budding yeast with pseudohyphae, consistent with candida albicans. She was started on micafungin and chest tubes were inserted with tPA infused to improve drainage and source control. The patient improved and was successfully extubated. She then acutely decompensated requiring re-intubation. Chest CT scan revealed persistent apical empyema for which she ultimately underwent decortication. Post-operatively, she improved and was transitioned from micafungin to fluconazole for continued treatment. Conclusion: FET is rare presentation commonly seen in immunosuppressed patients with a high associated mortality rate. Though its prevalence in this population is increasing, the overall low incidence of this presentation poses challenges to treatment. Systemic antifungal therapy, tubal drainage, tubal irrigation, fibrinolytic therapy and surgical intervention have all been utilized with varying degrees of success. Here, we presented a case of FET in an immunocompetent patient with a newly diagnosed malignancy successfully treated with systemic antifungals, drainage and decortication.
Leamon G, Shams C, Mehindiratta R, Mina N. Fungal Empyema Thoracis in an Immunocompetent Patient: An Account of Presentation, Evaluation and Treatment. InD59. FUNGAL INFECTION CASE REPORTS Am J Respir Crit Care Med 2019 May; 199:A6888. American Thoracic Society.