Case Presentation:

A 51–year–old man with liver cirrhosis secondary to alcoholism and hepatitis C complicated with refractory, paracentesis–dependent ascites was found unresponsive in his apartment. His medications were furosemide, spironolactone, thiamine and folic acid. On presentation, he appeared critically ill and unresponsive with GCS 3. Temperature was 26°C, BP 70/36, HR 50/min, RR 35/min, and SPO2 85% on room air. Skin was icteric and cold. Chest exam revealed diminished air entry with stony dullness to percussion on the left side. Abdomen was distended with shifting dullness. Blood work showed leukocyotosis (WBC 23000) with normocytic anemia, thrombocytopenia, coagulopathy, acute renal failure, acute hepatitis (AST>10,000, ALT 1853), anion gap metabolic acidosis (AG 28), elevated serum lactate (17.5 mmol/L) and hypoalbuminemia (albumin 1.9 g/dl). Brain CT was normal. The patient was admitted to the ICU for mechanical ventilation, rewarming measures, hemodynamic monitoring and stabilization. He had DIC. Broad spectrum antibiotics were initiated. He received albumin, NaHCO3, vitamin K and FFP. Lactulose was introduced rectally. His CXR showed left sided pleural effusion. Urine and blood cultures were negative. Therapeutic abdominal paracentesis was consistent with portal hypertension with no evidence of SBP (SAAG 1.6, WBC 125, PMN 5%, protein 0.7 g/dl). Therapeutic thoracentesis showed transudative effusion with 2500 WBC, PMN 67%, protein 1.4 g/dl, and albumin 0.6 g/dl; findings were consistent with hepatic hydrothorax superimposed with spontaneous bacterial empyema. Despite all the essential interventions he remained critical and expired few days later.

Discussion:

This case demonstrates a Spontaneous Bacterial Empyema (SBEM) in a cirrhotic patient. SBEM is an infection of a preexisting hydrothorax. It is defined as pleural fluid (PF) with a PMN >500 or positive culture with exclusion of a parapneumonic effusion. It occurs in up to 16% of patients with hepatic hydrothorax and may not be associated with SBP in up to 50% of patient. Presenting picture is septic shock in 15% of patients and mortality during treatment is up to 40%. Gram–negative pathogens, in particular E coli are the predominant organism (65%) but cultures can be negative in up to 40%. Early suspicion and therapy with IV third generation cephalosporin is crucial in addition to aggressive management of hepatic hydrothorax (e.g., low Na diet, diuretics, repeated thoracentesis and TIPS). Furthermore, all patients with hepatic hydrothorax and SBEM should be referred for evaluation for liver transplantation.

Conclusions:

This case emphasizes the importance of early detection and treatment of Spontaneous Bacterial Empyema in cirrhotic patients. Despite aggressive therapy, the mortality rate remains high.

Figure 1Largely distended abdomen due to massive ascites.

Figure 2CXR showed left sided massive pleural effusion.