Case Presentation: A 38 year-old-male with cirrhosis from hepatitis B and C complicated by recurrent ascites, previous spontaneous bacterial peritonitis (SBP), and recurrent hepatic hydrothorax requiring transjugular intrahepatic portosystemic shunt presented with two days of increasing dyspnea at rest. He had recently been nonadherent with SBP prophylaxis and diuretics. Laboratory findings revealed leukocytosis of 17,500k/uL, total protein 5.1 g/L, LDH 322 U/L. CT revealed minimal ascites but large loculated right pleural effusion with right to left mediastinal shift and no pneumonia. Pleural fluid analysis revealed pH 7.08, protein 2.2 g/dL, LDH 180 U/L, and 7962 WBCs with 84% PMN’s consistent with spontaneous bacterial pleuritis with empyema (SBEM). Pleural fluid gram stain was negative but culture grew E. coli. Leukocytosis promptly resolved with antibiotic treatment. Chest tube was placed and had continuous high output of >4000cc daily despite diuretics and TIPS revision. Due to loculations, surgical decortication was performed. Post operatively, drainage slowly decreased. He was discharged with home health for continued daily home drainage on levofloxacin for prophylaxis. At follow-up in cardiothoracic surgery clinic, despite lack of symptoms, the drain continued to have large volume thick yellow output and Eleosser flap is planned to ensure adequate drainage to prevent recurrent empyema.
Discussion: SBEM is believed to have a pathogenesis similar to that of SBP. While ~60% of patients with cirrhosis will have ascites requiring intervention, only 5-10% experience hydrothorax. Of those with hydrothorax, it is estimated 15% will develop SBEM. While SBP and SBEM can occur simultaneously, SBEM can occur in isolation. Thus in a patient with known hepatic hydrothorax, any effusion large enough to access via diagnostic thoracentesis should be evaluated using diagnostic criteria for SBEM, even if SBP has been ruled out. SBEM criteria are: no evidence of pneumonia on imaging AND positive pleural fluid culture and PMN cell count >250 cells/mm3 OR negative pleural fluid culture with PMN cell count >500 cells/mm3. Fluid is often transudative by Light’s criteria, as it was in this case. The most common bacteria cultured are E. coli and K. pneumoniae although cultures are frequently negative. Recommended empiric antibiotics are the same as in SBP, typically a third generation cephalosporin. Chest tube placement for uncomplicated SBEM, even if the culture is positive, is contraindicated due to resulting life threatening protein loss, fluid depletion and electrolyte imbalance. Chest tube placement is only indicated if the fluid is frankly purulent or pH is <7.2. Decortication may be needed for loculations. Even with proper management, mortality of SBEM approaches 20%.
Conclusions: Although SBEM is a rare complication in a patient with cirrhosis, missing it can have devastating results. Hospitalists must be aware of this clinical entity and be vigilant about obtaining pleural fluid for evaluation and avoiding chest tube placement if clinically avoidable.