CASE PRESENTATION
A 44-year-old ex-smoker with no known co-morbidities arrived at our
emergency room with a one-week complaint of left-sided chest discomfort
and left shoulder pain. The pain was gradual in onset and continuous in
nature, radiating to the shoulder. The pain increased while deep
breathing and on movements. The pain was not relieved by any
medications. The patient complained of fever at night and dry cough, and
some loss of appetite but no history of shortness of breath, productive
cough, no night sweats, no history of significant weight loss. He denied
known TB contact and any history of TB. No other history of any
traumatic event (Table 1). The patient was afebrile on examination, with
a heart rate (HR) of 90 beats per minute and blood pressure (BP) of
130/73 mmHg, respiratory rate (RR) of 19 breaths per minute, and an
oxygen saturation (O2 sat) of 100 percent on room air.
No clubbing or supraclavicular lymphadenopathy On examination of the
respiratory system, there was no visible deformity, no tenderness on
palpation, the percussion note was dull on the lower left side of the
chest, and the percussion note was dull on the on auscultation decreased
air entry on the left side with left basal crackles.
Examination of the left shoulder joint showed no tenderness and a normal
range of movements. The remaining systemic examination, including
cardiovascular, neurological, and gastrointestinal exam, was
unremarkable. A chest x-ray (CXR) (Figure 1) was performed, which showed
a mild/moderate amount of left-sided PE with underlying atelectasis. The
diagnosis of left-sided PE was made, and the patient was started on
antibiotics empirically as a case of parapneumonic effusion. Diagnostic
PF aspiration was done under septic conditions, and workup was sent for
PF analysis to determine the cause of the effusion without typical
respiratory symptoms. The patient was kept on isolation is suspicion of
TB. Within the next 24 hours; the patient developed worsening chest pain
on the left side, shortness of breath, and desaturation. A repeated CXR
(Figure 2) was performed and compared with the previous CXR; there is a
considerable interval increasing amount of PE with
collapse/consolidation left lung. In the account of thoracocentesis done
the previous day, traumatic hemothorax was suspected but was ruled out
as there was no drop in hemoglobin. The diagnosis of massive PE on the
left side that had rapidly progressed over 24 hours, with worsening
chest symptoms, was made. An urgent chest drain was inserted under
ultrasound guidance, and drainage was done. Following this, a CT chest
was done (Figure 3), and it showed improvement in the PE and no evidence
of empyema or abscess formation. The patient started feeling better with
the chest drain in place, and he drained. He improved clinically, and
the inflammatory markers improved from admission. The PF analysis showed
an exudative picture with a neutrophilic predominance (Table 2). PF
cultures were negative. Work up for TB and malignancy were negative.
On Day 9, after the chest tube was inserted, the drainage of fluid was
nil. A repeat CXR was done, and it showed resolution of PE, the chest
tube was removed, and the patient was discharged on antibiotics for a
total of 21 days, and an outpatient follow-up appointment with the
pulmonologist was given.