Category: Pleural Effusion

Pyogenic Vertebral Osteomyelitis Presenting as Exudative Pleural Effusion: ConclusionThe spectrum of organisms isolated in these patients (S aureus, S agalactiae, and P mirahilis) is similar to that reported by McHenry in their large series of osteomyelitis read online asthma inhalers. S agalactiae and P mirahilis have not been previously associated with pleural effusion secondary to vertebral osteomyelitis. S aureus was the cause of vertebral osteomyelitis in six of the eight cases presenting as pleural effusion. Cause of the osteomyelitis was not established in the two cases reported in the preantibiotic era.
In two large series of pyogenic osteomyelitis, diabetes mellitus was present in 25 to 33% of the cases. This study includes information on six of the eight patients reported in the literature. In this series and in the previously reported patients, 6 of the 11 patients had diabetes mellitus, suggesting that in addition to predisposing to osteomyelitis, diabetes may have contributed to its extra-vertebral spread to the pleural space. …Read the rest of this article

Case 5 also supports this in that the effusion markedly increased soon after the CT-guided aspiration of the vertebral lesion.
It can be argued that the osteomyelitis in these patients was secondary to an infection in the pleural space. Two points against such an argument are as follows: (1) Four of these patients (cases 1, 3, 4, and 5) had back pain preceding any respiratory complaints. (2) Empyema was diagnosed only in cases 2 and 5 whereas the effusion in the other patients was sterile. It is also possible that the osteomyelitis and pleural effusion resulted from bacterial seeding from a common source of infection elsewhere. It would be difficult to rule out such a pathogenic mechanism. …Read the rest of this article

Pyogenic Vertebral Osteomyelitis Presenting as Exudative Pleural Effusion: DiscussionOf the five patients with vertebral osteomyelitis in this series, four presented with pleural effusion. In three of these four patients, the effusion was large on presentation and exudative. In the fourth patient (case 4), though the effusion was large, the characteristics of the effusion were not determined. The focus on the exudative effusions and pulmonary signs and symptoms led to a significant delay in diagnosis of osteomyelitis with the development of neurologic complications in two patients (cases 2 and 4). add comment In the fifth patient, the effusion was initially small; however, it became large subsequent to the diagnostic aspiration of the spine. In all of these patients, plain films of the chest failed to show the bony abnormalities of osteomyelitis. Two of the five patients had empyema (cases 2 and 5). The pleural fluid characteristics, blood cultures, spinal fluid cultures, treatment, and clinical course of the patients in this series along with the eight cases reported in the medical literature are summarized in Table 1. …Read the rest of this article

A chest x-ray film revealed a small right-sided subpulmonic effusion. The WBC count was 15,000/μL with 78% neutrophils. An MRI of the spine suggested a disk space infection of the 6th and 7th thoracic vertebrae with epidural extension and posterior displacement of the spinal cord (Fig 4). A CT-guided aspiration of the spine yielded purulent fluid which grew methicillin-sensitive S aureus. The day after this procedure the pleural effusion progressed to complete opacification of the right hemithorax. Thoracentesis yielded exudative fluid (protein value, 3.9 g/dL; LDH level, 6,291 IU/L). The serum protein and LDH values were 6.2 g/dL and 442 IU/L, respectively. Pleural fluid cultures also grew methicillin-sensitive S aureus with the same sensitivity pattern as the spine isolate. The patient was treated with oxacillin and the pleural effusion resolved. The patient subsequently died during the same hospital stay due to renal failure. …Read the rest of this article

Pyogenic Vertebral Osteomyelitis Presenting as Exudative Pleural Effusion: Case 4A 55-year-old woman was admitted to the hospital with fever, left-sided back pain, and constipation. The pain was not pleuritic; however, it was aggravated by movement. There was a history of diabetes mellitus and a nonhealing ulcer on her right foot. Her temperature was 37.7°C. Breath sounds were decreased at the left lung base. Both legs were edematous, and a chronic noninflamed ulcer was on her right foot. There was no spinal tenderness. The WBC count was 15,000/μL with 80% polymorphonuclear leukocytes, 9% band cells, 5% lymphocytes, and 6% monocytes. The serum glucose level was 348 mg/dL. A chest x-ray film showed an infiltrate and effusion on the left side of the chest. Culture of the foot ulcer grew methicillin-sensitive S aureus and S agalactiae. The patient was treated with ceftriaxone, 1 g IV q 12 h, and erythromycin, 1 g IV q 6 h, for presumed pneumonia. …Read the rest of this article

Pyogenic Vertebral Osteomyelitis Presenting as Exudative Pleural Effusion: Case 2The entire left leg was tender and warm. There was no tenderness over the spine. The chest x-ray film showed bilateral pleural effusions, larger on the right side. The Pa02 was 51 mm Ilg (with the patient breathing room air). The WBC count was 20,000/n-L, with 85% polymorphonuclear leukocytes and 11% lymphocytes. Results of a chemistry profile were within normal limits except for the alkaline phosphatase level, which was 143 IU/dL (normal range, 38 to 126 IU/dL) and the glucose value, which was 326 mg/dL. Only matched defects were seen on a ventilation perfusion lung scan. Bronchoscopy was nondiagnostic and BAL fluid cultures were negative for bacterial organisms. Thoracentesis yielded 750 mL of serosanguineous exudative fluid (total protein level, 3.1 gm/dL; LDH value, 4,538 IU/dL). Serum protein and LDH values were 4.8 gm/dL and 611 IU/L, respectively. Cultures of the pleural fluid grew enterococci, diphtheroids, and Proteus mirahilis. A chest tube was placed, and the patient was treated for empyema with ceftazidime and vancomycin. canadian health and care mall …Read the rest of this article

The fluid was exudative (pleural fluid lactate dehydrogenase) (LDH) and protein values were 187 IU/L and 4.2 g/dL, respectively; the serum LDII and protein levels were 252 IU/L and 6.2 gm/dL, respectively). No organisms were seen with the Gram stain. Lumbosacral spine films were normal. Ampicillin/ sulbactam 3 g IV q 8 h, was administered for a presumed pleuropulmonary infection. Persistence of the effusion prompted a subsequent thoracentesis and pleural biopsy, which showed nonspecific chronic inflammation. The pleural fluid cultures were negative. The patient was discharged on the 12th hospital day on a regimen of oral erythromycin. He was readmitted 10 days later because of persistence of fever, chills, and back pain. At this time, he was noted to have tenderness over the 11th and 12th thoracic vertebrae. …Read the rest of this article