(571) Rapidly Progressive Sepsis Secondary to Bilateral Empyema in an Immunocompetent Patient

Introduction: Empyema thoracis which is the collection of pus within the pleural space, majority being unilateral, with rare bilateral cases usually a complication of pneumonia but can also be secondary to thoracic surgery or trauma. Its occurrence elevates morbidity and mortality to around 20 to 30%. Streptococcus pyogenes is a bacterium known to cause invasive infections with an incidence of about 3 to 10 per 100,000 in developed countries. The rarity of this infection and its occasional difficulty in isolating from pus makes it a diagnostic challenge.

Description: A 62-year-old male presented with 1 week history of sudden onset shortness of breath on exertion associated with intermittent chest pain, fever, and poor appetite. Physical examination was positive for an acutely ill looking man, shallow breathing due to pain, febrile, tachypneic tachycardic and hypoxic with bilaterally lower lung zone crackles. Laboratory investigations demonstrated profound leukocytosis with left shift, mild anemia, and reactive thrombocytosis. Chest X-ray was suggestive of septic emboli and CT PE showed multiple bilateral loculated empyema. Of note, he had an abdominal CT done a week earlier on account of abdominal pain and diarrhea which showed clear lung bases. Diagnostic thoracentesis yielded 60cc of pus with negative gram stain and culture. Cytology showed acute inflammatory cells. He received empiric antibiotics-Unasyn and Augmentin, had VATS decortication and chest tube drainage of empyema. His condition improved, chest tubes were successfully removed, and he continued with chest physiotherapy with incentive spirometry. Cultures remained negative but molecular testing of operative tissue sample by next generation 16S rRNA sequencing was positive for Streptococcus pyogenes. Special bacterial stains requested on the paraffin tissue blocks showed rare cocci in chains.

Discussion: This case highlights the aggressive behavior of Strep pyogenes, even in patients with apparent immune competence.
It emphasizes the role of molecular diagnosis as the final diagnosis was only recognized via molecular testing in the setting of negative cultures of the empyema (pus) and lung tissue.
Swift recognition and implementation of an interdisciplinary management approach are crucial in mitigating the morbidity and mortality.