Spontaneous Bacterial Empyema

Today, Dr. Amrock presented a very interesting case of shortness of breath which progressed to septic shock in an individual with ESLD. The patient was found to have Spontaneous Bacterial Empyema (SBEM) and required chest tube placement for a loculated effusions. This is a reminder to check the pleural fluid along with blood cultures and peritoneal fluid becuase it can be so much more than "just hepatohydrothorax!"

SBEM is a spontaneous infection of a prior hepatic hydrothorax. It is most commonly seen on the right but there are case reports of left sided infected effusions. The organisms are often enterobacteriaceae. Diagnosis is made by pleural fluid analysis:

  • culture positive pleural fluid + 250 PMNs/mm3 OR
  • culture negative pleural fluid + 500 PMNs/mm3 without pneumonia

Therapy is typically medical with 7-10 days of a third-generation cephalosporin. Chest tube placement is often not necessary and may result in excessive protein or fluid losses, coagulopathy or electrolyte imbalances. However, in cases of empeymea, complicated parapnumonic effusion or large effusions it may be necessary if frank pus is obtained form the plueral space. Ultimately, this is a very morbid and mortal condition with mortality estimated as high as 28%.

For additional reading, please refer to the following articles: Current Opinion in Pulmonary Medicine and Chest 2015 with a point vs. counterpoint discussion.