Woman With Dyspnea

An 83-year-old woman attended the emergency department with a 3-week history of progressive dyspnea that had started with SARS-CoV-2 infection that was treated at home. She presented with a temperature of 36 °C, a respiratory rate of 30 breaths/min, and an oxygen saturation level of 90% while breathing ambient air. On physical examination, the patient’s lungs were dull to conventional percussion, with reduced tactile vocal fremitus on the right side of her chest. Laboratory studies showed a WBC count of 38,400/μL with 75% neutrophils and a left shift. C-reactive protein level was 193 mg/L. A chest radiograph showed a large left pleural effusion (Figure 1 ). The emergency physician performed a tube thoracostomy and drained 2 L of purulent fluid that showed a high neutrophil count, a pH of 6.5, and a plasma glucose level close to 0.

Figure 1.

Chest radiograph showing a large right pleural effusion.

Diagnosis

Streptococcus pleural empyema. Microscopic examination of the pleural fluid revealed numerous intracellular cocci in chains, indicative of Streptococcal infection (Figure 2 ). A pleural fluid culture was later positive for Streptococcus intermedius. The patient was treated with intravenous amoxicillin and discharged from the hospital after 2 weeks.

Figure 2.

Microscopic images of the pleural cells containing cocci in chains (black arrows).

Courtesy of the Central Hospital Institute’s Laboratory, Rennaz.

Empyema caused by the Streptococcus anginosus group mostly occurs in patients with a history of alcohol misuse, immunosuppression, or underlying diseases. It has also been described in an older immunocompetent patient after SARS-CoV-2 infection. Because pleural fluid culture is negative in 20% to 40% of cases, the visualization of chains of cocci inside neutrophils provides an immediate suggestion of Streptococcal infection.