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Received Oct 8, 2017; Revised Jan 10, 2018; Accepted Jan 28, 2018
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1. Introduction
Empyema thoracis is a serious condition characterized by the accumulation of purulent fluid in the pleural cavity, typically following a pneumonia, subdiaphragmatic abscess, or esophageal rupture. Fungal empyema thoracis is a rare form of this condition with especially high mortality, in which the most frequently isolated fungus is Candida spp [1]. A high index of suspicion is required to diagnose this condition, as it may present as a community-acquired infection [2].
2. Case Presentation
A 74-year-old female with a history of schizophrenia, dementia, COPD, and a CVA presented to the Emergency Department with nausea and vomiting for 3 days, as well as dysphagia for 2 weeks, which all began after drinking hot water. Her vital signs on presentation were BP of 122/77 millimeter of mercury (mmHg), HR of 75 beats per minute (bpm), RR of 16 breaths/minute (br/min), oxygen saturation of 95% on room air, and temperature of 97.7°F. The chest examination revealed decreased air entry and diffuse rhonchi bilaterally. The remainder of physical examination was unremarkable. Her labs showed WBCs of 10,300/mm3, creatinine of 0.77 mg/dl, and a negative urine analysis. The chest X-ray (CXR) revealed left lower lobe consolidation with a left-sided pleural effusion. The abdominal X-ray exhibited dilation of the esophagus. The patient refused a modified barium swallow and a CT of the abdomen. She was started on azithromycin and ceftriaxone for community-acquired pneumonia.
On the third day of admission, she became short of breath, with vitals of HR 130 bpm, BP 86/43 mmHg, RR 38 br/min, temperature 98.6°F, and oxygen saturation 93% on 3 L/min of oxygen. On examination, the patient was cyanotic, using accessory muscles, taking rapid shallow breaths, with decreased air entry and hyperresonance to percussion on the right side of the chest. The CXR showed a large right-sided hydropneumothorax, and the esophagus was air-filled down to the distal segment (Figure 1). Surgery was consulted, and a chest tube was inserted on the right side, which removed 1.85 liters of pleural fluid. Analysis of the pleural fluid showed...