Hepatic hydrothorax occurs in up to 10% of patients with cirrhosis mostly on the right. This case demonstrates the rarity of isolated left-sided spontaneous bacterial empyema secondary to Morganella Morganii in a cirrhotic. CASE PRESENTATION: A 64-year-old man with alcoholic liver cirrhosis presented with a 2-week history of worsening shortness of breath, abdominal distention and chills. His physical exam was significant for hypotension, sinus tachycardia, decreased breath sounds in the left lung, abdomen distension,and bilateral pedal edema. Laboratory studies showed leukocytosis with neutrophil predominance, hyponatremia, elevated creatinine,lactic acid and INR. MELD score was calculated to be 36 points. Chest X-ray showed new large left pleural effusion and a clear right lung. CT chest revealed isolated left sided pleural effusion with complete collapse of the left lung and mild mediastinal shift to the right (Figures 1,2).Pleural fluid,peritoneal fluid and blood cultures returned positive for Morganella morganii. He was treated with IV Meropenem with improvement in symptoms and renal dysfunction. He continued to require repeat therapeutic thoracenteses and was transferred to a liver transplant facility for consideration for TIPS when clinically stable, as a bridge to eventual liver transplant.
The use of electromagnetic navigation as an adjunct to flexible bronchoscopy in the diagnosis of pulmonary lesions has been shown to improve yield. In this study, we compared the diagnostic yield of concurrently performed transbronchial needle aspiration (TBNA) and transbronchial forceps biopsy (TBFB) in patients undergoing electromagnetic navigation-guided bronchoscopy (ENB) for diagnosis of peripheral pulmonary lesions. METHODS: A retrospective study was conducted on all patients who underwent concurrent ENB-guided transbronchial needle aspirations and transbronchial forceps biopsies at Ochsner LSU Health Shreveport, LA between July 2018 to December 2019. RESULTS: 86 ENB procedures were performed on 82 patients (mean age 62 years; 35 females, 47 males); four patients needed repeat procedures for new pulmonary lesions or for prior negative studies. 72 (88%) patients had a history of nicotine use and 37 (45%) had a history of malignancy. Of 86 procedures done, samples were inadequate or non-diagnostic in 6 cases, while 9 cases were lost to follow up, and as such final diagnoses of the lung lesions could not be confirmed. Of the remaining 71 procedures, ENB was diagnostic in 53 cases (75%; 42 malignant, 11 non-malignant) and was falsely negative in 18 cases (25%; 16 malignant and 2 non-malignant). False negatives were diagnosed with CT-guided biopsy or at lobectomy. Overall, the sensitivity of concurrent ENB-guided TBNA with TBFB in the diagnosis of malignant and benign peripheral pulmonary lesions was 72% (p ¼ 0.03). Of 58 total malignant cases, transbronchial needle aspiration (TBNA) positively compared to transbronchial forceps biopsy (TBFB) with 39/58 vs 32/58 (sensitivity 67.2% vs 55.2%; p ¼ 0.0001). Sensitivity for diagnosis of malignant lesions increased to 72.4% (P < 0.0001) when both methods were combined. Of the 13 nonmalignant cases, TBFB gave a definite diagnosis in 10/13 vs 8/13 for TBNA (sensitivity 60% vs 30%; p ¼ > 0.05). Using both methods, sensitivity increased to 70% (p ¼ 0.0699). There were no significant complications. The average follow up period was from 3 months to 2 years; patients followed up for less than 6 months showed improvement or resolution of symptoms and or image findings on follow up. CONCLUSIONS: While TBNA alone appeared to have a better performance than TBFB alone in the diagnosis of malignant pulmonary lesions during ENB, the combination of both methods significantly increased diagnostic yield for both malignant and non-malignant lesions. Thus, more widespread use of both instruments during ENB, and even during simple endobronchial bronchoscopies, could increase the sensitivities of both procedures. CLINICAL IMPLICATIONS: To the best our knowledge, this is the first study comparing diagnostic yield of concurrently performed transbronchial needle aspiration (TBNA) and transbronchial forceps biopsy (TBFB) at electromagnetic navigation guided bronchoscopy.
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