A 48-year-old man presented with fevers, chills, weight loss, multiple liver masses, and several superficial and deep venous thromboses in lower extremities. Cancer work up was negative. A liver biopsy grew Fusobacterium nucleatum. To our knowledge, F. nucleatum infection presenting with multiple liver masses and Trousseau-like syndrome has not been reported earlier.
A 45-year-old man with a history of incarceration complained of right sided chest pain, nonproductive cough, and an area of painful swelling on his right back. Magnetic resonance imaging (MRI) of the chest showed empyema necessitatis ( Figs. 1 and 2). A purified protein derivative (PPD) test was positive at 13 mm of induration. Three acid-fast bacilli sputum smears were negative and he underwent drainage through chest tube placement. Blood cultures and drained fluid cultures were both negative. He was started on four-drug therapy for suspected tuberculous empyema necessitatis. After discharge, sputum cultures grew out Mycobacterium avium complex and Mycobacterium gordonae. He was continued on isoniazid, pyrazinamide, rifampin and ethambutol, but did not receive a full course of treatment due to poor compliance.Empyema necessitatis is a rare complication of empyema that occurs when pleural infection extends into the chest wall. 1 The most commonly reported pathogen is Mycobacterium tuberculosis, followed by Actinomyces species. Other organisms that have been implicated as causes of empyema necessitatis include Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus milleri, Burkholderia cepacia and Mycobacterium avium-intracellulare. 2 Often no causative organism is identified. The treatment of empyema necessitatis is surgical drainage in combination with antimicrobials, including consideration of antituberculous medications when appropriate. 2
Inspired by the ABIM Foundation's Choosing Wisely ® campaign, the "Things We Do for No Reason ™ " (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.
CLINICAL SCENARIOThe hospitalist admits a 52-year-old man with alcoholic cirrhosis for tense ascites and altered mentation. Home medications include furosemide, spironolactone, lactulose, and rifaximin, but his family notes he ran out last week. Although afebrile and hemodynamically stable, the patient's coagulopathy, with an international normalized ratio (INR) of 2.3, and thrombocytopenia, with a platelet count of 37,000/μL, worries the hospitalist. The hospitalist wonders whether to transfuse fresh frozen plasma (FFP) and platelets prior to diagnostic paracentesis to reduce the risk of procedural bleeding.
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