Spontaneous Bacterial Pleuritis in a Patient with Cirrhosis

Abstract

Empyema of the left pleural cavity developed suddenly in a nonalcoholic cirrhotic patient. Cultures of the pleural fluid under anaerobic conditions grew Clostridium perfringens, an organism normally found in the enteric flora. The infection developed in an old pleural effusion. Since there was no evidence of trauma, necrotizing pneumonitis or subphrenic infection, spontaneous bacterial pleuritis is proposed. Bacterial infections are frequent among cirrhotic patients. The ascitic fluid may be contaminated by blood-borne enteric bacteria [1]. The resulting ‘spontaneous bacterial peritonitis’ is characterized by an abrupt onset of fever, chills, abdominal pain and an increase in the amount of ascitic fluid [1]. The pleural cavity counterpart to ‘spontaneous bacterial peritonitis’ has not been described. We report the case of a cirrhotic patient who suddenly developed a clostridial empyema in the left pleural cavity despite the absence of trauma, necrotizing pneumonitis or subphrenic infection

Hepatic hydrothorax

“…Spontaneous infection within the pleural fluid is known as spontaneous bacterial empyema (SBEM), 30 although this term may be confusing because in most cases there is no evidence of pus or abscess in the thoracic cavity and some authors have proposed it be called spontaneous bacterial pleuritis. 31 However, this name has not gained acceptance and most published studies referring to infections of the pleural fluid in cirrhotics use the term SBEM. Regardless of the name used, infection of the pleural fluid must be considered in any patient with hydrothorax who develops fever, pleuritic pain, encephalopathy or unexplained deterioration in renal function.…”

Clostridium perfringens empyema in a patient with metastatic squamous cell carcinoma of the lung

“…[ 3 ] For example, cirrhotic patients can develop hepatic hydrothorax in which the pleural fluid begins as transudative but evolves into infectious exudative effusions. [ 6 7 ] Even without the evidence of trauma, such hydrothoraces have been observed to become infected, possibly from transient bacteremia. [ 7 ] In other cases, colonic instrumentation or colon cancer itself has been noted to pose risk to patients developing clostridial pleural effusions given that CP is an enteric commensal organism.…”

Spontaneous bacterial pleuritis

“…However, spontaneous bacterial infections of the pleural fluid in hepatic hydrothorax appear rare, with less than 30 case reports in the literature. Infected hepatic hydrothorax is referred to in the literature as spontaneous bacterial pleuritis [19], spontaneous bacterial empyema [20][21][22], and spontaneous neutrocytic hydrothorax [23]. Spontaneous bacterial pleuritis should be suspected in a patient with fevers and dyspnea with a known or suspected hepatic hydrothorax.…”

“…However, the infection appears to be due to either infected ascitic fluid migrating into the pleural space, or transient bacteremia with seeding of the pleural fluid. The bacteria that infect the effusions in spontaneous bacterial pleuritis are usually coliform bacteria, and in the case reports have included Escherichia coli, Clostridium perfringens, Klebsiella pneumoniae, and Morganella morganii [19][20][21][22]24]. There are no randomized controlled trials, but it seems reasonable to treat spontaneous bacterial pleuritis with the same antibiotic regimen as recommended for spontaneous bacterial peritonitis.…”