Sterile empyematous pleural effusion in a patient with systemic lupus erythematosus: a diagnostic challenge

Abstract

Herein we present a case of a patient with systemic lupus erythematosus (SLE) and a sterile empyematous pleural effusion, a complication not generally associated with SLE. A discussion of the diagnostic and treatment dilemmas follows the case presentation. Keywords empyema; nephritis; systemic lupus erythematosus Case presentationA 26-year-old woman from Cape Verde presented to the Beth Israel Deaconess Medical Centre with severe shortness of breath and chest pain. Several months prior to her presentation, the patient developed fever, progressive dyspnea on exertion, arthralgias, fatigue, weight loss (6 kg over 7 months) and a periorbital rash. One month prior to her presentation, she was found to have large bilateral pleural effusions and acute renal failure. Laboratory evaluation disclosed that she had positive anti-dsDNA antibodies and low complement levels; she was started on 60 mg oral prednisone daily. One week prior to admission to our hospital, she underwent leftsided thoracentesis in a hospital at Cape Verde. The laboratory tests from the pleural fluid demonstrated a glucose level less than 10 mg/dL, lactate dehydrogenase (LDH) of 2054 IU/L and a pH of 5.0 (Table 1). Bacterial cultures were negative. No antibiotics were administered.Following this treatment the patient came to the United States for further care. Three days prior to presentation she stopped taking prednisone. Upon presentation to the BIDMC emergency department the patient complained of chest and left flank pain. On physical examination, she was tachycardic, tachypneic and had a temperature of 100.6 °F. She had mild periorbital erythema, dullness to percussion over both lung bases with decreased breath sounds bilaterally and tenderness to palpation over the right flank. She received one tablet of levofloxacin 750 mg for empiric treatment of pneumonia and was admitted to the hospital. Initial laboratory evaluations are shown in Tables 2 and 3. Chest X-ray and computed tomography revealed left greater than right pleural effusions with loculated air (Figure 1 On hospital day one, she underwent thoracentesis of her left-sided effusion and chest tube placement. Pleural fluid laboratory tests and cultures are shown in Table 1. The patient was empirically started on a 14-day course of intravenous Vancomycin 1000 mg every 12 h and piperacillin-tazobactam 4.5 g every 8 h after the procedure. She was also started on prednisone 60 mg, hydroxychloroquine 200 mg and lisinopril 5 mg daily. On hospital day two, she underwent thoracentesis of the right pleural effusion, which was consistent with lupus pleuritis (Table 1). On hospital day five, a renal biopsy was performed. Multiple blood cultures remained negative despite continued fevers on broad-spectrum antibiotics. On hospital day six, she underwent a video-assisted thoracoscopy with total pulmonary decortication. Differential diagnosisPleuritis is the most common manifestation of serositis in patients with systemic lupus erythematosus (SLE). 1,2 Pleural effusions in patients with SLE can als...

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