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LETTER TO EDITOR  
Year : 2017  |  Volume : 9  |  Issue : 4  |  Page : 162-163
Enterococcal empyema and trapped lung in systemic lupus erythematosus


1 Department of Internal Medicine, College of Medicine, University of Florida, Jacksonville, Florida, USA
2 Department of Medicine, Eric Williams Medical Sciences Complex, San Fernando, Trinidad and Tobago
3 Department of Medicine, San Fernando General Hospital, San Fernando, Trinidad and Tobago

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Date of Web Publication12-Dec-2017
 

How to cite this article:
Maharaj S, Chang S, Seegobin K, Abrahim C. Enterococcal empyema and trapped lung in systemic lupus erythematosus. J Global Infect Dis 2017;9:162-3

How to cite this URL:
Maharaj S, Chang S, Seegobin K, Abrahim C. Enterococcal empyema and trapped lung in systemic lupus erythematosus. J Global Infect Dis [serial online] 2017 [cited 2019 Sep 15];9:162-3. Available from: http://www.jgid.org/text.asp?2017/9/4/162/220410




Sir,

Enterococci are facultative anaerobic Gram-positive cocci that very rarely cause lung infections.[1] Even rarer, enterococcal infection can cause empyema.[2] In patients with systemic lupus erythematosus (SLE), empyema due to  Salmonella More Details enteritidis, Mycobacterium tuberculosis, and Nocardia asteroides has been reported,[3] but Enterococcus has never been implicated.

A 23-year-old female with SLE presented with dyspnea, chest pain, and 2 weeks of fever and productive cough. There were absent breath sounds and dullness to percussion on the right hemithorax; investigations showed anemia, neutrophilia, and thrombocytopenia. Chest radiography confirmed a moderate pleural effusion and a concomitant right-sided pneumothorax. Tube thoracostomy resulted in purulent, malodorous drainage and fluid analysis confirmed empyema. On culture, there was heavy monomicrobial growth of Enterococcus. Despite drainage, the pneumothorax persisted over the next week [Figure 1]a. Computed tomography scanning confirmed persistent collapsed right lung and thickened visceral pleura [Figure 1]b, leading to the diagnosis of trapped lung. The patient was treated with antibiotics and pulmonary decortication, with improved symptoms.
Figure 1: (a) Chest radiograph and (b) computed tomography scan revealing persistent right-sided pneumothorax with visceral pleural thickening

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Enterococcus does not commonly cause pulmonary infection. However, when infection due to Enterococcus does occur, it tends to be complicated.[4] Recently, a case of culture-negative empyema in SLE was described,[5] the first in the literature. However, it was noted that the patient received a dose of levofloxacin before thoracentesis. The second case with a similar diagnosis of sterile empyema in SLE has since been reported, but this patient also received levofloxacin before culture.[3] Grupper et al. have questioned whether enterococcal-associated respiratory infections are underdiagnosed due to the increased use of amoxicillin or fluoroquinolones.

Pneumothorax ex-vacuo or trapped lung has been described with complicated parapneumonic effusion. It is thought that chronic inflammation leads to the formation of a fibrous layer on the visceral pleura that prevents re-expansion. Although rare, empyema due to Enterococcus is a potentially life-threatening event in patients with SLE. Physicians must keep in mind this differential, and early thoracentesis with culture before antibiotic therapy is important. Finally, persistent pneumothorax after drainage in these patients must prompt the evaluation for visceral pleural thickening and pneumothorax ex-vacuo.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Moellering RC Jr. Emergence of Enterococcus as a significant pathogen. Clin Infect Dis 1992;14:1173-6.  Back to cited text no. 1
[PUBMED]    
2.
Behnia M, Clay AS, Hart CM. Enterococcus faecalis causing empyema in a patient with liver disease. South Med J 2002;95:1201-3.  Back to cited text no. 2
[PUBMED]    
3.
Chang WT, Hsieh TH, Liu MF. Systemic lupus erythematosus with initial presentation of empyematous pleural effusion in an elderly male patient: A diagnostic challenge. J Microbiol Immunol Infect 2013;46:139-42.  Back to cited text no. 3
[PUBMED]    
4.
Grupper M, Kravtsov A, Potasman I. Enterococcal-associated lower respiratory tract infections: A case report and literature review. Infection 2009;37:60-4.  Back to cited text no. 4
[PUBMED]    
5.
Kriegel MA, Van Beek C, Mostaghimi A, Kyttaris VC. Sterile empyematous pleural effusion in a patient with systemic lupus erythematosus: A diagnostic challenge. Lupus 2009;18:581-5.  Back to cited text no. 5
[PUBMED]    

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Correspondence Address:
Satish Maharaj
Department of Internal Medicine, College of Medicine, University of Florida, 653 W 8th Street, LRC 4th Floor Box L-18, Jacksonville, Florida 32209
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgid.jgid_34_17

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2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008