Photo Quiz - October 2018

A 50 year old male presented with fever, non productive cough of 2 weeks duration along with 6 kg weight loss in the last 1 month. CXR was s/o right sided moderate pleural effusion and diagnostic aspiration (20ml) showed amber coloured fluid (WBC 220, N20/L80, protein-3gm/dl, sugar -30gm/dl), which was negative for AFB and gram stain, along with negative Xpert M TB. HIV ELISA was positive. He was started on empiric ATT along with deflazacort and referred in view of persistent symptoms despite 3 weeks of ATT.

Examination revealed oral candidiasis. CXR showed a right sided moderate pleural effusion (fig.1) CD4 count was 40 (6%), HIV-1 VL was 20,00,000 and serum cryptococcal antigen was negative, Hb- 10, Wbc 3600, plt 140,000. USG thorax showed loculated pleural fluid with multiple septae ( fig2 ). Sspiration showed amber colored fluid (wbc 150 - N8/L92, sugar 18.4mg/dl, protein -2.3gm/dl). Gram, AFB and fungal stain of the fluid was negative and cytology showed no malignant cells.

Figure 1: CXR (PA) s/o right sided Pleural effusion Figure 2. USG right thorax s/o multiloculated effusion (red arrowsepta, yellow arrow-collapsed lung)

What is your diagnosis? View Answer

Answer

Pleural fluid gram stain showed Gpc in pairs. It was inoculated directly into a blood culture bottle which flagged positive on day 2 and culture grew Strep pneumoniae (Figure 3). AFB culture showed no growth at 2 weeks.

Figure 3 Small grey moist colonies with alpha hemolysis on blood agar (courtesy Dr Rupali Suryawanshi and Dr Nita Munshi ) Figure 4 Antibiotic susceptibility testing

His ATT was discontinued and ceftriaxone 2 g iv OD added along with TDF/FTC/EFV. He required right thoracotomy and drainage in view of multiple septations and multiloculated empyema but in view of cost constraints, this was not done. At 2 weeks follow up patient was clinically better with good weight gain, no fever.

The prevalence of invasive pneumococcal disease is very high in patients with HIV, and pneumococcal infection should be considered and covered for in the appropriate clinical scenario. HIV patients should be routinely offered influenza and pneumococcal vaccination.

Final diagnosis: Pneumococcal empyema in a newly diagnosed PLHIV

Case provided by: Dr Kalpesh Sukhwani