CHEST Guidelines-A-37-Year-Old-Man-With-Pleuritic-Chest Pain

A-37-Year-Old-Man-With-Pleuritic-Chest Pain_c

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A 37-year-old man with uncontrolled type 2 diabetes presented with severe right-sided pleuritic chest pain and a productive cough. He initially sought treatment for bronchitis at an urgent care, receiving azithromycin but returned to the emergency department (ED) three days later due to worsened symptoms. Physical examination revealed moderate distress, shallow breathing, and diminished breath sounds on the right side of his chest. Tests showed a large right-sided pleural effusion and compressive atelectasis. Despite antibiotics, the effusion persisted, warranting tube thoracostomy drainage.<br /><br />Empirical treatment with vancomycin and piperacillin-tazobactam was initiated, but cultures later identified Coccidioides, leading to antifungal fluconazole therapy. Despite medical management, his pleural effusion grew, and his condition persisted, pointing towards Coccidioides empyema. Surgical intervention with video-assisted thoracoscopic surgery (VATS) for pleural space washout and adhesions lysis was necessary. Though surgery was successful in stabilizing symptoms, full decortication was deferred due to potential complications.<br /><br />Coccidioides, a fungal pathogen in endemic areas, can cause pneumonia and empyema. Routine antibiotics are often ineffective, and specific antifungal treatment and surgical intervention may be required. Patients with diabetes and certain ethnicities may be more vulnerable to severe or disseminated forms of the disease. While surgery is effective in managing empyema, initial decortication may increase complication risks, advising a conservative approach initially. Over months, the patient’s condition significantly improved under antifungal therapy, and future surgery remains an option if necessary for symptom management. The case highlights the complexity of managing Coccidioides empyema and underscores the importance of considering endemic fungal infections in differential diagnosis when classic bacterial pathogens are absent.

Keywords

Coccidioides empyema

pleural effusion

antifungal therapy

type 2 diabetes

VATS surgery

fluconazole treatment

endemic fungal infections

pleuritic chest pain

tube thoracostomy

empyema management