Empyema Mimicking Hollow Viscus Perforation: A Case Report

Abstract

Air-fluid levels seen on decubitus plain abdominal films are most often diagnosed as pneumoperitoneum. In this paper, we present a case of massive right-sided pyopneumothorax mimicking pneumoperitoneum. An 85-year-old female presented to the emergency department (ED) with a 1-day history of decreased urine output. She appeared in distress, with tachypnea and a systolic blood pressure of 60 ~ 70 mmHg. The patient's Glasgow Coma Scale (GCS) was E4VtM4, i.e., confused. Physical examination revealed decreased breathing sounds on the right side and pain and guarding with palpation of the abdomen. Plain abdominal films suggested an air-fluid level. Abdominal computed tomography (CT) identified an empyema on the right-hand side with an associated air fluid level. A chest tube drained cloudy, malodorous fl uid, and the pleural fluid contained Gram-negative bacilli (Escherichia coli and Klebsiella pneumoniae). Video-assisted thoracic surgery (VATS) was performed to address the persistent pleural effusion. Unfortunately, progressive hypotension developed along with generalized tonic-clonic seizures on day 18. After consultation with the family, palliative care only was administered, and the patient died 22 days after admission. Loculated or free air over the right lower lung observed on a chest X-ray should raise suspicion of a ruptured liver abscess, hollow viscus perforation and pyopneumothorax. Abdominal CT is the most reasonable next step to assist clinicians to make a decision regarding whether to provide surgical or conservative intervention.