Complicated Parapneumonic Effusion Post-Bronchoscopic Lung Volume Reduction Surgery Caused by Streptococcus Intermedius

Abstract

INTRODUCTION: Immediate complications after bronchoscopic lung volume reduction surgery (BLVRS) include pneumothorax, chest pressure and COPD exacerbation. Complicated parapneumonic effusion following BLVRS is an unusual delayed complication. Only a handful number of cases has been reported in literature. We present successful management of Streptococcus intermedius parapneumonic effusion in a patient post-BLVRS without removing endobronchial valves. CASE PRESENTATION: 58-year-old male with PMH of alpha-1 antitrypsin deficiency (AATD), emphysema and 30 pack year smoking history presented with fever, shortness of breath and left sided pleuritic chest pain, 3 weeks after successful BLVRS with Zephyr endobronchial valves in the left lower lobe. On presentation, he was tachycardic to 121 beats per minute, tachypneic to 26 breaths per minute and saturating at 94% with 6L O2 NC. Labs showed a leukocytosis of 30.8 thousand/uL, lactic acidosis of 2.7. Respiratory multiplex and Covid-19 were negative. Chest radiograph revealed small left pleural effusion and left basilar consolidation. Computed tomography scan of chest showed complete left lower lobe collapse due to BLVRS with well positioned endobronchial valves and moderate left pleural effusion. Ultrasound revealed evidence of septations consistent with complicated parapneumonic effusion. He underwent a pigtail chest tube placement. Fluid studies showed glucose level less than 5, LDH level of 1550. Patient was started on Unasyn and Azithromycin. Patient received tissue plasminogen activator and deoxyribonuclease therapy (TPA-DNase) per MIST II protocol. On Day 4, pleural fluid culture showed Streptococcus intermedius. He was monitored with serial Chest X-rays and bedside ultrasound which showed significant improvement. He underwent chest tube removal on 8th day of hospitalization. He was discharged with a total of 4-week course of Ceftriaxone and Flagyl. Dentist evaluation was emphasized. Patient is doing well on the follow up visit within a week after hospital discharge. DISCUSSION: Incidence of S. milleri causing thoracic infections ranges between 10-32%. Dental caries posing as a risk factor for S. intermedius infection, as in our patient, needs to be evaluated further. Our patient developed complicated parapneumonic effusion after left lower lobe BLVRS, that was successfully managed with chest tube placement, TPA-DNase per MIST II protocol and antibiotic therapy. In progressively worsening cases, uncertainty revolves around the possible need for removal of Zephyr valve and their candidacy for VATS decortication. Majority of guidelines are regarding upper lobe predominant BLVRS and immediate complications. Management of lower lobe BLVRS and delayed complications needs documentation to minimize occurrence and improve management.