SHM Converge Scientific Abstract ePoster Gallery-Are You Serous? A Fluid Diagnosis in a Cirrhotic Patient Without Ascites

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This case describes a 41-year-old man with cirrhosis from primary sclerosing cholangitis and recurrent right hepatic hydrothorax (HH), requiring frequent thoracenteses, who presented with worsening dyspnea but no clear infectious symptoms. He was afebrile and only mildly tachycardic, with jaundice and decreased right-sided breath sounds. Bedside ultrasound showed a large, simple right pleural effusion without ascites.<br /><br />Thoracentesis removed 2.5 L of serous fluid. The pleural fluid was transudative by protein and LDH ratios, consistent with HH, but the neutrophil count was elevated (819 nucleated cells with 87% neutrophils), raising concern for spontaneous bacterial empyema (SBE). Empiric ceftriaxone was started because of leukocytosis. Pleural fluid culture was negative, but repeat thoracentesis after a 7-day antibiotic course showed improvement to 250 nucleated cells. His HH continued to recur, so an indwelling pleural catheter was placed as a bridge to liver transplantation.<br /><br />The discussion highlights that HH can occur even without ascites because of impaired lymphatic drainage and a pleural-peritoneal pressure gradient. SBE is an infection of hepatic hydrothorax and is diagnosed by either a pleural fluid absolute neutrophil count of at least 250/mm³ or a positive pleural fluid culture. Importantly, about one-third of SBE cases lack infectious symptoms, and less than 10% present without ascites.<br /><br />Key teaching points: maintain a high index of suspicion for SBE in cirrhotic patients with HH, even when they appear clinically well; and unlike true empyema, SBE does not require chest tube drainage.

Asset Subtitle

Abigail Schulz

Meta Tag

Author List Abigail Schulz, John R. Stephens, Teresa Coogan

Category Clinical Vignettes

Concept Spontaneous Bacterial Empyema

Concept Hepatic Hydrothorax

Concept Cirrhosis

Concept Pleural Fluid Analysis

Concept Pleural Fluid WBC Count

Distinguished Non-Finalist

Presenter Organization University of North Carolina

Presenting Author Abigail Schulz

Track Adult

Keywords

hepatic hydrothorax

primary sclerosing cholangitis

cirrhosis

spontaneous bacterial empyema

pleural effusion

thoracentesis

transudative fluid

neutrophilic pleural fluid

ceftriaxone

indwelling pleural catheter

Spontaneous Bacterial Empyema

Hepatic Hydrothorax

Cirrhosis

Pleural Fluid Analysis

Pleural Fluid WBC Count