SHM Converge Scientific Abstract ePoster Gallery-Not Water Over the Diaphragm: A Potential Overlooked Diagnosis in a Patient With Cirrhosis

Pdf Summary

This case highlights spontaneous bacterial empyema (SBEM), a serious complication of hepatic hydrothorax in patients with cirrhosis. Although SBEM is estimated to occur in about 2% of cirrhotic patients overall, its incidence rises to as high as 16% among those with hepatic hydrothorax, and reported mortality can reach 38%. Diagnosis is based on pleural fluid neutrophil counts: either 250 cells/mL with a positive culture or 500 cells/mL with a negative culture. Symptoms may be vague or minimal, making the condition easy to miss.<br /><br />The patient was a 43-year-old woman with cryptogenic cirrhosis complicated by recurrent ascites, prior spontaneous bacterial peritonitis, recurrent bilateral hepatic hydrothorax, hepatic encephalopathy, and esophageal variceal bleeding. She presented with three days of shortness of breath and was found to have a large left pleural effusion. Thoracentesis removed 1.5 liters of opaque yellow fluid. Pleural fluid analysis showed 2,950 nucleated cells with 81% neutrophils, meeting criteria for SBEM despite a negative Gram stain and ultimately negative culture.<br /><br />She was treated with intravenous ceftriaxone for five days and received albumin, which is commonly used though not well studied for SBEM. Her condition improved, and she was discharged in good condition. The report emphasizes that pleural effusions in cirrhotic patients should not automatically be assumed to be uncomplicated hepatic hydrothorax. It also notes that chest tubes should generally be avoided unless there is frank pus, due to the risk of volume depletion and renal failure. The authors suggest that hospitalized cirrhotic patients with pleural effusions may benefit from routine diagnostic thoracentesis, similar to the standard practice of paracentesis for ascites to rule out SBP.

Asset Subtitle

William Kwan Jr.

Meta Tag

Author List William Kwan Jr.

Category Clinical Vignettes

Concept Spontaneous Bacterial Empyema

Concept Antibiotic Therapy

Concept Hepatic Hydrothorax

Concept Cirrhosis

Concept Neutrophil Count

Distinguished Non-Finalist

Presenter Organization University of North Carolina at Chapel Hill

Presenting Author William Kwan Jr.

Track Adult

Keywords

spontaneous bacterial empyema

hepatic hydrothorax

cirrhosis

pleural effusion

thoracentesis

neutrophil count

ceftriaxone

albumin therapy

spontaneous bacterial peritonitis

diagnostic thoracentesis

Spontaneous Bacterial Empyema

Antibiotic Therapy

Hepatic Hydrothorax

Cirrhosis

Neutrophil Count