An Unexpected Culprit: Sympathetic Pleural Effusion as a Rare Manifestation of Pyogenic Spondylodiscitis

Document Type

Conference Proceeding

Publication Date

5-2025

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

We report a case of a 59-year-old male with end-stage renal disease (ESRD) on hemodialysis following a failed bilateral kidney and pancreas transplant (5 years ago), who presented with neck pain, nausea and shortness of breath after a dialysis catheter replacement 4 days ago. Initial labs demonstrated leukocytosis(13.7k), lactic acidosis (2.4mmol/ml) and elevated Procalcitonin(16.15ng/ml). Imaging revealed a Right Internal jugular thrombus and large right lower lobar pulmonary embolism(PE) with signs of right ventricular (RV) strain (RV/LV ratio of 1) and Line cultures were positive for MRSA bacteremia, likely secondary to a dialysis port infection. Patient's dialysis catheter was removed and he was initially treated with cefepime and vancomycin, narrowed to vancomycin once blood cultures confirmed MRSA. The patient was anticoagulated with intravenous heparin for the PE, and a new Quinton catheter was placed. Despite appropriate antibiotic therapy, the patient remained persistently MRSA positive, leading to escalation of antibiotics to ceftaroline and daptomycin, and subsequent salvage therapy with linezolid added for 14 days due to prolonged bacteremia. Unfortunately patient developed worsening dyspnea and a new oxygen requirement of 2-3 L/min. Chest imaging identified a large left pleural effusion, and thoracentesis yielded 2150 mL of serosanguineous exudative fluid, meeting Light’s criteria (3/3) for an exudative effusion. Pleural fluid cultures and cytology were negative. Transesophageal echocardiogram (TEE) showed no vegetations, raising suspicion for alternative occult infectious source. Given complaint of back pain and to inquire for a spinal infectious source, MRI of the cervical and thoracic spine was performed, which revealed discitis and osteomyelitis at C5-C6 and T11-T12, with possible involvement at T5-T6. Neurosurgical consultation determined that no surgical intervention was needed, and the patient was subsequently discharged with an eight-week course of vancomycin, beginning from the first negative blood culture. This case highlights that pleural effusions can be associated with non-pulmonary local infectious etiologies. Exudative pleural effusions are commonly linked to Pneumonias, Tuberculosis or a malignancy however, the cause remains unknown in up to 20% of cases, even with comprehensive diagnostic efforts. Pleural effusion secondary to spinal discitis is generally a reactive process resulting from inflammatory mediators and increased vascular permeability near the spine. These sympathetic pleural effusions are usually sterile but may mimic infectious or malignant effusions due to their exudative nature. As initial investigations for pleural effusions often focuses on pulmonary pathology, diagnosis of non-pulmonary causes like spondylodiscitis may be delayed leading to potential adverse outcomes like poor neurological recovery.

Volume

211

First Page

A6247

Comments

American Thoracic Society (ATS) International Conference, May 16-21, 2025, San Francisco, CA

Last Page

A6247

DOI

10.1164/ajrccm.2025.211.Abstracts.A6247

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