CASE PRESENTATION
A 44-year-old ex-smoker with no known co-morbidities arrived at our emergency room with a one-week complaint of left-sided chest discomfort and left shoulder pain. The pain was gradual in onset and continuous in nature, radiating to the shoulder. The pain increased while deep breathing and on movements. The pain was not relieved by any medications. The patient complained of fever at night and dry cough, and some loss of appetite but no history of shortness of breath, productive cough, no night sweats, no history of significant weight loss. He denied known TB contact and any history of TB. No other history of any traumatic event (Table 1). The patient was afebrile on examination, with a heart rate (HR) of 90 beats per minute and blood pressure (BP) of 130/73 mmHg, respiratory rate (RR) of 19 breaths per minute, and an oxygen saturation (O2 sat) of 100 percent on room air. No clubbing or supraclavicular lymphadenopathy On examination of the respiratory system, there was no visible deformity, no tenderness on palpation, the percussion note was dull on the lower left side of the chest, and the percussion note was dull on the on auscultation decreased air entry on the left side with left basal crackles.
Examination of the left shoulder joint showed no tenderness and a normal range of movements. The remaining systemic examination, including cardiovascular, neurological, and gastrointestinal exam, was unremarkable. A chest x-ray (CXR) (Figure 1) was performed, which showed a mild/moderate amount of left-sided PE with underlying atelectasis. The diagnosis of left-sided PE was made, and the patient was started on antibiotics empirically as a case of parapneumonic effusion. Diagnostic PF aspiration was done under septic conditions, and workup was sent for PF analysis to determine the cause of the effusion without typical respiratory symptoms. The patient was kept on isolation is suspicion of TB. Within the next 24 hours; the patient developed worsening chest pain on the left side, shortness of breath, and desaturation. A repeated CXR (Figure 2) was performed and compared with the previous CXR; there is a considerable interval increasing amount of PE with collapse/consolidation left lung. In the account of thoracocentesis done the previous day, traumatic hemothorax was suspected but was ruled out as there was no drop in hemoglobin. The diagnosis of massive PE on the left side that had rapidly progressed over 24 hours, with worsening chest symptoms, was made. An urgent chest drain was inserted under ultrasound guidance, and drainage was done. Following this, a CT chest was done (Figure 3), and it showed improvement in the PE and no evidence of empyema or abscess formation. The patient started feeling better with the chest drain in place, and he drained. He improved clinically, and the inflammatory markers improved from admission. The PF analysis showed an exudative picture with a neutrophilic predominance (Table 2). PF cultures were negative. Work up for TB and malignancy were negative.
On Day 9, after the chest tube was inserted, the drainage of fluid was nil. A repeat CXR was done, and it showed resolution of PE, the chest tube was removed, and the patient was discharged on antibiotics for a total of 21 days, and an outpatient follow-up appointment with the pulmonologist was given.