B73-43 Empyema in Older Adult: Diagnostic Delay and Rapid Resolution With Combined Tissue Plasminogen Activator and Dornase Alfa Therapy
Abstract
Pleural empyema, defined as purulent exudate within the pleural space, carries significant morbidity and mortality, with 30-day mortality up to 10.5%. Presentation varies significantly from pneumonia-like symptoms to progressive dyspnea, purulent cough, and weight loss, often leading to delayed diagnosis in older adults. Early recognition and prompt medical-surgical management are essential for optimizing outcomes.
A 63-year-old male with hypertension, asthma, and gout presented with six weeks of progressive dyspnea, anorexia, and night sweats, and two days of right-sided pleuritic chest pain. His prior evaluations were unrevealing. At an outside emergency department, leukocytosis and chest radiograph showing near-complete right hemithorax opacification with apical lucency prompted transfer due to concern for parapneumonic effusion, pneumonia, or malignancy. On arrival, he was afebrile but tachycardic and tachypneic. Empiric ceftriaxone and metronidazole were initiated for suspected complicated parapneumonic effusion. Chest tube placement drained 2.4 liters of purulent fluid in 24 hours; pleural glucose was 2000 IU/L, confirming empyema. He received intrapleural tissue plasminogen activator (tPA) and dornase alfa (DNase) twice daily for 3 days per MIST-2 protocol, yielding an additional 1.3 liters of drainage. Cultures grew Streptococcus intermedius. Follow-up imaging showed near-complete resolution, the chest tube was removed, and the patient was discharged on a four-week…
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