key: cord-0875187-y6zi175e
authors: Silalahi, Todung D.A.; Suwita, Christopher S.
title: Culture-negative pleural empyema after Coronavirus disease-19 resolution – A case report
date: 2021-07-09
journal: Respir Med Case Rep
DOI: 10.1016/j.rmcr.2021.101473
sha: 75a7244d5d4ce926b8bd79c865c76000a313ca82
doc_id: 875187
cord_uid: y6zi175e

Even after more than a year, novel Coronavirus disease-19 (COVID-19) clinical presentation and complications are still being reported. We present a 75-year-old patient with culture-negative pleural empyema a month after COVID-19 resolution without re-infection. We hypothesize that culture-negative empyema can be present in patients with immune defect, e.g., elderly or diabetic patients, and prior antibiotic exposure. Empyema after COVID-19 resolution may be related to delayed inflammation improvement in chronic disease, which resulted in the patient's more vulnerability to secondary infection.

More than a year after first case in Wuhan, China, the number of Coronavirus disease-19 (COVID-19) patients is still very high; more than two million died and there is still no cure.

Vaccines may help lower new-severe cases but only few treatments can be given for patients already contracted with the disease. Patients with heart disease, diabetes, and hypertension have worse prognosis in COVID-19 compared to their age-gender counterparts without the same predicaments. 1 The risk increases exponentially with the presence of COVID-related complications. 2 Complications after COVID-19 resolutions are common but usually persist from the onset of the infection. We report a unique case in which an elderly patient with metabolic and cardiac comorbidities suffered from new onset empyema after a time we considered COVID-19 had been resolved.

A 75-year-old male, heavy smoker with a history of COVID-19 infection, coronary artery disease (CAD), heart failure with mid-range ejection fraction, diabetes, hypertension, and deep vein thrombosis was admitted to our emergency room for worsening dyspnea. He had no fever, chest pain, nor cough.

Diagnosed with COVID-19 infection two months ago, he had been hospitalized for 1.5 months because of severity of the disease. For his infection, we treated him with hydroxychloroquine, lopinavir/ritonavir, un-fractioned heparin, and quinolones. During that time, he slowly improved until the reverse transcription-polymerase chain reaction (RT-PCR)

for COVID-19 was tested negative twice. There was no residual dyspnea or other symptoms at discharge; his chest x-ray at discharge showed no pleural effusion ( 

After the procedure, we observed a progressive clinical and radiological improvement (Figure 4a, 4b, 4c ) that allowed discharge. Chest tube was removed on 10th day and he was discharged after the latest x-ray showed significant progress ( Figure 5 ). The patient visited outpatient clinic in good conditions without any further complication.

Empyema is purulent pleural fluid caused by infection. It usually arises from parapneumonic effusion from bacterial infection --causing pleural inflammationthat evolves into a full-blown pleural infection. 3 In COVID-19 setting, the incidence of COVID-related pleural effusion is highly varied across numerous observational studies. Those aged 60 years old or above and with severe diseases are the main risk factors. 4 Unilateral exudative effusion with high LDH and fluid-serum LDH ratio is predominant in such patients. [3] [4] [5] [6] Also a common finding in COVID-19, culture-negative empyema is usually associated with autoimmune patients, immunocompromised host, and or prior antibiotic exposure. 4, 7, 8 Our patient, an elderly man with many comorbidities, was clearly one of such patients. He had also been hospitalized earlier for quinolones; hence non-growth pleural fluid culture was highly probable. In this case, if readily available, bacterial PCR would have been useful to confirm bacterial presence. 5 To this date, within our knowledge there has been no report about delayed empyema after COVID-19 resolution. Therefore, we are proposing our take in the pathophysiology process. In CAD and or diabetic patients, the worsening chronic low-grade inflammation, due 

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