(Disclaimer: This article is for general science purposes only, and the relevant information in the following content has been processed to protect patient privacy)
Abstract: The patient came to our hospital due to fever, cough, sputum, and chest pain for 3 days, and was treated with antipyretic, sputum, and anti-infective therapy for 3 days at a local hospital without improvement. After examination, he was initially diagnosed with community-acquired pneumonia, combined with parapneumonic pleural effusion, which is a relatively serious lung infection. After hospitalization for drug treatment and pleural fluid drainage by thoracentesis, the patient’s body temperature returned to normal, his cough and sputum improved, and the lung inflammation was absorbed, and he resumed normal work and life.
Basic information】Male, 32 years old
Disease Type】Community-acquired pneumonia, combined with parapneumonic pleural effusion
【Treatment hospital】Tianjin Haihe Hospital
Consultation time】May 2016
Treatment plan】Medication (moxifloxacin hydrochloride injection, ambroxol hydrochloride tablets) + thoracentesis for drainage of pleural fluid
Treatment period】18 days of hospitalization and 2 months of follow-up
Treatment effect】The body temperature returned to normal, the cough and sputum improved, the inflammation in the lung was absorbed, and the patient resumed normal work and life.
I. Initial consultation
The patient came to the clinic for 3 days due to fever, cough, sputum and chest pain. He reported that he had fever after getting cold 3 days ago, with a temperature of 38.8℃, chills, no chills, cough and yellow sputum, and left-sided chest pain, which was obvious when he coughed. He was treated with antipyretic, anti-sputum and anti-infective therapy for 3 days without improvement, and had fever every day with temperature above 38.5℃. He was diagnosed with community-acquired pneumonia, combined with pneumonic parietal pleural effusion after comprehensive diagnosis.
(External chest X-ray)
(Outpatient chest CT)
II. Treatment history
In view of the fact that the patient was a young male with no underlying disease, he was given moxifloxacin hydrochloride injection intravenously and amiloride hydrochloride tablets for expectorant treatment. The patient was admitted to the hospital for 3 consecutive days with fever above 38.5℃, cough and sputum did not improve, and the left side chest pain was reduced. In order to clarify the nature of the pleural fluid, puncture and drainage was performed, which resulted in yellow turbid purulent pleural fluid, and the diagnosis of complications of septic chest was supported by low glucose and elevated LDH on laboratory tests.
On the same day, a total of about 800 ml of yellow turbid pleural fluid was drained, and the patient’s body temperature did not exceed 38℃ at night, and he felt less symptomatic and slept better. On the 12th day, the white blood cell count was 6.2×10 ^9/L, C-reactive protein was 7.17 mg/L, calcitoninogen was reduced to normal, and the lung infection was controlled. On day 16, the chest CT was repeated and most of the pulmonary exudate was absorbed, leaving the left pleural thickening. The antibiotics were discontinued and the patient was generally well and discharged on day 18. The patient recovered well and has resumed normal work and life after 2 months of outpatient follow-up.
(Chest CT on the 4th day of admission)
(Chest CT on day 16, most of the lung lesions were absorbed)
III. Treatment effect
Since the patient had community onset, cough and sputum, left-sided chest pain, and inflammatory exudative shadow in the left lung on chest X-ray, which was consistent with typical features of community-acquired pneumonia, but conventional empirical anti-infection treatment was not effective, noting that the patient had symptoms of chest pain and pleural effusion before admission, he was highly alert to the emergence of pus thoracic complications, promptly punctured and drained the chest fluid, and continued to apply moxifloxacin hydrochloride injection anti-infection, and soon the body temperature normalized, respiratory After 2 weeks, the inflammatory lesion was significantly absorbed on chest CT and the patient was discharged after 18 days of hospitalization. After 2 months of outpatient follow-up, the patient basically returned to the state before the onset of the disease.
IV. Notes
We are glad that the patient’s disease has improved after treatment, but we still need to pay attention to the following matters in daily life.
1. A reasonable diet during pneumonia is very crucial. Because the body consumes a lot during fever, you should eat more easily digestible food with high protein content and try not to eat spicy and stimulating and overly salty and greasy food to avoid irritating cough and aggravating the discomfort. If sweating is high, encourage patients to drink more water when gastrointestinal function allows, to replenish the water lost during heavy sweating and wheezing, as well as to moisten the airway and facilitate the discharge of phlegm.
2. During the recovery period, patients should pay attention to rest and sleep, pay attention to indoor air circulation to maintain the appropriate indoor temperature and humidity, avoid spitting and wear masks when going out.
V. Personal insight
The patient in this case is a relatively typical case of community-acquired pneumonia with complications of abscess thorax. We have learned from the treatment process that for community-acquired pneumonia with poor results after conventional empirical anti-infective therapy, attention needs to be paid to the evaluation of complications and comorbidities, especially abscess thorax and lung abscess, which require early drainage of pus. In particular, for those with unresolved high fever and unremitting symptoms, it is important not to hastily adjust the anti-infective regimen and attempt to enhance treatment by increasing the antimicrobial spectrum; treatment is best administered after a thorough evaluation, and assessment of efficacy after 72 hours of treatment for community-acquired pneumonia is critical.