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Complicated Parapneumonic Effusion — RACP Adult Medicine MCQ

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ModerateRespiratoryComplicated Parapneumonic EffusionRACP Adult Medicine

A 55-year-old man with recently treated community-acquired pneumonia develops a parapneumonic effusion. Pleural fluid pH is 7.15, glucose 1.5 mmol/L, LDH 2500 U/L, and Gram stain shows Gram-positive cocci. What is the definitive management?

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Correct answer: B — Observation with repeat thoracentesis

A complicated parapneumonic effusion/empyema (pH <7.2, glucose <3.3 mmol/L, high LDH, or positive Gram stain/culture) requires intercostal catheter drainage plus IV antibiotics. If the effusion is loculated and does not drain adequately, intrapleural fibrinolytic therapy (alteplase 10 mg + DNase 5 mg BD for 3 days – MIST2 trial protocol) significantly improves drainage, reduces surgical need, and shortens hospital stay. Surgical VATS decortication is reserved for failure of chest tube drainage ± fibrinolytics.

Reference: eTG – 2025 – Respiratory; BTS – 2023 – Pleural Infection Guidelines; MIST2 Trial