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Pleural infection with residual multiloculated collection — SCE Respiratory MCQ

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HardRespiratory InfectionsPleural infection with residual multiloculated collectionSCE Respiratory

A 68-year-old man is admitted with pneumococcal pneumonia and a moderate right pleural effusion. Ultrasound shows extensive septation. Pleural aspiration yields turbid fluid with a pH of 7.08, and a 12 F image-guided intercostal drain is inserted alongside intravenous antibiotics. After 48 hours, he remains febrile with a persistently elevated C-reactive protein. Drain output has fallen to 20 mL over 24 hours. The drain flushes freely and CT confirms that it is appropriately positioned, but a substantial multiloculated pleural collection remains. His platelet count and coagulation profile are normal, and he is not receiving anticoagulation. He would be physiologically fit for surgery if required. Which pleural intervention is most appropriate now?

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Correct answer: D — Start intrapleural alteplase–dornase alfa

The low pleural-fluid pH, septation and systemic inflammatory response establish a complex parapneumonic effusion requiring antibiotics and intercostal drainage. Initial management with a small-bore image-guided drain was appropriate. The decisive subsequent findings are cessation of effective drainage despite a patent, correctly positioned tube and persistence of a substantial loculated collection. BTS guidance recommends combined intrapleural tissue plasminogen activator and DNase in this situation. A commonly used evidence-based regimen is alteplase 10 mg plus DNase 5 mg twice daily for 3 days, with consent regarding bleeding risk. Upsizing the drain is not routinely beneficial: drains larger than 14 F have not demonstrated superior major outcomes and may increase pain; it might be appropriate if the existing catheter were blocked or could not access the collection. Saline irrigation is an alternative when combined enzyme therapy or surgery is unsuitable, rather than the preferred intervention here. Alteplase alone should not be used because single-agent fibrinolytic or DNase therapy is not recommended. VATS is important when optimal medical management fails or intrapleural treatment is contraindicated, but proceeding directly to surgery before a trial of combination therapy is not the best next step in this stable, surgically salvageable patient.

Reference: British Thoracic Society Guideline for pleural disease (July 2023) — https://www.brit-thoracic.org.uk/document-library/guidelines/pleural-disease/pleural-disease-full-supplement/ British Thoracic Society Guideline for pleural disease (July 2023) — https://www.brit-thoracic.org.uk/document-library/guidelines/pleural-disease/pleural-disease-full-supplement/ British Thoracic Society Guideline for pleural disease (July 2023) — https://www.brit-thoracic.org.uk/document-library/guidelines/pleural-disease/pleural-disease-full-supplement/