An unusual case of empyema

SummaryAbscess formation and empyema are serious sequelae of pneumonia. Colonisation of the pleural fluid occurs most frequently by aerobic organisms or mixed aerobic and anaerobic species including: Streptococcus pneumoniae, Streptococcus milleri, Bacteroides species and anaerobic fusobacteria. Actinomyces, Eikenella corrodens and Nocardia species are a rarely reported combination of anaerobic organisms resulting in empyema, especially in the Northern hemisphere. A 65-year-old man presented in a severely debilitated state with poor dentition and features of severe pneumonia. His past medical history included diabetes mellitus, peripheral vascular disease and cerebrovascular events. CT scan revealed consolidation, empyema and abscess formation. The patient was initially managed with intravenous dicloxacillin and metronidazole and a diagnostic aspirate was followed by chest drain insertion. Microscopy results showed Nocardia and antimicrobial therapy was altered to co-trimoxazole and ticarcillin/clavulanate. After additional nutritional support the patient was fit for video assisted thoracoscopy and decortication. Further culture results confirmed the growth of Actinomyces species and Eikenella corrodens and the therapy was modified to co-trimoxazole and benzylpenicillin. Pneumonia and empyema due solely to anaerobic organisms is rare but should be suspected if clinical onset is insidious. Anaerobic culture of specimens is indispensable to the rapid choice of appropriate antibiotic.