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Tension empyema is a rare complication of community-acquired pneumonia. Many did not recognize this medical emergency that could result in cardiorespiratory failure. We present a patient of massive left lung empyema with mass effect.
A 52-year-old female with underlying hypertension, complained of feeling breathless and prolonged fever. She was hypotensive and tachypnoea. There were no breath sounds over left lung. ECG showed sinus tachycardia. RUSH protocol revealed inadequate right ventricular filling with absent of pericardial effusion. Lung scan showed an anechoic lesion occupying the left lower zone. Chest x-ray (CXR) revealed a large round opacified lesion occupying left lower lobe. A left chest drain was inserted. She then proceeded with Computed tomography (CT) Thorax which reported as left lung abscess with rupture into the pleural cavity and mass effect (mediastinal and tracheal shift to opposite). Patient was subsequently discharged well after completed antibiotics for two weeks in ward.
Tension empyema occurs when massive purulent fluid entraps the lung and causes mediastinal structures shifting to the opposite. Diabetes mellitus has been listed as an independent risk factor for the development of empyema. The rapidly expanding empyema compressing onto major vascular structures resulting in decreased venous return and lung volume. CT thoraxes surpass CXR in diagnosing tension empyema by providing a better clinical picture. There have been literatures depicting cardiorespiratory arrest due to tension empyema and successfully reversed once drainage was done.
Clinician should maintain high index of clinical suspicion to diagnose tension empyema, with assistance of bedside ultrasound and chest x-ray. Failure to recognize it may cost inevitable mortality.
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