caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been detected in nasopharyngeal swabs (NPS), sputum, bronchoalveolar lavage, blood, feces and ocular fluid(1). To date, there are no reported cases of SARS-CoV-2 isolated in pleural fluid, that is associated with a lifethreatening complication, empyema.
He is a 64-year-old male with a known history of type 2 diabetes mellitus and hypertension who presented with a three-day history of progressive shortness of breath and generalized weakness which was preceded by a dry cough for a few weeks. He otherwise had no complaints or ill-contacts. On presentation, he was noted to be hypoxemic (saturation 93% on 4 liters of oxygen), tachycardic and afebrile. Initial exam was significant for mild respiratory distress and bilateral crackles on lung auscultation. Labs showed an elevated white blood cell count (11.6 x 10 6 ), troponin, D-dimer, ferritin and C-reactive protein. Serum interleukin-6 was elevated at 17.26 pg/mL. However, creatine phosphokinase, lactate dehydrogenase, transaminases and quantiferon gold were within normal limits. A chest x-ray was done that showed bilateral patchy infiltrates and a follow-up computerized tomography (CT) of the chest showed diffuse ground glass opacity with a large thick-walled septated mass in the left lower thorax. He was subsequently admitted for hypoxic respiratory failure likely secondary to COVID-19 pneumonia with superimposed bacterial infection complicated by possible empyema. Nasopharyngeal swab for SARS-CoV-2 was positive. Thoracentesis with chest tube placement revealed purulent material with pH of 6.5, that then later also tested positive for SARS-CoV-2. Final pleural fluid cultures grew pan sensitive Streptococcus pneumoniae. Pleural adenosine deaminase was elevated, however acid-fast bacilli cultures were no growth. He was treated with empiric antibiotics and the chest tube was removed after adequate drainage of empyema. He was discharged on room air to complete a course of oral antibiotics, selfquarantine and to follow-up in the pulmonary clinic after two weeks.
DISCUSSION: Empyema is defined by the presence of bacteria or pus in the pleural space and is a well-documented sequela of pneumonia with mortality of up to 20%(2). The isolation of SARS-CoV-2 within the pleural fluid with a superimposed bacterial infection highlights the increased risk of self-quarantine and delayed treatment pose to the management of high-risk patients. The MuLBSTA score, a 90-day mortality predictor for viral pneumonia, recognizes co-bacterial infection as an additional risk factor for mortality(3).
The presence of SARS-CoV-2 in body fluids such as pleural fluid has not yet been reported, nor are the implications known in regard to shedding duration and prognostication.