A 39-year-old male presented with left-sided chest pain and was diagnosed with left-sided pneumonia and pleural effusion, as well as hyperglycemia and suspected pulmonary embolism. He underwent various tests and treatments, including a pleural drain, antibiotics, and an interventional radiology procedure for a retroperitoneal hematoma. The patient was stabilized and discharged after treatment for ongoing infections and normalized inflammatory markers.

1. CASE PRESENTATION
DONE BY DR. MOHAMED TAHA
SUPERVISED BY DR. AHMED TAHA

2. HISTORY AND PRESENTATION
• 39 years old male presented to the ER with left sided
chest pain, radiating to the back/left shoulder for 3/7.
• He describes the pain as spasm-like in nature, it was
preceded by history of vigorous physical exercises 2
days, and it worsens with respiration and cough.
• No history of hemoptysis, fever, dizziness, LOC, leg pain
or swelling and history of sick contact or recent travel.

3. • K/C/O DM2 (not compliant to his medications), DLP,
Hypothyroidism, Vitiligo & Alopecia areata
• No Past surgical hx
• Ex-smoker
• Non-drinker

4. PHYSICAL EXAMINATION ON ADMISSION
• Conscious, alert & oriented to TPP
• Tachycardic
• Maintaining oxygen saturation 92% on RA
• Chest: Bilateral expiratory wheezes mid to lower zones, reduced AE over left side
• CVS: N S1+S2+0
• Abd: soft, lax, no tenderness
• No lower limbs edema, Calves soft on palpation, no tenderness

5. INVESTIGATIONS
• WBC 17.3 (NE% 82.6), Hb 12.5, Plt 301, D-Dimer 3.1
• Na 133.9, K 4.69, Cl 94.9, CO2 16.2, RFT NL, Cardiac enzymes NL, Trop-I 0
(repeated set of Trop-I <0.010)
• Ketones 2.7 (was 4.8), BS 13.7 (15.4)
• VBG PH 7.397 PCO2 33.3 HCO3 20 BE -3.5
• ECG sinus tachycardia
• CXR was done

6. WHAT DO YOU SEE?

7. • Do you think this patient require an admission?
• Why?

8. ADMISSION DAY 1/10/2023
Admission initial diagnosis:
• Left sided pneumonia with pleural effusion (Physical and
CXR findings)
• Hyperglycemia, resolving DKA (RBS, Ketones, CO2 16.2)
• Suspected PE (Chest pain, sinus tachycardia SPO2 92% RA,
D-Dimer 3.1)

9. HOSPITAL COURSE
1- DKA:-
• Kept on low dose insulin infusion then on sliding scale till out of
DKA.
2- Pulmonary Embolism:-
• CTPA (1/10/2023): Negative for PE. Lt sided moderate pleural
effusion with collapse/consolidation involving Lt lower lobe & Lt
lingular segment

11. ECHO 10/10/2023

12. ECHO 21/10/2023

13. ECHO 7/11/2023

14. LEFT SIDED PNEUMONIA WITH PLEURAL EFFUSION
• Left Sided Pleural Drain was Kept by Interventional Radiologist on 3/10
until 21/10
• Pleural Fluid Exudative: Chest tube kept draining continuously
• TB-Gene Expert PCR: Negative
• Received Tazocin 1-21/10/2023 and Azithromycin 1-2-10/2023
• Resp panel (1/10): Streptococcus agalactia
• CRP markedly improved
• US chest report (9/10): Scanning both CP angles revealed bilateral
minimal pleural effusion

15. 12 DAYS POST DRAINAGE

16. COURSE
• High Resolution CT Chest(10/10) : Significant decrease in the previously
seen left pleural effusion volume with mild residual/insisted
appearance.
• On (10/10) ECHO was done showing mild to moderate pericardial
effusion
• The patient management kept the same, draining and monitoring
inflammatory markers and the patient was stable until (20/10)

17. COURSE CHANGE (FIRST TWIST) CLINICAL

18. COURSE CHANGE (FIRST TWIST) BIOCHEMISTRY

19. COURSE CHANGE (FIRST TWIST) HEMATOLOGY

20. SEROLOGY

21. HORMONES

22. COURSE CHANGE (FIRST TWIST) CLINICAL NOTES

23. COURSE CHANGE (FIRST TWIST) CLINICAL NOTES

24. COURSE CHANGE (FIRST TWIST) MICROBIOLOGY
• Plural drain was positive for Ochrobactrum anthropi and vancomycin started but
after 2 days the level was 34 so it was discontinued
• Inflammatory markers (CRP230, PCT 63.9) and RFT (Cr 811) started to raise on
(21/10) chest drain was removed
• The patient started become hypotensive and was complaining of severe back pain
and Lt. sided groin pain. Antibiotics upgraded to Meropenem 1g, ICU review was
done
• What is your impression so far?

25. 1/10/2023 BIOFIRE PNEUMONIA PANEL PLUS

26. 28/10/2023 BIOFIRE PNEUMONIA PANEL PLUS

27. 4/10/2023 SPUTUM C/S

28. 7/10/2023 PLEURAL FLUID C/S

29. 25/10/2023 PLEURAL FLUID C/S

30. WHEN TESTS WERE REQUESTED (IS IT IMPORTANT?)

31. WHEN TESTS WERE REQUESTED (IS IT IMPORTANT?)

32. WHEN TESTS WERE REQUESTED (IS IT IMPORTANT?)

33. BLOOD CULTURES
• All blood cultures from admission till discharge came
negative.

34. RADIOLOGY

35. 22/10/2023 CT CHEST AND ABDOMEN

36. 22/10/2023 CT CHEST AND ABDOMEN

37. 22/10/2023 CT CHEST AND ABDOMEN

39. 22/10/2023 CT AORTA

40. • On (22/10) CT was performed for this pain showing Lt sided retroperitoneal
hematoma
• IR Procedure done (23/10/23): Selective left lumbar angiography shows contrast
extravasation from L2/3 lumbar artery. Embolization done with particles 300-500U
and one coil 4mm. Bleeding stopped. The right CFA access closed with angioseal.

41. 23/10/2023 LUMBAR ARTERY EMBOLIZATIION

42. COURSE CHANGE (SECOND TWIST) CLINICAL

43. COURSE CHANGE (SECOND TWIST) CLINICAL

44. • Presentation of stroke?
• CT Brain done

45. COURSE CHANGE (SECOND TWIST) RADIOLOGY
27/10/2023 CT ABDOMEN

46. COURSE CHANGE (SECOND TWIST) RADIOLOGY
27/10/2023 CT BRAIN

47. WHAT DO YOU SEE?

49. • On (6/11) patient was discharged from the ICU
• Kept on Linezolid 27/10 to 15/11/2023 until inflammatory markers and
RFT normalized
• CVP removed on (12/11) - Dialysis Catheter removed on (14/11)
• Patient was discharged on (16/11)

50. DISCHARGE CHEST X-RAY

51. THANK YOU