Empyema Presenting as Lower Extremity Weakness

March 2014, Vol 145, No. 3_MeetingAbstracts Chest Infections | March 2014

Empyema Presenting as Lower Extremity Weakness Debjit Saha, MD; Jillian Cepeda, DO; Daisha Hayden, MD; Ari Ciment, MD Mount Sinai Medical Center, Department of Internal Medicine, Miami, FL

Chest. 2014;145(3_MeetingAbstracts):118A. doi:10.1378/chest.1836709

Abstract SESSION TITLE: Infectious Disease Case Report Posters I SESSION TYPE: Case Report Poster PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM INTRODUCTION: The most common autoimmune inflammatory demyelinating disease of the central nervous system is multiple sclerosis. It has a unique clinical feature of unpredictable exacerbations and remissions. Systemic infectious process is one of the important precipitating factors for multiple sclerosis exacerbation1. CASE PRESENTATION: A 66-year-old Hispanic man with a 30 pack-year smoking history and chronic productive cough presented with complaints of intermittent lower extremity weakness, parasthesia for the last seven years with recent worsening and inability to ambulate. Exam findings included absent breath sounds at right base, lower extremity paraplegia, hypoactive knee and ankle jerk reflexes, bilateral Babinski and absent joint position and vibration sense. Pertinent negatives included no fevers or weight loss. A CXR showed rightsided lower lobe extensive effusion. CT of the chest showed a large right pleural effusion. Initial concern of a lung malignancy and possible paraneoplastic neurological syndrome was excluded by bronchoscopy and pleural fluid analysis. MRI of the brain with Gadolinium revealed extensive white matter signal abnormalities throughout both cerebral hemispheres with periventricular dominance. A subsequent lumber puncture confirmed the diagnosis of Multiple Sclerosis by demonstrating oligoclonal bands with an elevated CSF IgG index. Subsequently the Cultures of the pleural fluid grew Peptostreptococcus and the empyema was effectively treated with VATS procedure with chest tube placement and intravenous ampicillin and sulbactam.

After successful treatment of empyema, patient was noted to have marked improvements in lower extremity strength with resolution of a majority of his neurologic symptoms. DISCUSSION: Underlying immunological mechanisms play a major role in exacerbations of multiple sclerosis. There is a significant association between systemic infections and exacerbations1. The T cells activation and increase secretion of inflammatory mediators (IFNs, ILs) during infection, cause direct blockade of nerve impulse conduction1,2. Different virological agents have been reported with exacerbations, this is the first reported case of exacerbation associated with empyema caused by Peptostreptococcus. It will be interesting to study different pathogens associated with exacerbations in future. CONCLUSIONS: Our case report reflects the association of a multiple sclerosis exacerbation with an underlying infectious process. The patient’s neurological findings significantly improved following treatment of the empyema. Early detection and adequate treatment of systemic infection is a cornerstone of multiple sclerosis exacerbation management. Reference #1: Buljevac D, Flach HZ, et al. Prospective study on the relationship between infections and multiple sclerosis exacerbations. Brain. 2002;125(Pt 5):952-960 Reference #2: Correale J, Fiol M, et al. The risk of relapses in multiple sclerosis during systemic infections. Neurology. 2006;67(4):652-659 DISCLOSURE: The following authors have nothing to disclose: Debjit Saha, Jillian Cepeda, Daisha Hayden, Ari Ciment No Product/Research Disclosure Information