Multiloculated pleural effusion detected by ultrasound only in a critically-ill patient

BACKGROUND: Multiloculated pleural effusion is a life-threatening condition that needs early recognition. Drainage by chest tube might be difficult which necessitates a surgical intervention. While x-ray typically does not show loculations, CT scan might not also identify the loculations. Ultrasound has a high sensitivity in detecting pleural diseases including multiloculated pleural effusion. CASE REPORT: A 55-year-old female presented with dyspnea, cough and yellowish sputum for 3 days. Her heart rate was 136 bpm ,O2 saturation 88%, and WBC 21,000/mcL. Chest x-ray showed complete opacification of right lung. A chest tube insertion was unsuccessful. CT scan of the chest showed large pleural effusion occupying the right hemithorax with collapse of the right lung. Bedside ultra-sound showed a multiloculated pleural effusion with septations of different thickness. The patient subsequently underwent thoracotomy which showed multiple, fluid-filled loculations with significant adhesions. The loculations were dissected along with decortications of thick a pleural rind. Blood and pleural fluid cultures grew Streptococcus pneumoniae and the patient was treated successfully with Penicillin G. CONCLUSIONS: We advocate bedside ultrasound in patients with complete or near complete opacification of a hemithorax on chest x-ray. CT scan is less likely to show septations within pleural effusions compared to ultrasounnd. Therefore, CT scan and ultrasound are complementary for the diagnosis of empyema and multiloculated pleural effusion.