Case Report Clinical Microbiology

Empyema caused by Streptococcus dysgalactiae ssp dysgalactiae in

Patient with Breast Cancer

dr. Mawar Wulansari

dr. Willy Wirawan Guslianto
dr. Handayani

Supervisor
Dr. dr. Fadhilah, M.Kes., Sp.MK., Subsp. Vir. (K)
dr. Firdaus Hamid, Ph.D., Sp.MK., Subsp. Bakt. (K)
dr. Yoeke Dewi Rasita, M.Ked.Klin, Sp.MK

Clinical Microbiology in Training

Faculty of Medicine, Hasanuddin University
Makassar
2023
 IDENTITAS PASIEN
q Nama : Ny. MS q Rumah Sakit : Wahidin Sudirohusodo
q Tanggal Lahir : 22 Juli 1991 q Perawatan : Rawat inap, Perawatan Infeksi Paru
q Umur : 32 tahun q Spesimen : Cairan Pleura
q Jenis kelamin : Perempuan q Pemeriksaan : Kultur Aerob

q No. Rekam Medik : 01-05-56-86 q Masuk RS : 04 Oktober 2023.

q Diagnosis MK : q Pengambilan sampel : 05 Oktober 2023, pkl. 13.35 WITA
Empiema paru sinistra, efusi pleura masif sinistra, q Sampel tiba di lab : 05 Oktober 2023, pkl. 14.20 WITA
Community Acquired Pneumonia (CAP)
q Rilis Hasil Lab : 11 Oktober 2023
q Meninggal : 11 November 2023
 ANAMNESIS (Autoanamnesis) : 5 Oktober 2023

• Masuk Rumah Sakit dengan keluhan sesak nafas yang dialami sejak 1 bulan yang lalu dan memberat
satu minggu terakhir, sesak napas dipengaruhi oleh aktivitas, tidak dipengaruhi oleh cuaca. Riwayat
sesak napas sebelumnya tidak ada. Batuk berlendir warna putih sesekali sejak 1 Minggu terakhir,
Riwayat batuk lama dan batuk darah tidak ada. Demam tidak ada. Riwayat demam ada 3 hari yang
lalu. Mual ada, muntah tidak ada. Nafsu makan menurun ada. Penurunan Berat badan ada tidak
diketahui berapa kg. BAB normal, BAK tidak ada keluhan.
• Riwayat OAT dan kontak pasien TB tidak ada.
• Riwayat HT, DM, penyakit ginjal tidak ada
• Riwayat merokok tidak ada
• Riwayat keganasan dalam keluarga tidak ada
• Riwayat vaksin covid 3 kali
• Riwayat terkonfirmasi covid tidak ada
• Riwayat dirawat di RSUD Sinjai (3 Oktober 2023) selama 1 hari dengan diagnosa efusi pleura + Ca
mammae dan mendapatkan terapi (Santagesic/8jam/iv, Omeprazol/12 jam/IV)
• Riwayat kemoterapi Carcinoma Mammae sebanyak 6 siklus (selesai)
Riwayat : Ceftriaxone 2gr/24jam/IV 05 Oktober 2023 Hari pertama
Penggunaan Azitromycin 500mg/24jam/IV 05 Oktober 2023 Hari pertama
Antibiotik

Pemeriksaan : Status Generalisata Tanda-Tanda Vital

Fisik GCS 15 E4M6V5 / Compos Mentis. TD : 124/80 mmHg
Mata : Konjungtiva anemis (+/+), sklera ikterik -/-, HR : 116 x/menit
Leher : Trakea midline, tidak teraba pembesaran KGB. P : 24 x /menit
Thorax (supine, anterior) : Inspeksi : Asimetris saat statis dan dinamis, T : 36.7 oC
hemithoraks kiri tertinggal. Palpasi : Taktile fremitus menurun pada SpO2 : 90 % via room
hemithorax sinistra. Perkusi : Redup setinggi Intracostal II-basal pada
air, 99 % via nasal kanul
hemithorax sinistra. Auskultasi : bronkovesikuler, suara napas menurun 4 lpm
apeks-basal hemithorax sinistra, ronchi dan wheezing tidak ada.
Cor : Bunyi jantung I/II murni regular, tidak ada murmur
Pulmo : Bunyi pernafasan vesicular, Ronchi (-/-), Wheezing (-/-)
Abdomen : Supel, ikut gerak nafas, Peristaltik ada kesan normal. Hepar dan
Lien tidak teraba.
Extremitas : : Akral hangat, edema pretibial tidak ada, CRT 2 detik,
Penggunaan : IV line Tanggal 04 Oktober 2023 Hari kedua
Medical Device O2 via Nasal kanul Tanggal 04 Oktober 2023 Hari kedua
Status lokalis
Mammae Dextra

I : tidak tampak massa, warna kulit sama dengan warna kulit sekitar
P : tidak teraba massa, Nyeri tekan negatif

Mammae Sinistra

I : Payudara sinistra tampak bengkak, warna kulit memerah dibanding warna kulit
sekitar disertai Ulkus, Pus ada, perdarahan tidak ada.
P : Payudara Teraba hangat, konsistensi keras, terfiksir, nyeri tekan ada.
 Hasil Laboratorium
Complete 03/10/23
04/10/23 09/10/23 12/10/23 16/10/23 19/10/23 23/10/23 10/11/23 NILAI
Blood (RSUD SATUAN
(RS WS) (RS WS) (RS WS) (RS WS) (RS WS) (RS WS) (RS WS) RUJUKAN
Count Sinjai)
WBC 27.72 35.7 41.0 41.0 16.7 19.50 14.7 15.9 103/uL 4.00-11.0
RBC 3.57 106/uL 4.50-5.50
HB 9.9 8.5 8.9 8.0 8.5 9.7 10.9 g/dL 13.0-16.0
HCT 30 % 40.0-50.0
MCV 84 83 85 fL 80.0-100.0
MCH 24 26 29 Pg 27.0-34.0
MCHC 29 32 34 g/dL 31.0-36.0
PLT 376 439 321 274 356 316 397 327 103/uL 150-450
NEUT 24.42 86 95 85.8 86.5 88.1 86.5 95.2 % 50.0-70.0
LYMPH 0.56 1.1 1.2 3.2 3.0 2.3 2.9 1.9 % 20.0-40.0
MONO % 2.0-8.0
EO % 1.00-3.00
BASO % 0.00-1.00
NLR 43.60 78,18 79.16 26.81 28.8 38.3 29.82 50,10

Masuk RS Pemeriksaan Kultur Hasil Kultur Meninggal

04/10/23 05/10/23 11/10/23 11/11/23
PEMERIKSAAN 03-10- 06-10- 07-10- 12-10- 14-10- 16-10- 19-10- 23-10- SATUAN NILAI
2023 2023 2023 2023 2023 2023 2023 2023 RUJUKAN
GDS 73 56 112 113 mg/dL 80-140
Ureum 45 75 25 mg/dL 0.6-1.3
Kreatinin 0.4 0.32 0.20 mg/dL 0 - 53
Klorida 95 100 100 100 103 Mmol/L 97-111
Kalium 5.7 2.8 3.9 3.6 3.3 Mmol/L 3.5-5.1
Natrium 131 123 133 129 130 135 Mmol/L 136-145
SGOT 79 76 U/L 35
SGPT 62 54 U/L 45
Albumin 2.6 2.4 2.7 2.4 2.8 2.4 2.4 gr/dl 3.5-5.0
Asam Urat 8.2 mg/dL 2.4 – 6.0
HBsAg Reaktif Non Reaktif
Prokalsitonin 1.93 0.22 ng/ml <0.05
CRP >130 11.4 mg/l <5
D Dimer 1.83 0.80 <0.5
LED 164 mm/jam 0-20
PT 13.9 detik 10-13
APTT 31.9 detik 25-35
 Analisa Cairan Pleura ( 05 Oktober 2023 )
Parameter Hasil Nilai Normal Satuan
Glukosa 10 <200 mg/dl
Total Protein 1510 <3000 mg/dl
LDH >1150 100-190 U/L
Volume 10 1-10 cc
Warna Kuning keruh Jernih / Tidak
Berwarna
Bekuan Positif Tidak ditemukan
PH 6.5 7.60 – 7.64
BJ 1.020 < 1.08
Tes Rivalta Positif, Kesan : Eksudat Negatif

Hitung jumlah leukosit 99779 Jumlah leukosit Sel / ul

< 200
Hitung jenis leukosit PMN=99%, MN=1% 60 – 70 %
Mononukleus
Analisa Gas Darah 05/10/2023 USG Whole Abdomen (20/10/2023)
pH 7.464
pO2 137.3 Kesan :
pCO2 25.0 • Hepatomegaly
• Efusi pleura bilateral
SO2 99.8
HCO3 18.1
BE -5.8

Kesan :
Alkalosis Respiratorik Terkompensasi Sebagian
 Tanggal Foto Thorax PA/AP MSCT Scan Thorax Tanpa kontras
09 Mei 2023 Kesan :
(RS Pelamonia) Inflammatory breast carcinoma sinistra with pleural metastasis.
03 Oktober 2023 Kesan:
(RS Sinjai) Efusi Pleura Masif Sinistra
06 Oktober 2023 Kesan :
(RS Wahidin) • Efusi pleura kiri yang mengakibatkan atelektasis kompresif paru kiri
• Massa mammae kiri yang meluas ke regio axilla kiri hingga ke fossa
clavipectorale kiri
• Multiple lymphadenopathy level 4L dan regio axilla bilateral
10-10-2023 Kesan :
Foto thorax PA/AP - Efusi pleura sinistra
+ lateral (RS Wahidin) - Massa mammae kiri

13-10-2023 Kesan :
(RS Wahidin) • Efusi pleura kiri yang mengakibatkan atelektasis kompresif paru kiri
(dibandingkan foto Tgl 6/10/2023 kesan : Progresif)
• Massa mammae kiri yang meluas ke regio axilla kiri hingga ke fossa clavipectorale
kiri
• Multiple lymphadenopathy level 4L, 5C dan regio axilla bilateral
• Empisema subkutis regio superolateral hemithorax kiri dengan terpasang chest
tube didalamnya (chest tube tidak masuk ke dalam rongga hemithorax kiri)
16-10-2023 Kesan :
Foto thorax PA/AP • Terpasang chest tube pada hemithorax kiri
(RS Wahidin) dengan insersi ICS 6- 7 dengan tip setinggi CV
T10
• Efusi pleura sinistra.
• Massa mammae kiri
 Pre Analitik
Lembar Permintaan
Waktu pengambilan:
Pengambilan spesimen tanggal 05 Oktober 2023
pukul 13.35 WITA
Pengambilan spesimen:
Spesimen cairan pleura dalam spoit 10 ml
dengan needle, diambil intra thoracosintetis.
Setelah dilakukan tindakan asepsis terlebih
dahulu, dengan volume 10 ml, berwarna kuning
keruh, konsistensi encer.
Dan segera dikirim ke laboratorium
Mikrobiologi Klinik.

Waktu Pengerjaan : Tanggal 05 Oktober 2023

pukul 15.33 WITA
 Direct Gram
05 Oktober 2023

Pembesaran 400x :
Epitel : tidak ditemukan
Leukosit : Tipe Polymorphonuclear
3+/LPK
 Direct Gram
05 Oktober 2023

Pembesaran 1000x
Mikroorganisme: Coccus berantai Gram positif 3+/LPB
Follow Up hari I 06 Oktober 2023 pukul 09.00 WITA
(inkubasi 17 jam)
Karakteristik Hasil
Blood Agar koloni
(Mikroaerofilik) Bentuk Halus

Tepi Rata

Permukaan Mengkilap

Elevasi Cembung

Kejernihan Keruh

Warna Putih keabuan

Sifat Beta
Hemolisis Hemolisis

Katalase (-)

Coccus berantai Gram Positif

Hasil Vitek Teridentifikasi “Streptococcus
dysgalactiae ssp dysgalactiae ”
(11 Oktober 2023)
 AST MANUAL AST VITEK
Antimicrobial Interpretation
Benzylpenicillin Susceptible
Ampicillin Susceptible
Cefotaxime Susceptible
Ceftriaxone Susceptible
Levofloxacin Susceptible
Maxifloxacin Susceptible
Erythromycin Susceptible
Clindamycin Intermediate
Linezolid Susceptible
Erythromycin 25 mm Susceptible
Penicillin 27 mm Susceptible Vancomycin Susceptible
Levofloxacin 20 mm Susceptible Tetracycline Resistance
Ceftriaxone 27 mm Susceptible
Chloramphenicol Susceptible
Clindamycin 24 mm Susceptible
Vancomycin 17 mm Susceptible Trimethoprim/Sulfamethoxazole Resistance
Maldi tof mass spectrometry:
“Streptococcus dysgalactiae ssp equisimilis /
Streptococcus dysgalactiae ssp dysgalactiae”
 Kamis Jumat
05-10-2023 06-10-2023
Subject Sesak, batuk, nyeri dada, Demam (-). Sesak, batuk, nyeri dada, Demam (-).

Objective TD: 124/80 mmhg Tensi: 120/70 mmhg

Nadi: 116 kali /menit Nadi: 116 kali /menit
Napas: 24 kali /menit Napas: 24 kali /menit
Suhu: 36.7 C Suhu: 36.7 C
Ø Telah dilakukan tindakan toracosintesis pada hemithoraks sinistra sebanyak -Telah dilakukan tindakan proof pungsi pada hemithoraks sinistra sebanyak 10
500cc dan dilakukan pemeriksaan analisa cairan pleura dan pemeriksaan kultur cc dan dilakukan pemeriksaan analisa cairan pleura dan pemeriksaan kultur
Ø Telah di lakukan tindakan toracosisntesis degan usg guiding pada hemitorax
sisnistra sebanyak 600 cc . Pemasangan Chest tube
- Pemasangan Chest tube (tertunda karena tangan kiri tidak bisa diangkat)
- Rencana Toracosintesis pro terapeutik bila belum memungkinkan
pemasangan WSD
Assessment Empiema paru sinistra Empiema paru sinistra
Efusi pleura masif sinistra ec malignancy dd/Infeksi Efusi pleura masif sinistra ec malignancy dd/Infeksi
CAP PSI Score minimal 72 CAP PSI Score minimal 72
Cancer Pain VAS Skor 3/10 Cancer Pain VAS Skor 3/10
Carcinoma Mammae sinistra Carcinoma Mammae sinistra
Peningkatan enzim transaminase Peningkatan enzim transaminase
Hipoalbuminemia ( 2,6 ) Hipoalbuminemia ( 2,6 )
Planning O2 via 4 Lpm O2 via 4 Lpm
IVFD Nacl 0.9% 20 tpm IVFD Nacl 0.9% 20 tpm
Ceftriaxone 2gr/24jam/IV Ceftriaxone 2gr/24jam/IV
Azitromycin 500mg/24jam/IV Azitromycin 500mg/24jam/IV
Paracetamol 500mg/6jam/ Oral Paracetamol 500mg/6jam/ Oral
Ranitidin 1amp/12jam/IV Ranitidin 1amp/12jam/IV
Acetylsistein 200mg/8jam/oral Acetylsistein 200mg/8jam/oral
Curcuma 1tablet/8jam/oral Curcuma 1tablet/8jam/oral
Vip albumin 1 cap/8jam/ oral Vip albumin 1 cap/8jam/ oral
 Minggu
08-10-2023
Subject Sesak ada, batuk ada, nyeri dada ada,
bengkak pada tangan kiri, nyeri ada
Objective Tensi: 110/70 mmhg
Nadi: 98 kali /menit
Napas: 24 kali /menit
Suhu: 36.7 C
Assessment Empiema paru sinistra
Efusi pleura masif sinistra ec
malignancy dd/Infeksi
CAP PSI Score minimal 72
Cancer Pain VAS Skor 3/10
Carcinoma Mammae sinistra
Peningkatan enzim transaminase
Hipoalbuminemia ( 2,6 )
Planning Ceftriaxone 2gr/24jam/IV
Azitromycin 500mg/24jam/IV
Metronidazole 500mg/8jam/IV Hari
ke -1
Senin Rabu
09-10-2023 11-10-2023
Sesak ada, batuk ada, nyeri dada ada, bengkak pada Sesak masih ada, batuk ada, nyeri
tangan kiri, nyeri ada dada ada, bengkak pada tangan kiri, nyeri ada
Tensi: 120/70 mmhg Sakit sedang/compos mentis
Nadi: 90 kali /menit Saturasi oksigen 93% via room air Saturasi oksigen 97% via nasal canul 4 lpm
Napas: 20 kali /menit Tensi: 110/70 mmhg
Suhu: 36.7 C Nadi: 90 kali /menit
Pemasangan Chest tube (tertunda karena tangan kiri Napas: 20 kali /menit
tidak bisa diangkat) - Rencana Toracosintesis pro Suhu: 36.7 C
terapeutik (9/10/2023) *Hasil kultur cairan pleura (5/10/23)* Ditemukan pertumbuhan bakteri coccus berantai gram
- Periksa sitologi cairan pleura (9/10/2023) positif yang teridentifikasi sebagai Streptococcus dysgalactiae ssp dysgalactiae.
- Periksa Hematologi rutin, Elektrolit *Hasil tes sensitivitas antibiotik 5/10/2023*
- Konsul TS Onkologi (Belum di jawab) No. Antibiotik
1. Ampicillin
2. Ceftriaxone
3. Gentamicin
4. Vancomycin
5. Clindamycin*
*Antibiotik ini dapat digunakan dengan meningkatkan dosis atau memperpanjang durasi
pemberian.
*Kesimpulan:*
Ditemukan pertumbuhan bakteri coccus berantai gram positif yang teridentifikasi sebagai
Streptococcus dysgalactiae ssp dysgalactiae. Bakteri ini dapat menjadi agen infeksi pada kasus ini
Empiema paru sinistra Empiema paru sinistra
Efusi pleura masif sinistra ec malignancy dd/Infeksi Efusi pleura masif sinistra ec malignancy dd/Infeksi
CAP PSI Score minimal 72 CAP PSI Score minimal 72 + Cancer Pain VAS Skor 3/10
Cancer Pain VAS Skor 3/10 Carcinoma Mammae sinistra post kemoterapi
Carcinoma Mammae sinistra Peningkatan enzim transaminase
Peningkatan enzim transaminase Hipoalbuminemia ( 2,7 )
Hipoalbuminemia ( 2,6 ) Hiperkalemia
Ceftriaxone 2gr/24jam/IV - Ceftriaxone 2gr/24jam/IV Hari ke-6
Azitromycin 500mg/24jam/IV - Clindamicyn 300mg/8jam/oral hari ke- 3
Metronidazole 500mg/8jam/IV STOP - Azitromycin 500mg/24jam/IV H4 >> STOP
Clindamicyn 600mg/8jam/oral hari pertama dan
kedua, lanjut 300mg/8jam/oral hari ke-3
 Kamis Jumat
12-10-2023 13-10-2023
Subject Sesak masih ada, batuk ada, nyeri dada ada, bengkak pada tangan kiri Post chest tube hemitoraks kiri
masih ada, nyeri ada
Objective TD: 110/70 mmhg Composmentis
Nadi: 85 kali /menit TD :123/74 mmHg
Napas: 20 kali /menit N : 100 kali/menit
Suhu: 36.7 C P : 20 kali/menit
Pemasangan Chest tube (Bila KU optimal) SB : 36,7 C
- Pasang chest tube >> Tidak berhasil
- Rencana transfusi PRC 1 bag

Assessment Empiema paru sinistra Empiema paru kiri on chest tube

Efusi pleura masif sinistra ec malignancy dd/Infeksi
CAP PSI Score minimal 72
Cancer Pain VAS Skor 3/10
Carcinoma Mammae sinistra
Peningkatan enzim transaminase
Hipoalbuminemia ( 2,6 )

Planning Ceftriaxone 2gr/24jam/IV Hari ketujuh Takar WSD/24jam

Clindamicyn 300mg/8jam/oral hari ke- 4 Ceftriaxone 2gr/24jam/IV Hari ke-8
Clindamicyn 300mg/8jam/oral Hari ke- 5
MSCT non kontras (13/10/2023) untuk pastikan tip masuk di cavum
pleura
Ketorolac 30mg/8jam/IV
Ranitidin 50mg/12jam/IV
Transfusi PRC 1 bag
 Sabtu Jumat
21-10-2023 27-10-2023
Subject Sesak masih ada, batuk ada, nyeri dada kiri sesekali, bengkak pada tangan kiri Sesak masih ada, batuk ada, nyeri dada kiri hilang timbul, bengkak pada tangan kiri masih ada, terasa nyeri
masih ada, terasa nyeri dan hangat bila di pegang, nyeri pada bokong dan hangat bila di pegang, nyeri pada bokong, nyeri perut kiri hilang timbul
Objective Sakit sedang/composmentis Sakit sedang/composmentis
Saturasi oksigen 94% via room air Saturasi oksigen 96% via nasal canul 4 lpm Saturasi oksigen 94% via room air Saturasi oksigen 97% via nasal canul 4 lpm
Tensi: 130/70 mmhg Tensi: 120/72 mmhg
Nadi: 88 kali /menit Nadi: 82 kali /menit
Napas: 18 kali /menit Napas: 18 kali /menit
Suhu: 36.7 C Suhu: 36.7 C
Assessment - Empiema paru sinistra on WSD H-9 - Empiema paru sinistra on WSD H-15
- Efusi pleura masif sinistra ec malignancy dd/Infeksi - Efusi pleura masif sinistra ec malignancy dd/Infeksi
- CAP PSI Score minimal 72 - CAP PSI Score minimal 72
- Cancer Pain VAS Skor 3/10 - Cancer Pain VAS Skor 5/10
- Carcinoma Mammae sinistra post kemoterapi - Carcinoma Mammae sinistra post kemoterapi
- Peningkatan enzim transaminase - Peningkatan enzim transaminase
- Hipoalbuminemia ( 2,6) - Hipoalbuminemia (3.2)
- Elektrolit imbalance - Elektrolit imbalance (Perbaikan)

Planning - O2 via 4 Lpm - O2 via 4 Lpm

- IVFD Nacl 3% 10 tpm cabang NaCl 0,9% 20tpm - IVFD Nacl 3% 10 tpm cabang NaCl 0,9% 20tpm
- Ceftriaxone 2gr/24jam/IV Hari ke-15 (STOP), Ganti levofloxacin - Levofloxacin 750mg/24jam/IV Hari ke-7
- Levofloxacin 750mg/24jam/IV - Clindamicyn 300mg/8 jam/oral hari ke-16 (STOP)
- Clindamicyn 300mg/8jam/oral hari ke- 13 - Ranitidin 1amp/12jam/IV
- Ranitidin 1amp/12jam/IV - Ambroxol 30mg/8jam/oral
- Acetylsistein 200mg/8jam/oral (STOP karena sudah Limit) - Curcuma 1tablet/8jam/oral
- Ambroxol 30mg/8jam/oral
- Vip albumin 1 cap/8jam/ oral
- Curcuma 1tablet/8jam/oral
- Vip albumin 1 cap/8jam/ oral - Methylprednisolon 62.5mg/24jam/IV
- Methylprednisolon 62.5mg/24jam/IV - Xarelto 20mg/24jam/oral
- Ketorolac 30mg/8jam/IV - Vip Albumin 2caps/8jam/oral
- Xarelto 20mg/24jam/oral - KSR 600mg/8jam/oral
- Vip Albumin 2caps/8jam/oral - Gabapentin 300mg/24jam/oral
- KSR 600mg/8jam/oral - Paracetamol 500mg/8jam/oral (K/P)
- Gabapentin 300mg/24jam/oral - Sucralfat sirup 2cth/8jam/oral
- Paracetamol 500mg/8jam/oral (K/P) - Human albumin 20% 100mL/24jam/IV (Bila albumin <2.5)
- Human albumin 20% 100mL/24jam/IV (Bila albumin <2.5) + Metamizole 1gr/8jam/IV
+ MST 10mg/8jam/oral
 Sabtu Rabu
28-10-2023 08-11-2023
Subject Sesak masih ada, batuk ada, nyeri dada ada, bengkak pada Sesak masih ada, batuk ada, nyeri dada kiri hilang timbul, bengkak pada tangan kiri masih ada, terasa nyeri dan
tangan kiri masih ada, nyeri ada. hangat bila di pegang, nyeri pada bokong, nyeri perut kiri hilang timbul, demam ada hilang timbul.
Objective Sakit Sedang/composmentis Sakit sedang/compos mentis Saturasi oksigen 94% via room air Saturasi oksigen 98% via NK 3lpm Tensi:
Saturasi oksigen 93% via room air Saturasi oksigen 96% via 120/76 mmhg
nasal canul 4 lpm Nadi: 88 kali /menit
Tensi: 120/70 mmhg Napas: 18 kali /menit
Nadi: 90 kali /menit Suhu: 36.4 C
Napas: 18 kali /menit
Suhu: 36.7 C
Assessment Empiema paru sinistra + - Empiema paru sinistra on WSD H-27
Efusi pleura masif sinistra ec malignancy dd/Infeksi + - CAP PSI Score minimal 72
CAP PSI Score minimal 72 + - Cancer Pain VAS Skor 5/10
Cancer Pain VAS Skor 3/10 + - Carcinoma Mammae sinistra post kemoterapi
Carcinoma Mammae sinistra + - Peningkatan enzim transaminase
Peningkatan enzim transaminase + - Hipoalbuminemia (3.2)
Hipoalbuminemia ( 2,6 ) - Elektrolit imbalance (Perbaikan)
Planning O2 via 4 Lpm - O2 via NRM 10 Lpm
- IVFD Nacl 3% 10 tpm cabang NaCl 0,9% 20tpm - IVFD Nacl 3% 10 tpm
- Levofloxacin 750mg/24jam/IV H-7 >> STOP, ganti oral - Levofloxacin 750mg/24jam/oral , Hari ke – 10 --- STOP
- Levofloxacin 750mg/24jam/oral --- HARI PERTAMA - Ranitidin 1amp/12jam/IV
- Ranitidin 1amp/12jam/IV - Ambroxol 30mg/8jam/oral
- Ambroxol 30mg/8jam/oral - Curcuma 1tablet/8jam/oral
- Curcuma 1tablet/8jam/oral - Xarelto 20mg/24jam/oral
- Vip albumin 1 cap/8jam/ oral
- Vip Albumin 2caps/8jam/oral
- Methylprednisolon 62.5mg/24jam/IV
- Xarelto 20mg/24jam/oral - KSR 600mg/8jam/oral
- Vip Albumin 2caps/8jam/oral - KSR 600mg/8jam/oral - Gabapentin 300mg/24jam/oral
- Gabapentin 300mg/24jam/oral - Paracetamol 500mg/8jam/oral (K/P)
- Paracetamol 500mg/8jam/oral (K/P) - Sucralfat sirup 2cth/8jam/oral
- Sucralfat sirup 2cth/8jam/oral - Metamizole 1gr/8jam/IV
- Human albumin 20% 100mL/24jam/IV (Bila albumin <2.5) - MST 10mg/12jam/oral
+ Metamizole 1gr/8jam/IV - Transfusi 2 bag PRC dengan premedikasi dipenhidramin (1 bag per 24 jam)
+ MST 10mg/12jam/oral
 Jumat Sabtu
10-11-2023 11-11-2023
Subject Sesak memberat, batuk ada, nyeri dada kiri hilang timbul, bengkak pada tangan kiri S/: henti nafas henti jantung.
bertambah, terasa nyeri dan hangat bila di pegang, nyeri pada bokong, nyeri perut kiri hilang
timbul, demam ada hilang timbul.
Objective Sakit Sedang/composmentis Vital sign =
Saturasi oksigen 94% via room air Saturasi oksigen 98% via NK 3lpm Tensi: 138/72 mmhg TD : tidak terukur
Nadi: 118 kali /menit N : tidak teraba
Napas: 24 kali /menit Suhu: 36.4 C R : tidak ada
Evaluasi WSD H29 9/11/2023 SpO2 : tidak terbaca
Produksi : cc , Warna : seroxantochrome + PUS (minimal), Undulasi : ada, Buble : tidak
ada
Assessment - Empiema paru sinistra on WSD H-29 pasien meninggal pada pukul 07:12
- CAP PSI Score minimal 72
- Cancer Pain VAS Skor 5/10
- Carcinoma Mammae sinistra post kemoterapi
- Peningkatan enzim transaminase
- Hipoalbuminemia (3.2)
- Elektrolit imbalance (Perbaikan)
Planning - O2 via NRM 10 Lpm Perawatan jenazah
- IVFD Nacl 3% 10 tpm
- Metronidazole 500mg/8jam/IV Hari ke-1
- Furosemide 40 mg/24 jam (bila TDS>100/60)
- Ranitidin 1amp/12jam/IV
- Ambroxol 30mg/8jam/oral
- Curcuma 1tablet/8jam/oral
- Xarelto 20mg/24jam/oral
- Vip Albumin 2caps/8jam/oral
- KSR 600mg/8jam/oral
- Gabapentin 300mg/24jam/oral
- Paracetamol 500mg/8jam/oral (K/P)
- Sucralfat sirup 2cth/8jam/oral
- Metamizole 1gr/8jam/IV
- MST 10mg/12jam/oral
- Transfusi 2 bag PRC dengan premedikasi dipenhidramin (1 bag per 24 jam)
Selesai pemberian
- (5 Oktober 2023) Ceftriaxone 2gr/24jam/IV Hari ke-15 >> STOP, Ganti Levofloxacin inj.
- (5 Oktober 2023) Azitromycin 500mg/24jam/IV Hari ke-4 >> STOP
- (8 Oktober 2023) Metronidazole 500mg/8jam/IV Hari ke-2>>STOP
- (9 Oktober 2023) Clindamicyn 300mg/8jam/oral Hari ke- 16 >> STOP Limit dari apotik
- (21 Oktober 2023) Levofloxacin 750mg/24jam/IV Hari-7 >> STOP, ganti oral
- (28 Oktober 2023) Levofloxacin 750mg/24jam/oral Hari ke-10 >>STOP
- (10 November 2023) Metronidazole 500mg/8jam/IV Hari ke-2 >> Meninggal

Konsul Gizi. Tanggal 18 Oktober 2023.

Konsul Bedah Onkologi. Tanggal 10 Oktober 2023. Rencana kemoterapi bila KU optimal.
Tanggal 16 Oktober 2023. Pasien dan keluarga menolak kemoterapi.
Konsul Anestesi. Tanggal 8 November 2023.
DISCUSSION
Specimen Collection, Transport
and Handling
Specimen Collection

Collect prior to antimicrobial therapy for greatest diagnostic

sensitivity.

Clean the needle puncture site with alcohol, and disinfect it

with an iodine solution. Chlorhexidine antisepsis following
the
initial alcohol cleaning step is also acceptable.

Aseptically perform percutaneous aspiration with syringe and

needle to obtain pleural

Syringe with needle removed that has been capped with a

Luer-Lok. Specimens received by the laboratory in a syringe
with the needle still attached may be rejected because of the
risk of a sharps exposure by laboratory staff.
 Specimen transport
Label specimens with
patient demographics
(including two forms of Clearly indicate
microbiology tests being
identification) and date,
time, and site of ordered.
collection.

Record the patient

Deliver to the laboratory
diagnosis for improved as soon as possible.
processing of specimen.

Do not refrigerate during

transport.
 Rejection criteria

Laboratories must follow specimen received Contact physician if

explicit protocols specimen is insufficient for
regulating transport time, after prolonged the number of tests
transport containers, and
unlabeled or mislabeled
delay ( > 2 hour ) requested.
specimens
Management of pleural effusion and empyema
- Pleural effusions are common
in patients who develop In some patients the
pneumonia. parapneumonic effusion
- At least 40-60% of patients becomes fibrinous and later
with bacterial pneumonia will develops an infection, resulting
develop a pleural effusion of in an empyema.
varying severity.

- Empyema may result as a

complication of cardiothoracic The infecting organism may
surgery. have spread from blood or
other organs into the pleural
- Trauma can also lead to space
infection of the pleural space.

Shebl E, Paul M. Parapneumonic Pleural Effusions And Empyema Thoracis. 2021

Parapneumonic effusion is classified into 4 groups based on risk for the poor outcome :

Category 3
Category 2 (low (moderate risk),
Category 1 in which one of
(very low risk): The effusion the following
is small to
risk): The moderate (equal criteria is
effusion is to 10 mm and
present: the fluid
small (less than less than half the equal to half the Category 4 (high
10-mm hemithorax) and hemithorax, risk): This is when
loculated pleural fluid is in
thickness on free-flowing with effusion, thicken the form of pure
decubitus) and negative culture
and Gram stain pleura on pus
free-flowing. contrast-
regardless of the
No prior use of
enhanced CT
thoracentesis is antibiotics and scan, positive
indicated pH equal to 7.20 Gram stain or
culture or pH less
than 7.20

Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc. 2006
 Patients with category 1 and category
2 may not require drainage. In
Treatment of patients with category 3 and
parapneumonic effusion 4, drainage is recommended.
includes appropriate Fibrinolytics, VATS, and surgery may
antibiotic therapy together be indicated for managing patients
with drainage of pleural with category 3 and category 4
fluid as indicated parapneumonic effusion not
responding to less invasive drainage
methods

Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc. 2006
Antibiotic Therapy

It must cover the suggested causative organisms of pneumonia according to the clinical setting. The duration of
antibiotic therapy depends on many factors, for example, the sensitivity of the organism, extent of pulmonary
parenchymal and pleural disease, response to initial therapy and adequacy of drainage

Chest Tube Drainage

Chest tube drainage is generally preferred for patients with uninoculated effusions and free-flowing fluid. Chest
tubes are ideally inserted under ultrasound or CT-guidance. The choice of a thoracostomy tube size is controversial.
Imaging performed within 24 hours is essential for documenting the correct position of the chest tube. Chest tubes
are left in place until the drainage rate is less than 50 ml per day and the empyema cavity has closed

Fibrinolytic Agents

The intrapleural administration for fibrinolytic agents (for example, streptokinase and tissue plasminogen activator)
or fibrinolytic plus mucolytic agents aiming for facilitating the drainage of the loculated parapneumonic effusion is
controversial

[Guideline] Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. 2000
Thoracoscopy

Thoracoscopy is an alternative therapy for loculated empyemas when antibiotics and tube thoracostomy fail for the
drainage. Thoracoscopy disrupts the intrapleural adhesions and allows the drainage of the pleural fluid. Previous
studies showed that delay for referral for thoracoscopy more than two weeks was associated with failure of
thoracoscopy and conversion to thoracotomy

Decortication

Decortication is indicated when persistent (present after 6 months) pleural peel is formed, leading to significant
pulmonary restriction.

Rib Resection and Open Drainage of Pleural Space

A vertical incision through the chest wall with rib resection (1 to 3) is done to allow pleural fluid drainage. A chest
tube is left in place (about 60 to 90 days). Open drainage of the pleural space may be considered when the
previous methods fail, and when the patient is too ill to tolerate decortications

[Guideline] Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. 2000C
 Antibiotic susceptibility testing
identification for Streptococcus
dysgalactiae spp dysgalactiae
(SDSD) isolates in our study
revealed Tetracyclin and
Trimethoprim-Sulfamethoksazole
resistance
On the other hand,
susceptibility to ß-lactam
antibiotics, including penicillin
and cephalosporins, was high,
suggesting that they should be
the usual drugs of choice.
Antimicrobial Susceptibility of the Streptococcus dysgalactiae ssp dysgalactiae in this case :
Antimicrobial Agent MIC (ug/ml) Zone Diameter (mm) MIC Interpretation

Benzylpenicillin ≤ 0.06 Susceptible

Ampicillin ≤ 0.25 Susceptible

Cefotaxime ≤ 0.12 Susceptible

Ceftriaxone ≤ 0.12 27 Susceptible

Levofloxacin 1 20 Susceptible

Moxifloxacin 0.25 Susceptible

Erythromycin ≤ 0.12 25 Susceptible

Clindamycin 0.5 24 Intermediate

Linezolid ≤2 24 Susceptible

Vancomycin 0.5 17 Susceptible

Tetracycline ≥16 Resistant

Chloramphenicol 4 Susceptible

Trimethoprim- Sulfamethoksazole 160 Resistant

In this case, although the Ceftriaxone therapy showed good sensitivity to antibacterial
agents, the infection was not fully controlled.

The addition of clindamycin and frequent flushing of the drainage proved effective in
controlling the infection.

Generally, SDSD is highly sensitive to β-lactam antibiotics, such as penicillin and

cephalosporins, which are used as the first-line therapy in the treatment of infections
caused by SDSD.
In the present case, drainage was presumed to be the most useful intervention for reducing
the infection

Cinthia Alves-Barroco, et. al., New Insights on Streptococcus dysgalactiae subsp. Dysgalactiae Isolates, Frontiers in microbiology, 2021
Terima Kasih