Refractory Spontaneous Bacterial Empyema in Cirrhotic Patient

Spontaneous bacterial empyema (SBEM), also called spontaneous bacterial pleuritis, is an infection of the pleural space that arises in the setting of cirrhosis and, by definition, the absence of pneumonia. It is likely underdiagnosed as its symptoms are nonspecific and it lacks standardized diagnostic and therapeutic recommendations. SBEM represents a distinct complication of hepatic hydrothorax with different pathogenesis, presentation, and treatment strategy from those of empyema secondary to pneumonia. Surprisingly, nearly 40% of episodes of spontaneous empyema are not associated with spontaneous bacterial peritonitis. Although SBEM is amenable to prompt antibiotic therapy, it has a high rate of mortality and morbidity. A high clinical suspicion is crucial for patient survival and timely initiation of appropriate antibiotics. Increased understanding, recognition, and standardization of treatment would help alleviate the relatively high burden of SBEM. In this case vignette, we provide a review of the relevant literature, and we describe a rare case of SBEM in a patient with a history of alcohol-associated liver cirrhosis and prior episode of spontaneous bacterial peritonitis (SBP). SBEM was diagnosed with thoracentesis and analysis of the aspirate, and he was treated with ceftriaxone with resolution of his presenting abdominal pain and leukocytosis.