A pleural fluid analysis shows: pH 7.1, glucose 35 mg/dL (serum 95), LDH 850 IU/L, protein 5.2 g/dL. The pleural fluid is exudative (Light's criteria satisfied). Gram stain is negative but pleural fluid culture grows Streptococcus constellatus. The MOST appropriate management is:

• A IV antibiotics alone; repeat thoracocentesis in 72 hours
• B Chest tube drainage plus antibiotics; intrapleural fibrinolytics if loculated ✓
• C Urgent decortication for all complicated parapneumonic effusions
• D IV antibiotics plus daily pleural fluid sampling without drainage

Explanation

This is a complicated parapneumonic effusion (CPE) or empyema based on pH <7.2, glucose <60 mg/dL, LDH >1000, positive culture, and frank pus. BTS guidelines mandate chest tube drainage for CPE with pH <7.2, glucose <3.3 mmol/L, or culture-positive fluid, plus appropriate antibiotics. For loculated empyema inadequately drained by tube alone, intrapleural fibrinolytic therapy (tPA + DNase per MRC MIST2 trial) is recommended to improve drainage and reduce surgical referral rates. Surgery (VATS decortication) is reserved for those failing medical management.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.