Primary immunodeficiency associated with a SAMD9L mutation

Background: SAMD9L is a tumor suppressor involved in regulating the proliferation and maturation of cells, particularly those derived from the bone marrow, and appears to play an important role in cerebellar function. It can be activated in hematopoietic stem cells by type I and type II interferons. It has been hypothesized to act as a critical antiviral gatekeeper regulating interferon dependent demand driven hematopoiesis. Gain of function mutations can present with an immunodeficiency due to transient severe cytopenias during viral infection. Case presentation: We report a 3-year-old boy born full term with a history of severe thrombocytopenia requiring transfusions, developmental delay, ataxia, seizure disorder, and recurrent severe respiratory viral infections. His infectious history was significant for respiratory syncytial virus with shock requiring extracorporeal membrane oxygenation complicated by cerebral infarction and a group A streptococcus empyema, osteomyelitis requiring a left below the knee amputation, and infections with rhinovirus, COVID-19, and parainfluenza requiring hospitalizations for respiratory support. Initial immunologic evaluation was done during his hospitalization for parainfluenza. His full T cell subsets was significant for lymphopenia across all cell lines with CD3 934/microL, CD4 653/microL, CD8 227/microL, CD19 76/microL, and CD1656 61/microL. His mitogen stimulation assay to phytohemagglutinin and pokeweed was normal. Immunoglobulin panel showed a mildly decreased IgM of 25 mg/dL, but normal IgA and IgG. Vaccine titers demonstrated protective titers to 12/22 pneumococcus serotypes, varicella, diphtheria, mumps, rubella, and rubeola. Repeat full T cell subsets 6 weeks later revealed marked improvement in lymphocyte counts with CD3 3083/microL, CD4 2101/microL, CD8 839/microL, CD19 225/microL, and CD1656/microL. A primary immunodeficiency genetic panel was ordered and positive for a heterozygous SAMD9L c.1549T>C (p.Trp517Arg) mutation classified as a variant of unknown significance. Discussion(s): This patient's history of severe viral infections, ataxia, thrombocytopenia, and severe transient lymphopenia during infection is suggestive of a SAM9DL gain of function mutation. Protein modeling done by the laboratory suggests this missense mutation would affect protein structure. The mutation found has been observed in individuals with thrombocytopenia. This case highlights the importance of immunophenotyping both during acute illness and once recovered.Copyright © 2023 Elsevier Inc.

Intrapleural therapy for pleural infection from bronchopleural fistula in an adult with hyper-IgE syndrome.

We presented the case of an adult patient with hyper-IgE syndrome (HIES) who was admitted acutely with a large hydropneumothorax from lung consolidation, a bronchopleural fistula and pleural infection. He has had recurrent pulmonary and skin infections since childhood and longstanding pneumatoceles. He was treated with systemic antibiotics and chest tube drainage. Administration of two doses of low-dose intrapleural therapy (1 mg tissue plasminogen activator and 5 mg deoxyribonuclease) allowed complete evacuation of his residual loculated pleural fluid, aided resolution of his infection without provoking a significant air leak and avoided the need for surgery.

Changes in the epidemiology of pediatric sinogenic and otogenic intracranial infections during the COVID-19 pandemic: a single-institution study.

OBJECTIVE: Focal intracranial infections (epidural abscesses, subdural empyemas, and intraparenchymal abscesses) are uncommon complications of sinusitis and otitis media but can be associated with significant morbidity. Treatment typically requires neurosurgical and otolaryngological interventions in combination with antibiotic treatment. Historically, children have presented to the authors' pediatric referral center with sinusitis- or otitis media-related intracranial infections in low numbers. However, since the onset of the COVID-19 pandemic, the incidence of intracranial pyogenic complications has increased at this center. The objective of this study was to compare the epidemiology, severity, microbial causes, and management of pediatric sinusitis- and otitis-related intracranial infections in the periods before and during the COVID-19 pandemic. METHODS: All patients 21 years of age or younger who presented with an intracranial infection in the setting of sinusitis or otitis media and who underwent neurosurgical treatment at Connecticut Children's from January 2012 to December 2022 were retrospectively reviewed. Demographic, clinical, laboratory, and radiological data were systematically collated, and variables before and during COVID-19 were compared statistically. RESULTS: Overall, 18 patients were treated for sinusitis-related (n = 16) or otitis media-related (n = 2) intracranial infections during the study period. Ten patients (56%) presented from January 2012 to February 2020, none from March 2020 to June 2021, and 8 (44%) from July 2021 to December 2022. There were no significant demographic differences between the pre-COVID-19 and COVID-19 cohorts. The 10 patients in the pre-COVID-19 cohort underwent a total of 15 neurosurgical and 10 otolaryngological procedures, while the 8 patients in the COVID-19 cohort underwent a total of 12 neurosurgical and 10 otolaryngological procedures. Surgically obtained wound cultures yielded a variety of organisms; Streptococcus constellatus/S. anginosus/S. intermedius were more prevalent in the COVID-19 cohort (87.5% vs 0%, p < 0.001) as was Parvimonas micra (62.5% vs 0%, p = 0.007). CONCLUSIONS: At an institutional level, there has been an approximately threefold increase in cases of sinusitis- and otitis media-related intracranial infections during the COVID-19 pandemic. Multicenter studies are needed to confirm this observation and to investigate whether the mechanisms of infection are related directly to SARS-CoV-2, changes in the respiratory flora, or delayed care. The next steps will include expansion of this study to other pediatric centers throughout the United States and Canada.

Empyema with an extensive retroperitoneal abscess after the first dose of the COVID-19 vaccine, a case report.

Introduction: The most common side effects were mild pain at the injection site and fever after the COVID-19 vaccination. A retroperitoneal abscess is a rare disorder with a deceptive onset and difficult diagnosis. It has various reasons and is related to a high mortality rate. Case presentation: A 29-year-old man with a recent history of first-dose Covid-19 vaccination, was referred for dyspnea, chest, and abdominal pain. Chest imaging revealed a lung abscess evacuated to pleural space. Left posterolateral thoracotomy surgery was done. Post-operation abdominopelvic imaging revealed increased fat stranding and fluid collection, suggesting retroperitoneal infection and abscess formation and the patient underwent drainage. Clinical discussion: Common side effects after COVID-19 vaccination were mild and expectable without hospitalization. But in our case, a rare complicated side effect was seen. Conclusion: Uncommon side effects should be observed to recognize whether they are related to the vaccine or not.

Subdural empyema in immunocompetent pediatric patients with recent SARS-CoV-2 positivity: case report.

Subdural empyema refers to the collection of purulent material in the subdural space and the most source of it is bacterial meningitis in infants while sinusitis and otitis media in older children. It has been very recently reported that coronaviruses (CoV) exhibit neurotropic properties and may also cause neurological diseases. CoV-related complications as hypercoagulability with thrombosis and associated inflammation, catastrophic cerebral venous sinus thrombose sand bacterial-fungal superinfections have been well documented in adult patients. Hereby, we describe 15-year-old and 12-year-old female children with subdural empyema after SARS-CoV2. The patients presented limitation of eye in the outward gaze, impaired speech, drowsiness, fever, vomiting and they also were tested positive for COVID-19. MRI indicated subdural empyema and surgical interventions were needed to relieve intracranial pressure and drain pus after receiving broad spectrum antibiotics treatments. The microbiological analysis of abscess material revealed Streptococcus constellatus which is extremely rare in an immunocompetent child and the patients received appropriate IV antibiotic therapy. Eventually, patients became neurologically intact. Pediatric patients with CoV infections should be closely monitored for neurological symptoms. Further research and more data on the correlation between CoV infections would provide better recognition and treatment options in an efficient manner in children.

Propensity-Matched Comparison of Robotic-Assisted Pulmonary Lobectomy Outcomes in Pre-COVID-19 Patients versus COVID-19-Era Patients

INTRODUCTION: The COVID-19 pandemic has presented patients with barriers to receiving healthcare. We sought to determine whether changes in healthcare access and practice during the COVID-19 pandemic has affected perioperative outcomes after robotic-assisted pulmonary lobectomy (RAPL). METHOD(S): We retrospectively analyzed 721 consecutive patients who underwent RAPL between September 2010 and March 2022 by one surgeon at one institution. With March 1st, 2020, defining the start of the COVID-19 pandemic, we grouped 638 patients as PreCOVID-19 and 83 patients as COVID-19-Era based on surgical date. An optimal variable ratio matching method of one to four PreCOVID-19 patients (with average of three) were matched to each COVID-19-Era patient. Variables used for matching were age, gender, smoking history in pack-years, and preoperative diabetes mellitus, coronary artery disease or myocardial infarction, and FEV1%. Variables of interest were compared utilizing Student's t-test, Wilcoxon rank-sum test, and Chi-square (or Fisher's exact) test, with significance at p<=0.05. Multivariable generalized linear regression was used to investigate predictors of the presence of postoperative complications and report odds ratios (OR). RESULT(S): COVID-19-Era patients had higher incidences of preoperative atrial fibrillation (p=0.027), peripheral vascular disease (p=0.0425), and pancreatitis (p=0.0349) compared to PreCOVID-19 patients. Differences in tumor size and histology, nodal status, and AJCC v8 pathologic stage were statistically insignificant. COVID-19-Era patients experienced a high incidence of effusion or empyema postoperatively (p< 0.0001). The PreCOVID-19 and COVID-19-Era cohorts had comparable odds for developing a postoperative complication. Older age, longer intraoperative skin-to-skin duration, and preoperative COPD are all predictive of an increased risk of developing a postoperative complication (Table 1). CONCLUSION(S): Despite our COVID-19-Era patients having greater indices of preoperative comorbidities, our analysis showed that they had a similar risk of developing a postoperative complication when compared to our PreCOVID-19 patients. Risk factors for development of postoperative effusion should be determined to minimize risk of empyema in COVID-19-Era patients. Patient age, skin-to-skin duration of the procedure, and preoperative COPD should be considered when planning for complication risk following RAPL.

Critical COVID-19 Associated Pulmonary Mucormycosis (CAPM): The underreported life-threatening spectrum of the Mucormycosis epidemic

Background: The explosive rise of Mucormycosis (MM) in India and other parts of the world has been described as the 'epidemic following the COVID-19 pandemic'. We report a series of 5 COVID-19 associated pulmonary MM (CAPM) cases with an aggressive clinical course. Method(s): Only confirmed pulmonary mucormycosis cases with COVID infection were included. Demographic,bronchoscopy,microbiological and histopathological details were collected and analysed. Result(s): 5 patients were included (3 males),with an average age of 61.2 yrs. While all five had diabetes mellitus, 4/5 had an average HbA1C > 9. Median duration from COVID symptom onset to MM diagnosis was 19 days. The most common CXR finding was patchy consolidation in 4/5 patients, concurrent empyema in 1, and a thick-walled cavity in another. Fungal smear of the BAL/biopsy was positive in all patients. Histopathology was consistently positive in all, fungal culture was positive in 3/5, and fungal PCR was positive in 2 cases. Endobronchial necrosis was noted in 4/5 cases. All patients were initiated on amphotericin B but could not be operated due to instability and extensive bilateral disease. The late presentation,comorbidities,critical state and fulminant course led to demise within 4 days of diagnosis in 4/5 patients. Dual infection with Aspergillus and Mucor spp. was seen in 3/5 patients. Concurrent MDR bacterial infection present in all patients may have added to mortality. Conclusion(s): Critical CAPM following COVID 19 infection was difficult to diagnose and treat,with an aggressive course and fatal outcome. Bronchoscopy was an invaluable tool in diagnosis and prognostication but could not impact the outcomes.

Day case thoracoscopy in a UK district general hospital

Background: Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to mininize length of stay in the Covid pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid pleurodesis with talc is not performed due to staffing problems. All patients receive erector spinae catheters to control post-op pain. Method(s): All patients undergoing day case LAT between Dec 2019-Jan2022 were analysed. Basic demographics and outcomes were collected for a descriptive analysis of data. Result(s): 32 patients underwent day case LAT. All had negative pre-op Covid-19 swabs: mean age 72.4 years (range 34-83);22M/10M. Diagnoses were 9 lung cancers, 11 mesotheliomas and 9 fibrinous pleuritis (1 of those went for VATS and proved mesothelioma). The lung did not deflate, not enabling biopsies in 3 (Non-malignant diagnoses). 28 IPCs and 2 large bore drains were inserted due to surgical emphysema. 1 patient developed an empyema and 1 had cellulitis within 30 days. 28 IPCs have already been removed due to pleurodesis (median 54 range 21-197). All were discharged the same day except the 2 requiring a large bore drains. Mean length of stay is 0 days. Diagnostic sensitivity of LAT is 96.5%. Pain scores at day 0,1,2 of surgery were consistently low. No patient caught Covid in the 30 days post surgery. Conclusion(s): Day case LAT is feasible with our current set up and should be widely adopted. The health economics of preventing admission are considerable.

A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: results from the ACTion trial

Background: Pleural infection has a considerable healthcare burden with an average hospital stay of 14 days. There have been no randomised trials on the use of therapeutic thoracentesis (TT) for initial pleural fluid drainage. Aim(s): To assess the feasibility of a full-scale trial of chest tube vs TT for pleural infection. The primary outcome was defined as the acceptability of randomisation (ad priori defined as successful if >=50% of eligible patients were randomised). Method(s): Adult patients admitted with a pleural effusion related to infection and meeting recognised criteria for drainage were eligible. Participants were randomised (unblinded) to chest tube insertion or TT. Patients were followed up at 90 days. Result(s): From September 2019 and June 2021, 51 patients were diagnosed with complex parapneumonic effusion/empyema. Eleven patients met the inclusion criteria for trial and 10 patients were randomised (91%). The COVID-19 pandemic had a significant impact on recruitment. Patients randomised to TT had a shorter overall mean hospital stay (5.4 days, SD 5.1) compared to the chest tube control group (13 days, SD 6.0), p=0.04. Total number of pleural procedures required per patient were similar, 1.2 in chest tube group and 1.4 in TT group. No patients required surgical referral. Adverse events were similar between the groups with no readmissions related to pleural infection. Data completeness was high with no protocol deviations. Conclusion(s): The ACTion trial met its prespecified feasibility criteria for patient acceptability. The suggestion that TT can reduce hospital length of stay requires further investigation.

Antibiotic Use in Acute Upper Respiratory Tract Infections

Upper respiratory tract infections are responsible for millions of physician visits in the United States annually. Although viruses cause most acute upper respiratory tract infections, studies show that many infections are unnecessarily treated with antibiotics. Because inappropriate antibiotic use results in adverse events, contributes to antibiotic resistance, and adds unnecessary costs, family physicians must take an evidence-based, judicious approach to the use of antibiotics in patients with upper respiratory tract infections. Antibiotics should not be used for the common cold, influenza, COVID-19, or laryngitis. Evidence supports antibiotic use in most cases of acute otitis media, group A beta-hemolytic streptococcal pharyngitis, and epiglottitis and in a limited percentage of acute rhinosinusitis cases. Several evidence-based strategies have been identified to improve the appropriateness of antibiotic prescribing for acute upper respiratory tract infections.Copyright © 2022 American Academy of Family Physicians.

Evaluation of pleural complications affecting mortality in COVID-19 patients

INTRODUCTION: This study aimed to retrospectively evaluate pleural complications in patients who were polymerase chain reaction (PCR)-positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and admitted to the hospital with COVID-19 pneumonia. METHODS: A total of 164 patients who applied to our hospital between March 2020 and May 2021 with PCR-positive for SARS-CoV-2 were retrospectively evaluated and were followed up and treated in the service or intensive care unit. Pleural complications were detected during the treatment of COVID-19 pneumonia. In the current study, mortality was taken as the death of the patients in the first 30 days after hospitalization. Pleural complications occurring during treatment were classified into two groups: the pneumothorax (PNX) group and the pneumomediastinum (PMN) group. RESULTS: Of the patients, 69 (52.3%) had isolated PNX and 14 (43.7%) had isolated PMN. PNX and subcutaneous emphysema were determined in 50 (37.9%) patients, PMN and subcutaneous emphysema were determined in 13 (40.6%), PMN, PNX, and subcutaneous emphysema were determined in 3 (9.4%), and PMN and PNX were determined in 2 (6.3%) patients. Hydro-PNX was determined in 12 (9.1%) patients, and PNX and empyema were determined in 1 (0.7%) patient. When the relationship between pleural complications occurring during treatment due to COVID-19 pneumonia and mortality was examined, mortality was observed in 14 (43.8%) of the PMN patients and 104 (78.8%) of the PNX patients (p<0.001). When the relationship between gender and mortality was examined, mortality was observed in 75 (65.8%) of the male patients and in 43 (86%) of the female patients (p=0.008). DISCUSSION AND CONCLUSION: As a result, it was found that PNX after positive pressure ventilation increased mortality more than other pleural complications and worsened the prognosis. We think this issue will contribute to the literature in the COVID-19 pandemic and in pandemic diseases that may occur later and cause pleural involvement.

Loculated Empyema and SARS-CoV-2 Infection: A Report of Two Cases and Review of the Literature.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clinical manifestations are diverse and can vary from mild respiratory symptoms to severe hypoxic respiratory failure. In severe cases, infection can cause gastrointestinal, renal, cardiac, neurological and haematological complications and result in multi-organ failure. There are very few reports of parapneumonic effusion in patients with COVID-19. We describe two patients with COVID-19 who had loculated empyema and discuss the clinical course and therapeutic options. LEARNING POINTS: The clinical manifestations of COVID-19 vary from mild to severe disease and can result in multi-organ failure.Pleural empyema is usually treated with a combination of antibiotics and surgical drainage of the pleural cavity.

Subdural empyema secondary to pansinusitis after coronavirus disease 2019 infection in an immunocompetent patient: illustrative case.

BACKGROUND: Superimposed intracranial infection is an uncommon but clinically significant complication in patients with active coronavirus disease 2019 (COVID-19), particularly in those with predisposing immunocompromising conditions. OBSERVATIONS: The authors describe a case of subdural empyema, secondary to extension from pansinusitis, in a 20-year-old otherwise healthy immunocompetent male who was recently diagnosed with COVID-19. Despite his critical condition at time of presentation, he made a full clinical recovery with aggressive multidisciplinary surgical management between neurosurgery and otolaryngology, despite negative cultures to guide directed antimicrobial therapy. Ultimately, use of molecular-based polymerase chain reaction testing diagnosed Aspergillus fumigatus as the offending pathogen after the patient had already recovered and was discharged from the hospital. LESSONS: This case demonstrates the potential for significant superimposed intracranial infection even in young, healthy individuals, infected by COVID-19 and suggests an aggressive surgical approach to achieve source control, particularly in the absence of positive cultures to guide antimicrobial therapies, may lead to rapid clinical improvement.

Changes in Etiology and Clinical Outcomes of Pleural empyema during the COVID-19 Pandemic.

Healthcare-seeking behavior changed during the COVID-19 pandemic and might alter the epidemiology of pleural empyema. In this study, the incidence, etiology and outcomes of patients admitted for pleural empyema in Hong Kong in the pre-COVID-19 (January 2015-December 2019) and post-COVID-19 (January 2020-June 2022) periods were compared. Overall, Streptococcus pneumoniae was the predominant organism in <18-year-old patients, while Streptococcus anginosus, anaerobes and polymicrobial infections were more frequent in adults. In the post-COVID-19 period, a marked decline in the incidence of pleural empyema in children was observed (pre-COVID-19, 18.4 ± 4.8 vs. post-COVID-19, 2.0 ± 2.9 cases per year, p = 0.036), while the incidence in adults remained similar (pre-COVID-19, 189.0 ± 17.2 vs. post-COVID-19, 198.4 ± 5.0 cases per year; p = 0.23). In the post-COVID-19 period, polymicrobial etiology increased (OR 11.37, p < 0.0001), while S. pneumoniae etiology decreased (OR 0.073, p < 0.001). In multivariate analysis, clinical outcomes (length of stay, ICU admission, use of intrapleural fibrinolytic therapy, surgical intervention, death) were not significantly different in pre- and post-COVID-19 periods. In conclusion, an increase in polymicrobial pleural empyema was observed during the pandemic. We postulate that this is related to the delayed presentation of pneumonia to hospitals.

Massive empyema due to Lactococcus garvieae

Introduction Lactococcus garvieae, a zoonotic pathogen, may rarely infect humans through the consumption of fish. Documented manifestations of L. garvieae infection in humans include infective endocarditis, prosthetic joint infections, liver abscesses, peritoneal dialysis-associated peritonitis, osteomyelitis, meningitis, infective spondylodiscitis, acalculous cholecystitis, and urinary tract infection. Case report An 87-year-old female was hospitalized for coffee-ground emesis secondary to acute gastritis after eating cooked fish. One week after her discharge, she developed new-onset confusion and was returned to the hospital. Chest computed tomography revealed total consolidation of the left lung and a multiloculated left pleural effusion. The patient required intubation and direct admission to the intensive care unit. Pleural fluid and blood cultures grew L. garvieae, which was susceptible to ceftriaxone, penicillin, and vancomycin. Despite intensive antibiotic therapy and supportive care for thirteen days, the patient remained in irreversibl e shock, and the family opted for comfort care. Conclusions Heretofore unreported, this case demonstrates that L. garvieae can cause bronchopneumonia and empyema. Copyright © GERMS 2022.

Sinusitis complicated by intracranial abscess in 3 patients with coronavirus disease 2019: illustrative cases.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) can be associated with various neurological manifestations, including cerebrovascular disease, seizures, peripheral nerve disease, and encephalitis. Intracranial abscess related to COVID-19 is rare but illustrates a serious complication in the studied cases. OBSERVATIONS: The authors report 3 cases of patients presenting with COVID-19 complicated by sinusitis with associated intracranial abscesses. Each patient underwent craniotomy with washout and sinus debridement during their hospital stay. All 3 patients improved to their baseline following treatment. Similar outcomes have been observed in other cases of intracranial abscess associated with COVID-19 infections. LESSONS: Patients achieved significant improvement following evacuation of the abscess and intravenous antibiotics. Further investigation is needed to determine treatment in relation to COVID-19, and the authors recommend following the standard treatment of intracranial abscess at this time.

Management and outcome of infectious spondylodiscitis in patients with and without neurological deficit: A prospective study

Introduction: The term Infectious Spondylodiscitis involves infection of the vertebra and infection of the intervertebral disc, or both. Any delay in its diagnosis or management may cause serious long-term morbidity and mortality. In this study, we report the experiences in our Institution in the management of severe and complicated cases of infectious spondylodiscitis. Material(s) and Method(s): Over the period of 2 years from 2020-2022 (covid-19) 40 patients were operated in our medical college the management was tailored according to the clinical condition based on VAS, ODI, radiological studies and lab results of each case;and patients were then prospectively followed-up for 2 years. Result(s): The goals of treatment for spondylodiscitis is to relieve pain, restore pain free mobilization of the patient and to eliminate infection. Magnetic resonance imaging (MRI) was considered the main choice of investigating tool other assessments were done by ODI, VAS, Neurologic deficits was assessed by Modified McCormick scale, sepsis, an intraspinal empyema, the failure of conservative treatment, and spinal instability are all indications for surgical treatment. Conclusion(s): The quality of life of patients who have been appropriately treated for infectious spondylodiscitis has been found to be highly satisfactory in general. The risk of recurrence increases in the presence of accompanying illnesses such as diabetes mellitus, renal failure, which were managed by immediate debridement and results were good which was assessed according to above mentioned post-op ODI and VAS. Copyright © 2023 Ubiquity Press. All rights reserved.

Fatal Pyopneumothorax in a COVID-19 Patient.

The COVID-19 pandemic has impacted every aspect of our lives since its start in December 2019. Among various COVID-19 complications, pleural complications are also increasingly reported but rarely from Nepal. Here, we presented a case of pyopneumothorax in a 52-year-old male patient referred from another center and admitted to the ICU of Nepal Armed Police Force Hospital with a diagnosis of severe COVID-19 pneumonia in the background of alcohol withdrawal syndrome with delirium tremens and generalized tonic-clonic seizures. He developed a rapid decline in respiratory status with a right-sided pneumothorax and underwent an immediate needle thoracostomy, followed by chest tube insertion. On the sixth day of admission, he had thick yellowish pus in the chest drain (pyopneumothorax), and despite the rigorous efforts in treatment, he died on the 15th day of admission. Though relatively uncommon, clinicians should consider pleural complications like pneumothorax, pleural effusion, pneumomediastinum, and empyema in patients with impaired immune status. In such patients, we should ensure prompt diagnosis with the earliest intervention and rationale use of antibiotics.