The decision on the need for thoracostomy and drainage of a parapneumonic effusion can be difficult. A pleural fluid pH of less than 7.00 is often used to identify an empyema needing immediate drainage. Infection with urea-splitting organisms may, however, cause an empyema with an elevated pH. We report a case of Proteus vulgaris empyema demonstrating that a high pleural fluid pH does not preclude the need for thoracostomy.

A 55-year-old man was admitted with foul-smelling sputum, fever and an abscess cavity in the right lower lobe. Sputum culture showed multiple organisms and bronchoscopy demonstrated no obstructing lesion or malignancy. The patient was treated with intravenous penicillin and, subsequently, clindamycin.

He returned two weeks later with increasing right-sided chest pain, cough and fever. He had a temperature of37.8°C on admission and an increasing air-fluid level on chest roentgenogram. Intrave­nous clindamycin was started but the patient remained febrile to 39°C. Sputum culture grew Proteus vulgaris. Five days after admission, a new right pleural effusion developed. Thoracentesis yielded hazy yellow fluid with a protein content of 3.1 gm/dl, LDH 208 IU and a leukocyte count of 350/mm3 with 37 percent polymor­phonuclear cells and 59 percent lymphocytes. Serum values were as follows: protein 6.4 gm/dl and LDH 184 IU. Pleural fluid gram stain was negative and pleural fluid pH was 7.61. Culture of pleural fluid grew Enterococcus and two strains of Proteus vulgaris. Antibi­otics were changed to gentamicin, penicillin and cefoxitin. A chest tube was placed and the patient improved. Viagra Super Active

Pine and Hollman reported three cases of Proteus mirabilis empyema with elevated pleural fluid pH.3 Ammonia levels were elevated where measured in their patients. Proteus vulgaris as well.