The Curious Hiatal Hernia Which Was Actually Streptococcus Constellatus Empyema

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Publication Date


Publication Title

American Journal of Respiratory and Critical Care Medicine


American Thoracic Society

Publisher Location

San Diego, CA



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INTRODUCTION: We present a surprising case which appeared as type IV hiatal hernia in CT imaging but turnedout to be a case of Streptococcus constellatus empyema.CASE A 55-year-old male presented with 1-month history of progressive altered mental status and failure to thrive including loss of appetite, self-care, and 2 days of verbal communication. Past medical history included hospitalization for major depressive disorder and schizophrenia. The patient had been stable on Seroquel for 10 years until developing current symptoms. Upon initial examination, he generally appeared catatonic and only showed movement or opened his eyes upon localized pain with no verbal response. His eyes displayed mild scleral icterus. On physical exam, the patient was tachycardic with high diastolic pressure and depressed respiration rate. Pulmonary exam was significant for absent breath sounds on left chest and coarse breath sounds on the right. Abdominal exam showed scaphoid abdomen, soft and non-tender to palpation. Laboratory results showed leukocytosis and anemia. Chest X-ray showed moderate elevation of the left hemidiaphragm below which is cast distended stomach and/or colon. Chest CT showed a large left hydropneumothorax which appeared loculated at the basilar aspect and appeared to invert the left hemidiaphragm. Images were equivocal for possible bowels in the thoracic cavity and we consulted with the cardiothoracic surgery team. A chest tube was placed and diagnostic thoracentesis fluid was a purulent, brown, and fetid effusion. The effusion was classified in the lab as transudative by light criteria but later grew Streptococcus constellatus and Parvimonas micra with concomitant S. constellatus bacteremia. The patient was successfully treated with ampicillin/sulbactam for a total of 8 weeks. Follow-up in clinic after discharge showed complete symptoms and imaging resolution. DISCUSSION S. constellatus thrives poorly in highly aerobic environments like the lungs and is classified within the Streptococcus milleri group, a part of the normal flora of the mouth, gastrointestinal and genitourinary tract. For example, when 153 strains of the group were examined in 1991 from laboratories in the UK, only 12 were isolated from the respiratory tract, causing empyema. As such, empyema caused by S. constellatus is quite unexpected, especially given its shape and septation of the collection, which mimicked the appearance of hiatal hernia and translocation of bowel into the thoracic cavity on X-ray and CT imaging.

Controlled Subject

Hernia; Bacterial diseases; Case studies


Bacterial Infections and Mycoses | Pulmonology



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