CRA77 A JUSTIFIABLE RISK: FIBRINOLYTICS IN POST-SPLENECTOMY THALASSAEMIC WITH EMPYEMA

Muhamad Thaqif Sidek¹, Nik Nuratiqah Nik Abeed¹, Boon Hau Ng¹, Andrea Ban Yu Lin¹, Nor Safiqah Sharil²

¹Respiratory Unit, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
²Faculty of Medicine and Science, Universiti Sains Islam Malaysia, Negeri Sembilan, Malaysia

Background
Empyema thoracis may be associated with splenic bed abscess following splenectomy, occurring either via hematogenous spread or through direct contiguous extension. Herein, we report a case of empyema thoracis following splenectomy in a young woman with transfusion-dependent thalassaemia major.

Case Presentation
A 29-year-old woman with thalassaemia presented one week post-splenectomy with fever and purulent wound discharge. She was admitted for a surgical site infection and developed a dry cough, dyspnoea, and left-sided pleuritic chest pain in ward. Contrast-enhanced computed tomography (CECT) of the thorax and abdomen revealed a splenic bed collection and a large left pleural effusion. A pigtail catheter was inserted, and pleural fluid culture grew Enterobacter roggenkampii. Full blood count showed anaemia with a haemoglobin level of 6.8 g/dL. Despite targeted antibiotics, minimal effusion was drained and fever persisted. Repeat CECT thorax showed a large, complex, multiloculated left pleural effusion, and thoracic ultrasound revealed multiseptated, non-communicating locules. A second pigtail catheter was inserted, and intrapleural fibrinolytic therapy was administered into both locules for three cycles over a three-day period. More than 1000 ml of haemoserous effusion was successfully drained. After two weeks of intravenous antibiotics followed by two weeks of oral antibiotics, the patient showed clinical improvement. At her three-month outpatient follow-up, both clinical and radiological resolution were observed.

Discussion
Fibrinolytic therapy, even in high-risk patients—particularly those with a history of surgery, thalassaemia, low haemoglobin levels, and increased bleeding risk—can be considered a safe and justifiable approach. It significantly reduces the need for surgical decortication and helps prevent progression to severe sepsis.