The Role of High Dose Corticosteroid (Methylperednisolone Pulse Therapy) in Treatment of Multi-organ Involvement After Bacterial Pneumonia and Pleural Empyema; a case series

The Role of High Dose Corticosteroid (Methylperednisolone Pulse Therapy) in Treatment of Multi-organ Involvement After Bacterial Pneumonia and Pleural Empyema; a case series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report The Role of High Dose Corticosteroid (Methylperednisolone Pulse Therapy) in Treatment of Multi-organ Involvement After Bacterial Pneumonia and Pleural Empyema; a case series Seyed Hossein Mirlohi, Sanaz Tajfirooz, Mitra Rouhi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5219169/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Mar, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 4 You are reading this latest preprint version Abstract Parapneumonic effusions and empyema usually occur after bacterial pneumonia. Inflammation plays an essential role in the occurrence of pneumonia and can lead to an autoinflammatory condition. In this study, we will present three cases including multi-organ involvement following pleural empyema that have been treated with pulse corticosteroid therapy. Apparently, pleural empyema can lead to multi-organ involvement due to underlying inflammatory processes. This condition is usually associated with symptoms and changes in laboratory parameters that manifest after empyema treatment or reappear after temporary recovery. Hence, managing this condition by pulse corticosteroid therapy can result in positive outcomes. Introduction: Pulmonary infection can cause pleural effusion known as parapneumonic effusion and empyema. This condition usually results in an increased number of morbidity and mortality, emphasizing the need for early intervention and comprehensive management. Bacterial infections are common causes of parapneumonic effusion, although they can also be caused by viral, fungal, and mycoplasma pneumonias, as well as tuberculosis. Approximately 2 to 12% of children with pneumonia cause parapneumonic effusion and about one-third of these children are hospitalized ( 1 , 2 ). The high inflammatory factors after the treatment of infection and the response to corticostroid pulse therapy suggests that an autoinflammatory disease occurred following empyema and bacterial pneumonia. In this paper, we will present three cases with evidence of multi-organ involvement following pleural empyema, that have been treated by pulse corticosteroid therapy. Case 1 An 8-year-old boy without any past medical history had been admitted to Children’s Medical Center Hospital in Tehran, with coughs and fever where he did not respond to outpatient treatment, and was then diagnosed with pneumonia. The chest X-ray showed unilateral involvement in favor of pneumonia and pleural effusion. Antibiotics were initiated for the patient, a chest tube was inserted and the pleural fluid was sent for analysis and culture. And the findings are as shown in Table 1 . Table 1 Pleural fluid analysis and culture results of Case 1 Volume (ml) 11 Color Yellow Appearance Turbid WBC (cells/µL) 2080 Poly (%) 56 Lymph (%) 44 Smear Bacteria were not seen Culture No growth Glucose (mg/dL) 63 LDH (U/L) 3706 Blood LDH (U/L) 370 pH 7 Moreover, PCR for influenza, Covid-19 and RSV were negative. The treatment by antibiotics and inserting the chest tube, led to the recovery of his symptomes and the decision was made to discharge him from the hospital. However, he suddenly experienced arrhythmia (PVC) and a rise in BUN, creatinine, CRP and ESR. Although the patient's fever and lung infection were treated, the complications brought up the possibility of an autoinflammatory disease. As a result, the patient was diagnosed with auto-inflammatory disease and received a pulse of corticosteroid (30 mg/kg) for three days. After receiving corticosteroids, the arrhythmia was treated and the levels of BUN, creatinine, CRP, and ESR became normal. Case 2 A 6-year-old girl without a past medical history had been admitted to Children's Medical Center in Tehran, with fever and respiratory distress and was diagnosed with community-acquired pneumonia. The initial chest sonography revealed a severe pleural effusion, including internal septa on the right side. The patient's regimen was initiated with broad-spectrum intravenous antibiotics. In addition, a chest tube was inserted, and the infected pleural fluid was drained and the tissue plasminogen activator (tPA) was started. Although her respiratory symptoms disappeared, the patient complained of moderate pain in her pelvic and knee joints. Likewise, the range of motion in her joints had reduced and fever still continued. Additionally, P-ANCA and ANA were positive, leading to the consideration of autoinflammatory disease, where methylprednisolone pulse was administered, resulting in an improvement in the patient's condition. Pleural fluid analysis and culture results of this case are showns in Table 2 and blood and pleural fluid biochemistry test results of the cas can be found in Table 3 . Table 2 Pleural fluid analysis and culture results of Case 2 Initial Final Volume 8 - Colour Red Yellow Appearance Turbid Clear WBC Moderate - Direct Smear Gram positive cocci and diplococci - Culture alpha-hemolytic Streptococcus viridans - Table 3 Blood and pleural fluid biochemistry test results of Case 2 Initial Final LDH(fluid) 10910 - pH(fluid) 7 - Albumin(fluid) 2.8 - Pro(fluid) 3700 - Blood Glucose 130 85 ESR 1hr 87 24 CRP 53.4 27.2 Ferritin 670 477 P-ANCA 19.5 - C-ANCA 6.5 - D-Dimer 4560 652 Case 3 A 5-year-old girl, without any past medical history was admitted to Children's Medical Center in Tehran with fever, respiratory symptoms and abdominal pain was then diagnosed with pneumonia. Her initial chest ultrasound demonstrated mild pleural effusion with a maximum thickness of 10 mm on the right side. However, her chest ultrasound showed mild pleural effusion with a maximum thickness of 6 mm on the left side. After four days since first imaging, her chest ultrasound demonstrated a multiloculated pleural effusion with septation of a maximum thickness of 29 mm in the right hemithorax, suggesting empyema. Moreover, the infected pleural fluid was drained using a chest tube and tPA was initiated. Following proper treatment, there was no evidence of effusion on sonography. The patient was suspected to have an autoinflammatory disease due to continuous fever, increase in inflammatory markers and cytopenia, despite the treatment of empyema. By taking into account the probability of multi-organ involvement, the patient underwent echocardiography resulting in RCA stenosis. Therefore, the decision was to administer high doses of corticostroid therapy. Table 4 shows pleural fluid analysis and culture results of case 3 and blood and pleural fluid biochemistry test results of this case is shown in Table 5 . Table 4 Pleural fluid analysis and culture results of Case 3 Initial Final Volume 4 - Colour Yellow Yellow Appearance Clear Semi-clear WBC 30 - Poly 85 - Lymph 15 - RBC 520 (90% fresh) - Direct Smear Bacteria were not seen - Table 5 blood and pleural fluid biochemistry test results of Case 3 Initial Final LDH(fluid) 1309 - pH(fluid) 7 - Albumin(fluid) 3.3 3.7 Pro(fluid) 5000 - Glucose(fluid) 70 - Blood Glucose 100 88 ESR 1hr 50 56 CRP 59.7 1 Ferritin 600 565 D-Dimer 3237 2010 Discussion Lung infections can cause pleural effusions, known as parapneumonic effusions. This condition imposes a substantial healthcare burden, due to the necessity of tube thoracostomy, intrapleural fibrinolytics, or surgical procedure. Furthermore, epidemiological studies indicate that pleural effusion appears to be increasing ( 2 , 3 ). In addition, bacterial pneumonia is more prone to cause parapneumonic effusions, while it can also occur along with other infections like fungal and viral pneumonia. Young children are more frequently affected, by rates ranging from 3.7 to 3.9 cases per 100,000 children younger than 4 years. Addtionally, the impact is equally distributed between men and women ( 4 ). There is probably a correlation between seasonal influenza and bacterial pneumonias ( 5 , 6 ), clarifying why Parapneumonic effusion/empyema is more prevalent in spring and winter ( 7 , 8 ). However, Covid-19 pandemic has caused significant changes for evaluating children with pulmonary complications, like indication of bronchoscopy procedure ( 9 ). Moreover, evidence has shown that some children that were hospitalized during influenza pandemics have been diagnosed with empyema on paraclinical evaluations. On the other hand, it is unclear how viral infections can cause empyema, yet they can make the environment vulnerable to bacterial co-infection with their secretions ( 6 , 10 ). Furthermore, parapneumonic effusion is not a rare condition and affects about 13% of pediatric pneumonia cases during hospitalization. In the first line of treatment, broad-spectrum antibiotics are administered, unless the effusion is large (more than 2 cm) and drainage is required. In addition, intrapleural fibrinolysis is usually recommended, when the fluid effusions are thick with loculation and septation. However, if these treatments do not respond, video-assisted thoracoscopic surgery (VATS) will be considered in the treatment plan ( 11 ). In order to clarify, two cases in our study required drainage of pleural effusion along with TPA administration, and one of them was only treated with antibiotic therapy. Surgery was not required in any cases. Although the sonography indicated that empyema had been treated, there were signs of multi-organ involvement. The involvement in the first case includes, increased BUN, creatinine, CRP and ESR along with arrhythmia. In the second case, moderate pain in the pelvis and joints along with positive P-ANCA and ANA were involved. The involvement in the third case includes, persistent fever, increased inflammatory markers, cytopenia and RCA stenosis. As a result, corticosteroid pulse therapy was considered for the patients with sn autoinflammatory condition, resulting in the complete recovery of all the cases. Additionally, inflammatory processes are the primary cause of parapneumonic effusion, treated by the use of corticosteroids as a powerful anti-inflammatory agent. Recent research suggest that 97 children with parapneumonic effusion were administered with methylprednisolone. This medication significantly reduced the duration of fever, white blood cell count and the length of hospitalization compared to the control group. In addition, fewer complications and less need for invasive interventions were reported compared to the patients who were only treated with antibiotics ( 12 ). Likewise, another study reported several cases of children with flu-like symptoms, who were then diagnosed with pleural effusion and were recovered with conventional treatment. Patients who were prescribed corticosteroids in the early stages showed favorable results and less complications ( 13 ). In addition, during the Covid-19 pandemic, a similar situation to the multisystem inflammatory syndrome in children (MISC) happened to be mutual in these cases ( 14 , 15 ). Conclusion In order to conclude, patients with pleural empyema can show multi-organ involvement due to underlying inflammatory processes. This condition is usually associated with symptoms and changes in laboratory parameters that are not resolved after empyema treatment or reappear after temporary recovery. Management of this condition with pulse corticosteroid therapy can provide favorable results. Declarations Ethical Approval The Ethics Committee of Tehran University of Medical Sciences has approved this study. (Code IR.TUMS.CHMC.REC.1403.134). Informed Consent The patient gave written informed consent to publish the current case report and any accompanying images. The editor-in-chief of this journal can review a copy of the written consent. Consent for Publication Complete written informed consent was obtained from the patient for the publication of this study and accompanying images. Availability of Data and Material The data that support the findings of this study have been deposited in Children’s Medical Centre’s Archive in Tehran, Iran with the case numbers 2137021 (Case 1), 1782695 (Case 2), 2145150 (Case 3) and can be provided to you from the corresponding author (S.H.M.), upon reasonable request. Competing Intrests The authors have no competig intrests to declare. Funding Not applicable Authors’ Contribution All authors have accepted the responsibility for the entire content of this manuscript and consented to its submission to the journal, reviwed all the results and approved the final version of the manuscript. All authors have accepted the responsibility for the entire content of this manuscript and consented to its submission to the journal, reviewed all the results and approved the final version of the manuscript. Specifically, S.H.M supervised and revised the writing process. S.T.wrote the main manuscript text. M.R. has collected the data. Clinical Trial Not Applicable Acknowledgments We extend our gratitude to the patient and her parents for generously contributing their time and valuable information to the study. References Finley C, Clifton J, FitzGerald JM, Yee J. Empyema: an increasing concern in Canada. Can Respir J. 2008;15:85–9. Farjah F, Symons RG, Krishnadasan B, Wood DE, Flum DR. Management of pleural space infections: a population-based analysis. J Thorac Cardiovasc Surg. 2007;133(2):346–51. e1. Grijalva CG, Zhu Y, Nuorti JP, Griffin MR. Emergence of parapneumonic empyema in the USA. Thorax. 2011;66(8):663–8. Byington CL, Spencer LY, Johnson TA, Pavia AT, Allen D, Mason EO, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis. 2002;34(4):434–40. Ampofo K, Bender J, Sheng X, Korgenski K, Daly J, Pavia AT, et al. Seasonal invasive pneumococcal disease in children: role of preceding respiratory viral infection. Pediatrics. 2008;122(2):229–37. Dawood FS, Chaves SS, Pérez A, Reingold A, Meek J, Farley MM, et al. Complications and associated bacterial coinfections among children hospitalized with seasonal or pandemic influenza, United States, 2003–2010. J Infect daiseases. 2014;209(5):686–94. Freij B, Kusmiesz H, Nelson J, McCracken G Jr. Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatr Infect disease. 1984;3(6):578–91. Hardie W, Bokulic R, Garcia VF, Reising SF, Christie CD. Pneumococcal pleural empyemas in children. Clin Infect Dis. 1996;22(6):1057–63. Ghanbari N, Badkoubeh F, Shirzadi R, Modaresi MR, Sadeghi B, Dahka ZH et al. Compare Indications and Findings of Fiberoptic Bronchoscopy in Children Before and During the COVID-19 Outbreak. Iran J Pediatr. 2023;33(3). Ampofo K, Herbener A, Blaschke AJ, Heyrend C, Poritz M, Korgenski K, et al. Association of 2009 pandemic influenza A (H1N1) infection and increased hospitalization with parapneumonic empyema in children in Utah. Pediatr Infect Dis J. 2010;29(10):905–9. Griffith D, Boal M, Rogers T. Evolution of practice in the management of parapneumonic effusion and empyema in children. J Pediatr Surg. 2018;53(4):644–6. Thimmesch M, Mulder A, Lebrun F, Piérart F, Genin C, Loeckx I, et al. Management of parapneumonic pleural effusion in children: is there a role for corticosteroids when conventional nonsurgical management fails? A single-center 15‐year experience. Pediatr Pulmonol. 2022;57(1):245–52. Olfat M, Mirlohi SH, Sharifzadeh M, Mohammadpour M. Is a New Post-infectious Inflammatory Phenomenon Emerging? Increasing Evidence of a New Multiple Organ Involvement Syndrome in Children. Brieflands; 2023. Nakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. Multi-system inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection: review of clinical presentation, hypothetical pathogenesis, and proposed management. Children. 2020;7(7):69. Guimarães D, Pissarra R, Reis-Melo A, Guimarães H. Multisystem inflammatory syndrome in children (MISC): a systematic review. Int J Clin Pract. 2021;75(11):e14450. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Mar, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 22 Oct, 2024 Editor assigned by journal 21 Oct, 2024 Submission checks completed at journal 21 Oct, 2024 First submitted to journal 07 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5219169","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":369031653,"identity":"137c9dab-07bf-4960-80dc-383d9bcb843b","order_by":0,"name":"Seyed Hossein Mirlohi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYDACCSBOYLBgMGBmPnAggccGyGVsPECEFgmgFrbEBx9k0kBaGghrAZEGDDzGhjNsDoO5eLXIz25g3fBwj4ScOTuDmTRPznm7te2HgbbU2ETj0mJw5wDbjYRnEsaWzQxp0jxnbidvO5MI1HIsLbcBlxaJBKCWAxKJGw4zHJPm7bmdbHYAqIWx4TBOLfIz4FoY26R5/51LNjv/EL8WhhtwLczMhjN4DtiZ3SBgi8GNxDaQFmODw2yMDz7wJCeY3QDakoDHL/Izko/d/HHARs7g/PkPwKi0szc7n/7wwYcaG9wOA0YcCjcRzE3AqRwLsCdF8SgYBaNgFIwMAABg/2aqZLhz3QAAAABJRU5ErkJggg==","orcid":"","institution":"Pediatric Respiratory and Sleep Medicine Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran","correspondingAuthor":true,"prefix":"","firstName":"Seyed","middleName":"Hossein","lastName":"Mirlohi","suffix":""},{"id":369031654,"identity":"ad5fc2fd-dd03-44e7-a18a-30a67d3d2836","order_by":1,"name":"Sanaz Tajfirooz","email":"","orcid":"","institution":"Children's Medical Center, Pediatric Center of Excellence, Tehran, Iran","correspondingAuthor":false,"prefix":"","firstName":"Sanaz","middleName":"","lastName":"Tajfirooz","suffix":""},{"id":369031655,"identity":"ea4b32c3-b2b0-4f5b-a4ad-8c3d66da94c5","order_by":2,"name":"Mitra Rouhi","email":"","orcid":"","institution":"Children's Medical Center, Pediatric Center of Excellence, Tehran, Iran","correspondingAuthor":false,"prefix":"","firstName":"Mitra","middleName":"","lastName":"Rouhi","suffix":""}],"badges":[],"createdAt":"2024-10-07 15:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5219169/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5219169/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-10719-7","type":"published","date":"2025-03-14T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":78688907,"identity":"3425e127-8308-4eda-8171-baed010c196d","added_by":"auto","created_at":"2025-03-17 16:06:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":592348,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5219169/v1/22691742-05c2-4693-9c38-4399dfc9bfb3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Role of High Dose Corticosteroid (Methylperednisolone Pulse Therapy) in Treatment of Multi-organ Involvement After Bacterial Pneumonia and Pleural Empyema; a case series","fulltext":[{"header":"Introduction:","content":"\u003cp\u003ePulmonary infection can cause pleural effusion known as parapneumonic effusion and empyema. This condition usually results in an increased number of morbidity and mortality, emphasizing the need for early intervention and comprehensive management. Bacterial infections are common causes of parapneumonic effusion, although they can also be caused by viral, fungal, and mycoplasma pneumonias, as well as tuberculosis. Approximately 2 to 12% of children with pneumonia cause parapneumonic effusion and about one-third of these children are hospitalized (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The high inflammatory factors after the treatment of infection and the response to corticostroid pulse therapy suggests that an autoinflammatory disease occurred following empyema and bacterial pneumonia. In this paper, we will present three cases with evidence of multi-organ involvement following pleural empyema, that have been treated by pulse corticosteroid therapy.\u003c/p\u003e"},{"header":"Case 1","content":"\u003cp\u003eAn 8-year-old boy without any past medical history had been admitted to Children\u0026rsquo;s Medical Center Hospital in Tehran, with coughs and fever where he did not respond to outpatient treatment, and was then diagnosed with pneumonia. The chest X-ray showed unilateral involvement in favor of pneumonia and pleural effusion. Antibiotics were initiated for the patient, a chest tube was inserted and the pleural fluid was sent for analysis and culture. And the findings are as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePleural fluid analysis and culture results of Case 1\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolume (ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eColor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYellow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppearance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTurbid\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWBC (cells/\u0026micro;L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePoly (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLymph (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmear\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBacteria were not seen\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCulture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo growth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlucose (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLDH (U/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood LDH (U/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003epH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMoreover, PCR for influenza, Covid-19 and RSV were negative. The treatment by antibiotics and inserting the chest tube, led to the recovery of his symptomes and the decision was made to discharge him from the hospital. However, he suddenly experienced arrhythmia (PVC) and a rise in BUN, creatinine, CRP and ESR.\u003c/p\u003e \u003cp\u003eAlthough the patient's fever and lung infection were treated, the complications brought up the possibility of an autoinflammatory disease. As a result, the patient was diagnosed with auto-inflammatory disease and received a pulse of corticosteroid (30 mg/kg) for three days. After receiving corticosteroids, the arrhythmia was treated and the levels of BUN, creatinine, CRP, and ESR became normal.\u003c/p\u003e "},{"header":"Case 2","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cp\u003eA 6-year-old girl without a past medical history had been admitted to Children's Medical Center in Tehran, with fever and respiratory distress and was diagnosed with community-acquired pneumonia. The initial chest sonography revealed a severe pleural effusion, including internal septa on the right side. The patient's regimen was initiated with broad-spectrum intravenous antibiotics. In addition, a chest tube was inserted, and the infected pleural fluid was drained and the tissue plasminogen activator (tPA) was started. Although her respiratory symptoms disappeared, the patient complained of moderate pain in her pelvic and knee joints. Likewise, the range of motion in her joints had reduced and fever still continued. Additionally, P-ANCA and ANA were positive, leading to the consideration of autoinflammatory disease, where methylprednisolone pulse was administered, resulting in an improvement in the patient's condition. Pleural fluid analysis and culture results of this case are showns in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and blood and pleural fluid biochemistry test results of the cas can be found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePleural fluid analysis and culture results of Case 2\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVolume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eColour\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYellow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppearance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTurbid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDirect Smear\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGram positive cocci and diplococci\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCulture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ealpha-hemolytic Streptococcus viridans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBlood and pleural fluid biochemistry test results of Case 2\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLDH(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003epH(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumin(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePro(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood Glucose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eESR 1hr\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFerritin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e477\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP-ANCA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eC-ANCA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD-Dimer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4560\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e652\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Case 3","content":"\u003cp\u003eA 5-year-old girl, without any past medical history was admitted to Children's Medical Center in Tehran with fever, respiratory symptoms and abdominal pain was then diagnosed with pneumonia. Her initial chest ultrasound demonstrated mild pleural effusion with a maximum thickness of 10 mm on the right side. However, her chest ultrasound showed mild pleural effusion with a maximum thickness of 6 mm on the left side. After four days since first imaging, her chest ultrasound demonstrated a multiloculated pleural effusion with septation of a maximum thickness of 29 mm in the right hemithorax, suggesting empyema. Moreover, the infected pleural fluid was drained using a chest tube and tPA was initiated. Following proper treatment, there was no evidence of effusion on sonography. The patient was suspected to have an autoinflammatory disease due to continuous fever, increase in inflammatory markers and cytopenia, despite the treatment of empyema. By taking into account the probability of multi-organ involvement, the patient underwent echocardiography resulting in RCA stenosis. Therefore, the decision was to administer high doses of corticostroid therapy. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows pleural fluid analysis and culture results of case 3 and blood and pleural fluid biochemistry test results of this case is shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePleural fluid analysis and culture results of Case 3\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVolume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eColour\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYellow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYellow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppearance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSemi-clear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePoly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLymph\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e520 (90% fresh)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDirect Smear\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBacteria were not seen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eblood and pleural fluid biochemistry test results of Case 3\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLDH(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003epH(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumin(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePro(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlucose(fluid)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood Glucose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eESR 1hr\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFerritin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e565\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD-Dimer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLung infections can cause pleural effusions, known as parapneumonic effusions. This condition imposes a substantial healthcare burden, due to the necessity of tube thoracostomy, intrapleural fibrinolytics, or surgical procedure. Furthermore, epidemiological studies indicate that pleural effusion appears to be increasing (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In addition, bacterial pneumonia is more prone to cause parapneumonic effusions, while it can also occur along with other infections like fungal and viral pneumonia. Young children are more frequently affected, by rates ranging from 3.7 to 3.9 cases per 100,000 children younger than 4 years. Addtionally, the impact is equally distributed between men and women (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). There is probably a correlation between seasonal influenza and bacterial pneumonias (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), clarifying why Parapneumonic effusion/empyema is more prevalent in spring and winter (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, Covid-19 pandemic has caused significant changes for evaluating children with pulmonary complications, like indication of bronchoscopy procedure (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Moreover, evidence has shown that some children that were hospitalized during influenza pandemics have been diagnosed with empyema on paraclinical evaluations. On the other hand, it is unclear how viral infections can cause empyema, yet they can make the environment vulnerable to bacterial co-infection with their secretions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, parapneumonic effusion is not a rare condition and affects about 13% of pediatric pneumonia cases during hospitalization. In the first line of treatment, broad-spectrum antibiotics are administered, unless the effusion is large (more than 2 cm) and drainage is required. In addition, intrapleural fibrinolysis is usually recommended, when the fluid effusions are thick with loculation and septation. However, if these treatments do not respond, video-assisted thoracoscopic surgery (VATS) will be considered in the treatment plan (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In order to clarify, two cases in our study required drainage of pleural effusion along with TPA administration, and one of them was only treated with antibiotic therapy. Surgery was not required in any cases. Although the sonography indicated that empyema had been treated, there were signs of multi-organ involvement. The involvement in the first case includes, increased BUN, creatinine, CRP and ESR along with arrhythmia. In the second case, moderate pain in the pelvis and joints along with positive P-ANCA and ANA were involved. The involvement in the third case includes, persistent fever, increased inflammatory markers, cytopenia and RCA stenosis. As a result, corticosteroid pulse therapy was considered for the patients with sn autoinflammatory condition, resulting in the complete recovery of all the cases.\u003c/p\u003e \u003cp\u003eAdditionally, inflammatory processes are the primary cause of parapneumonic effusion, treated by the use of corticosteroids as a powerful anti-inflammatory agent. Recent research suggest that 97 children with parapneumonic effusion were administered with methylprednisolone. This medication significantly reduced the duration of fever, white blood cell count and the length of hospitalization compared to the control group. In addition, fewer complications and less need for invasive interventions were reported compared to the patients who were only treated with antibiotics (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLikewise, another study reported several cases of children with flu-like symptoms, who were then diagnosed with pleural effusion and were recovered with conventional treatment. Patients who were prescribed corticosteroids in the early stages showed favorable results and less complications (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In addition, during the Covid-19 pandemic, a similar situation to the multisystem inflammatory syndrome in children (MISC) happened to be mutual in these cases (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn order to conclude, patients with pleural empyema can show multi-organ involvement due to underlying inflammatory processes. This condition is usually associated with symptoms and changes in laboratory parameters that are not resolved after empyema treatment or reappear after temporary recovery. Management of this condition with pulse corticosteroid therapy can provide favorable results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethics Committee of Tehran University of Medical Sciences has approved this study. (Code IR.TUMS.CHMC.REC.1403.134).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient gave written informed consent to publish the current case report and any accompanying images. The editor-in-chief of this journal can review a copy of the written consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplete written informed consent was obtained from the patient for the publication of this study and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study have been deposited in Children\u0026rsquo;s Medical Centre\u0026rsquo;s Archive in Tehran, Iran with the case numbers 2137021 (Case 1), 1782695 (Case 2), 2145150 (Case 3) and can be provided to you from the corresponding author (S.H.M.), upon reasonable request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Intrests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competig intrests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have accepted the responsibility for the entire content of this manuscript and consented to its submission to the journal, reviwed all the results and approved the final version of the manuscript. All authors have accepted the responsibility for the entire content of this manuscript and consented to its submission to the journal, reviewed all the results and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eSpecifically, S.H.M supervised and revised the writing process. S.T.wrote the main manuscript text. M.R. has collected the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eWe extend our gratitude to the patient and her parents for generously contributing their time and valuable information to the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFinley C, Clifton J, FitzGerald JM, Yee J. Empyema: an increasing concern in Canada. Can Respir J. 2008;15:85\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarjah F, Symons RG, Krishnadasan B, Wood DE, Flum DR. Management of pleural space infections: a population-based analysis. J Thorac Cardiovasc Surg. 2007;133(2):346\u0026ndash;51. e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrijalva CG, Zhu Y, Nuorti JP, Griffin MR. Emergence of parapneumonic empyema in the USA. Thorax. 2011;66(8):663\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eByington CL, Spencer LY, Johnson TA, Pavia AT, Allen D, Mason EO, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis. 2002;34(4):434\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmpofo K, Bender J, Sheng X, Korgenski K, Daly J, Pavia AT, et al. Seasonal invasive pneumococcal disease in children: role of preceding respiratory viral infection. Pediatrics. 2008;122(2):229\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDawood FS, Chaves SS, P\u0026eacute;rez A, Reingold A, Meek J, Farley MM, et al. Complications and associated bacterial coinfections among children hospitalized with seasonal or pandemic influenza, United States, 2003\u0026ndash;2010. J Infect daiseases. 2014;209(5):686\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreij B, Kusmiesz H, Nelson J, McCracken G Jr. Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatr Infect disease. 1984;3(6):578\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHardie W, Bokulic R, Garcia VF, Reising SF, Christie CD. Pneumococcal pleural empyemas in children. Clin Infect Dis. 1996;22(6):1057\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhanbari N, Badkoubeh F, Shirzadi R, Modaresi MR, Sadeghi B, Dahka ZH et al. Compare Indications and Findings of Fiberoptic Bronchoscopy in Children Before and During the COVID-19 Outbreak. Iran J Pediatr. 2023;33(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmpofo K, Herbener A, Blaschke AJ, Heyrend C, Poritz M, Korgenski K, et al. Association of 2009 pandemic influenza A (H1N1) infection and increased hospitalization with parapneumonic empyema in children in Utah. Pediatr Infect Dis J. 2010;29(10):905\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGriffith D, Boal M, Rogers T. Evolution of practice in the management of parapneumonic effusion and empyema in children. J Pediatr Surg. 2018;53(4):644\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThimmesch M, Mulder A, Lebrun F, Pi\u0026eacute;rart F, Genin C, Loeckx I, et al. Management of parapneumonic pleural effusion in children: is there a role for corticosteroids when conventional nonsurgical management fails? A single-center 15‐year experience. Pediatr Pulmonol. 2022;57(1):245\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlfat M, Mirlohi SH, Sharifzadeh M, Mohammadpour M. Is a New Post-infectious Inflammatory Phenomenon Emerging? Increasing Evidence of a New Multiple Organ Involvement Syndrome in Children. Brieflands; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. Multi-system inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection: review of clinical presentation, hypothetical pathogenesis, and proposed management. Children. 2020;7(7):69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuimar\u0026atilde;es D, Pissarra R, Reis-Melo A, Guimar\u0026atilde;es H. Multisystem inflammatory syndrome in children (MISC): a systematic review. Int J Clin Pract. 2021;75(11):e14450.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5219169/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5219169/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eParapneumonic effusions and empyema usually occur after bacterial pneumonia. Inflammation plays an essential role in the occurrence of pneumonia and can lead to an autoinflammatory condition. In this study, we will present three cases including multi-organ involvement following pleural empyema that have been treated with pulse corticosteroid therapy. Apparently, pleural empyema can lead to multi-organ involvement due to underlying inflammatory processes. This condition is usually associated with symptoms and changes in laboratory parameters that manifest after empyema treatment or reappear after temporary recovery. Hence, managing this condition by pulse corticosteroid therapy can result in positive outcomes.\u003c/p\u003e","manuscriptTitle":"The Role of High Dose Corticosteroid (Methylperednisolone Pulse Therapy) in Treatment of Multi-organ Involvement After Bacterial Pneumonia and Pleural Empyema; a case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-05 15:27:10","doi":"10.21203/rs.3.rs-5219169/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-22T11:16:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-21T08:58:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-21T08:57:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-10-07T14:58:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab1d807c-9df0-43b3-adc0-f3476c689031","owner":[],"postedDate":"November 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T15:59:44+00:00","versionOfRecord":{"articleIdentity":"rs-5219169","link":"https://doi.org/10.1186/s12879-025-10719-7","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-03-14 15:57:06","publishedOnDateReadable":"March 14th, 2025"},"versionCreatedAt":"2024-11-05 15:27:10","video":"","vorDoi":"10.1186/s12879-025-10719-7","vorDoiUrl":"https://doi.org/10.1186/s12879-025-10719-7","workflowStages":[]},"version":"v1","identity":"rs-5219169","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5219169","identity":"rs-5219169","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}