Empyema with pleuropulmonary mucormycosis

Pleuropulmonary mucormycosis is relatively rare disease and that too localised disease is very rare but has got better prognosis. Maintaining a high level of suspicion is important in right clinical setting with pleuropulmonary involvement that fails to antibacterial agent either clinically or radiologically.

[Pulmonary mycobacterium intracellulare infection complicated with pneumothorax and chronic empyema]

A 75-year-old woman who had been treated for pulmonary Mycobacterium intracellulare infection was admitted to a nearby hospital because of hemoptysis, right pneumothorax, and empyema. She had been treated by thoracic drainage and pleural lavage, but was reffered to our hospital because of refractory empyema. Her chest radiograph and chest computed tomography( CT) showed right chronic empyema of which pleural aspirate was smear positive for acid-fast bacilli and positive for the polymerase chain reaction method(PCR)-Mycobacterium intracellulare. Serum levels of white blood cell and C-reactive protein(CRP) were found to be slightly elevated. She was treated with combined use of ethambutol, rifampicin, clarithromycin, and kanamycin and with pleural curettage by thoracoscopic surgery. After surgery additional treatment was done using urokinase which was administered into the thoracic cavity via an thoracic tube. Chronic empyema gradually improved with the treatment and the pleural effusion became bacterial free, enabling the patient to discharge from hospital without thoracic drainage.

[Intrathoracic washing with urokinase was effective for empyema with atelectasis]

A 60-year-old man had a medical examination because of fever in the emergency hospital and had a diagnosis of pneumonia and was treated, but he was admitted to our hospital 2 days later because there was not the improvement of his symptom. The chest computed tomography(CT)image showed multilocular pleural effusions and lower lobe atelectasis with the air bronchogram on the left side. We diagnosed the case as empyema and inserted a catheter, but drainage was very few and injected 60,000 urokinase units for 3 days from the next day. We removed a drain 2 days after the 3rd infusion, and the pleural thickening became mild, and atelectasis was gradually improved in the chest CT image, and the inflammatory reaction was reduced, too. The intrathoracic washing with urokinase was thought to be effective for empyema with atelectasis.

Empyema thoracis in children: a short term outcome study

This study prospectively evaluates clinical course of pyogenic empyema thoracis in 25 children (2 mo to 12 y) treated with injectable antibiotics and chest tube drainage, and followed for 6 weeks. The median (range) age at presentation was 3 y (4 mo to 11 y). The pleural fluid culture was positive in 24% of patients. Staphylococcus aureus was the most commonly isolated organism. The median (range) duration of injectable antibiotics was 14(14-52) d; median duration of total antibiotics (injectable and oral) was 4 weeks. The median (range) duration of chest tube insertion and hospital stay was 8(5-45) and 14(14-56) days, respectively. All patients were discharged without any surgical intervention besides chest tube drainage. At discharge, pleural thickening was present in 84% and crowding of ribs was seen in 60% of the subjects on radiological examination. All these patients were asymptomatic at discharge. Chest deformity was present in 20% of the patients at 6-weeks follow up. Antibiotics and chest tube drainage is an effective method of treating pyogenic empyema thoracis in children in resource-poor settings.

Empyema and psoas abscess in a previously undiagnosed diabetic patient

A 48-year-old man presented with a 2-month history of polyuria, polydypsia, chest pain, fever, cough and extreme weight loss. He was diagnosed with diabetic ketoacidosis and investigations revealed widespread infection with an empyema complicated by bronchopleural fistula, and iliopsoas, suprapubic and periarticular abscesses. Streptococcus milleri was cultured from all sites. A multidisciplinary medical and surgical approach was required for treatment. This case highlights the immunosuppression, and life-threatening complications arising from undiagnosed diabetes mellitus.

[Treatment of empyema thoracis in children]

Empyema, an accumulation of infected fluid in the thoracic cavity, is commonly secondary to bacterial pneumonia in children. Despite the high prevalence and availability of many medical treatment options, there is no general consensus on the optimal management approach, which would lead to full and rapid recovery. Especially, there are the big differences in treatment options for the child with empyema. Regardless of the differences in the procedures, the ultimate outcomes are good. This article reviews the current literature and discusses the important considerations in managing these patients. This paper describes thoracoscopic and open thoracic surgery procedures in children. The authors present their own observations based on years of experience in the treatment of thoracic empyema.

Pulmonary emergencies: pneumonia, acute respiratory distress syndrome, lung abscess, and empyema

This article describes the clinical presentation of pneumonia, acute respiratory distress syndrome, lung abscess, and empyema: life-threatening infections of the pulmonary system. The etiology and risk factors for each of these conditions are described, diagnostic approaches are discussed, and evidence-based management options are reviewed.

Streptococcus anginosus group disseminated infection: case report and review of literature

Streptococcus anginosus group is widely known for its ability to cause invasive pyogenic infections. There are very few reports of disseminated infections sustained by members of this streptococcal group. We report a case of a highly disseminated infection and analyse previous literature reports. Disseminated pyogenic infection has been defined as an infection affecting two or more of the following organs/systems: central nervous system, lung, liver and spleen. We performed a PubMed search using the terms: S. milleri, S. anginosus, brain abscess, pulmonary abscess, hepatic abscess, spleen abscess. We reviewed 12 case reports including the one presented in this paper. Underlying conditions such as dental infections, malignancy, gastrointestinal and respiratory tract disease accounted for 42% of cases. No definite endocarditis was encountered, even though positive blood cultures were found in 67% of patients. Concomitant brain-liver, brain-lung and brain-spleen involvement occurred in 50%, 42% and 8% of cases respectively. Ninety-one percent (91%) of patients were treated with β-lactams, and surgical procedures were performed in 67% of patients. Infections caused by S. anginosus group members are satisfactorily treated with penicillin G and cephalosporins. It is very important to associate surgery to antimicrobial chemotherapy in order to achieve a full or nearly full clinical recovery.

[Actinomyces empyema treated with decortications]

Actinomyces infections are rare infections, involving the head and neck, abdominal cavity, and the lung. We report a case of a 66 year old woman with shortness of breath and a pleural effusion from which Actinomyces meyeriwas cultured. The diagnosis was confirmed by the polymerase chain reaction technique. The infection was successfully treated with a combination of ampicillin and surgical decortication. Due to their rarity, Actinomyces infections are not often suspected. These infections are difficult to diagnose due to specific microbiologic requirements for isolation of Actinomyces. In many reviewed cases of Actinomyces infection, patients underwent surgery for presumed cancer but were eventually diagnosed as being infected with actinomycosis. Due to lack of improvement of our patient, surgical decortication was performed, which led to a successful outcome.

Management of thoracic empyema: review of 112 cases

To review our experience in treatment of patients with thoracic empyema at a teaching hospital chart of patients were retrospectively reviewed over a 72-month period. A total of 112 patients (94 men, 18 women, mean age: 39, range: 6-89 years) underwent therapeutic procedures for thoracic empyema between 2001-2006. The causes of empyema included parapneumonic empyema (60.7%), thoracic trauma (20.5%), surgical procedures (7.1%) and seeding from an extra-pulmonary source (11.7%). Multiloculated empyemas were documented in 45 patients (40%). Insertion of chest tube was the first procedure in 103 patients (92%). Nineteen patients (17%) were treated by thoracotomy, ten patients (8.9%) had fibrinolytic therapy, eight patients (7.2%) underwent video assisted thoracic surgery (VATS) and sixteen patients (14.3%) had subsequent radiologic-guided drainage. Thoracotomy-Decortication was successful in 90% of patients undergoing surgery and the least successful intervention was tube thoracostomy alone. Twelve of 112 patients (10.7%) died in the hospital including one patient in the thoracotomy group. Long-term follow-up was available in 67 patients including all of patients requiring surgery and fibrinolytic therapy. Thirty four patients (50%) obtained complete functional recovery. Simple drainage as the first procedure for the treatment of thoracic empyema has a high failure rate. Selection of a therapeutic option should be based on age, underlying disease, stage of the empyema, state of the loculation, local expertise and availability. Surgical procedures such as VATS or thoracotomy are recommended as the first procedure in elderly patients and advanced empyema.

[Optimization of treatment methods of surgical complications in lung cancer]

The present report analyses the immediate and long-term results of treatment of surgical complications in 998 patients with lung cancer. There were complications in 37,5% of the cases, with a fatality rate of 14,7%. The most frequent complications were as follows: postoperative empyema with bronchopleural fistula (41,3%), bleeding (12,0%), pneumonia (9,8%), pulmonary arteries embolism (8,1%) and heart rhythm disorders (8,1%). Adjuvant and neoadjuvant treatment does not increase the rate of surgical complications as compared to just surgery alone (p = 0,1). Postoperative empyema with bronchopleural fistula requires intensive therapy, affects the quality of life of patients but does not decrease survival rates as compared to patients at the same stages of disease with uncomplicated course (p = 0,001). Timely drainage of pleural cavity accompanied by its adequate sanation does not differ (p = 0,1) from usage thoracoplasty (MS 29,9 months to 33,2 months).

[Lung abscess and thoracic empyema: retrospective analysis in an internal medicine department]

INTRODUCTION

Lung abscess is a collection of necrotic and suppurated tissue located at the pulmonary parenchyma. Empyema is defined as the presence of pus in the pleural space.

OBJECTIVES

To study the clinical and microbiological characteristics, treatment and prognosis of patients with lung abscess and/or empyema admitted to an Internal Medicine ward.

METHODS

A retrospective analysis of medical records was performed, including all patients admitted to an Internal Medicine ward for lung abscess or empyema, between 2000 and 2008.

RESULTS

Thirty patients were included (22 males/ eight females), accounting for 0.18% of all patients admitted in this ward in the same period. Three patients had pulmonary abscess, 18 empyema, and nine both diseases. The average age was 68.5 years (31 to 90). The most frequent complaints were dyspnoea (90%), fever (73.3%), cough (66.7%), weight loss (60%) and chest pain (53.3%). The most frequent associated disorders were stroke associated disability (46.7%), heart failure (43.3%) and arterial hypertension (33.3%). Thoracentesis was performed in all patients with empyema. In one patient with lung abscess an anaerobic microorganism was identified. In patients with empyema, cultures were positive in 61.1% of cases, with a slight predominance of methicillin-resistant Staphylococcus aureus (27.3%) and Prevotella intermedia (18.2%). In patients with both abscess and empyema, cultures of the abscess were positive in 44.4% and of the pleural fluid in 33.3%, with no predominant microorganism. Empiric antimicrobial therapy was started in all patients and later adapted to the antibiotic sensitivity test results. Surgery was performed in three patients. Seven patients (23.3%) died during admission. The average age of the patients who died was 81.3 years and of those who survived was 64.5 years.

CONCLUSION

Lung abscess and empyema are infrequent diseases in an Internal Medicine ward, affect mostly males and have unspecific clinical manifestations. The chest X-ray, computed tomography (CT) and thoracentesis were the main diagnostic tests. Most cultures were negative. Medical treatment was the most frequent choice, with surgery being used in 10% of cases. Older age and multiple associated conditions were associated with a worse prognosis.

Computed tomographic modeling before and after treatment for posttraumatic empyema: early decortication is superior to catheter drainage

BACKGROUND

Posttraumatic empyema is relatively unusual. There are little data comparing the results of various interventions, and no data that have documented the restoration of lung volumes.

METHODS

We compared patients with posttraumatic empyema who were treated with catheter drainage or decortication. Computed tomographic scans of the chest were obtained before and after treatment, and computed tomographic modeling was used to determine the change in lung volumes after each intervention.

RESULTS

From 2006 to 2010 there were 478 patients admitted after sustaining chest trauma and 25 (5%) developed an empyema. The definitive treatment was decortication in 15 patients (60%) and chest tube or catheter drainage in 10 (40%). Four patients (16%) initially treated with chest tubes later required decortication. The overall complication rate was 33% for decortication and 100% for catheters. There was no significant difference in days of mechanical ventilation (catheter-median 0, SD±13 days; decortication-median 10, SD±12 days; p=0.6), total length of stay (catheter-median 15, SD±36 days; decortication-median 27, SD±17 days; p=0.9), and intensive care unit days (catheter-median 6, SD±19 days; decortication-median 15, SD±17 days; p=0.5). After chest tube drainage, the lung volume increased on average by 751 cubic centimeters (range, 99 to 1,982 cc). After decortication, the lung volume increased on average by 1,519 cc (range, 616 to 2,916, p=0.02).

CONCLUSIONS

Decortication for posttraumatic empyema results in higher postoperative lung volumes than catheter drainage and has a lower complication rate. Decortication is more effective in restoring full pulmonary capacity in the treatment of posttraumatic empyema.

Increased incidence of empyema in Polynesian children

AIM

The aim of this study was to review the epidemiology, treatment and outcome of surgically managed empyema in children.

METHOD

A retrospective review was undertaken of all surgically managed empyema at Starship Children's Hospital (Auckland, New Zealand) from 1 July 2003 to 30 June 2008.

RESULTS

Of the 93 children diagnosed with empyema, 62 were managed surgically (55 VATS, 7 thoracotomy) and 31 with tube thoracostomy alone. 71% were of Maori or Pacific ethnicity despite making up just 30% of the New Zealand paediatric population (p<0.0001). Median duration of chest drainage following VATS was 3 days and postoperative hospital stay 14 days. There was a 5% conversion of VATS to thoracotomy. The VATS complication rate was 16%: one intraoperative cardiorespiratory arrest following rupture of an intrapulmonary abscess into the bronchial tree, two contralateral empyema, one recurrent empyema, four air leaks and a wound infection.

CONCLUSION

For the first time increased incidence of empyema in the Polynesian population has been documented. Severity of empyema may be higher within the Polynesian population affecting treatment outcome.

[Complex treatment of pulmonary abscesses and pleural empyema in patients with severe thoracic trauma]

The results of complex treatment of 40 injured persons with severe thoracic trauma, in whom pulmonary abscesses and pleural empyema had occurred postoperatively, were analyzed. Complex treatment of pulmonary abscesses and pleural empyema, using the methods of a local superhighfrequency irradiation of purulent foci have promoted their accelerated regression occurrence and reduction of a systemic inflammatory reactions severity, as well as prophylaxis of secondary purulent-septic complications, permitting to achieve lethality lowering and to escape practically reoperations performance.

[Pleural drainage for the treatment of the acute empyema]

Treatment of 675 patients with the acute pleural empyema was analyzed and supplemented with anatomometric investigations of costophrenic sinus in 60 male corpses. Technical features of effective pleural drainage were fundamentally substantiated and depicted in pictures and schemes. The original method of the retrograde thoracoscopic drainage with the original device were suggested.

[Treatment of empyema]

Pleural infections constitute a group of diseases, among which the most severe one is empyema. Their incidence is increasing. The major predisposing factor is alcoholism. The pleura becomes most commonly infected in connection with pneumonia. The condition always requires an effective antibiotic therapy. With the exception of an effusion of less than one centimeter, a sample should always be taken from the pleural fluid. The appearance and acidity of the fluid dictate the need for drainage. If the disease does not seem to improve, the need for surgical treatment should be assessed without delay.