Non-typhi Salmonella empyema: Case report and review of the literature

A case of non-typhi Salmonella empyema is reported. A review of the literature over the past century found only 13 other empyemas due to Salmonella typhimurium and 25 cases of other non-typhi Salmonella. A review of pleuropulmonary disease due to non-typhi Salmonella is provided along with management recommendations.

Pseudomonas aeruginosa pleural empyema in a preterm infant

Pleural empyema is defined as the pyogenic infection of the pleural space with purulent effusion. Although it is frequently seen in children and therapy protocols have been developed for it, there are only a few reports about pleural empyema in newborn infants. To our knowledge, just one preterm infant has been reported in the literature. In this article, we report an male infant born at 29 weeks of gestation who had pleural empyema on the 53rd day of life. Multidrug-resistant Pseudomonas aeruginosa (P. aeruginosa) was isolated from his pleural fluid culture. We suggest that this is the first preterm infant with P. aeruginosa empyema.

Chronic expanding hematoma with bronchopleural fistula and empyema space

Chronic expanding hematoma of the thorax is not typically accompanied by a bronchopleural fistula or purulent lesion. We report an extremely rare case of chronic expanding hematoma with a bronchopleural fistula and empyema space in a 66-year-old man with a history of tuberculous pleurisy admitted because of fever and bloody sputa. Computed tomography and a magnetic resonance imaging revealed a huge mass and an air space in the right thorax. A fiber-optic bronchoscope examination showed hemorrhagic effusion from the apical bronchus of the right lower lobe. First, open-window thoracostomy was undertaken to control the septic state and to prevent aspiration of infected pleural fluid. At operation, air leakage was found at the most superior portion in the rear of the thoracic empyema space; this was thought to be from the bronchopleural fistula. Enterococcus casseliflavus was detected in cultures for bacteria of the effusion from the empyema space. After an improvement of his general condition, a radical operation, including the complete extirpation of the hematoma and intrathoracic muscle transposition using the latissimus dorsi muscle, was successfully performed.

Thoracic empyema - a review based on three cases reports

Complicated parapneumonic effusion is one in which an invasive procedure is necessary for its resolution and empyema means pus in the pleural space. An early diagnosis and therapy of these conditions results in less morbidity and mortality. CT of the chest is important to study complex pleural effusions. Loculated effusions, those occupying more than 50% of the thorax, or which show positive Gram stain or bacterial culture, or a purulent effusion with a pH below 7.20, with a glucose level below 60 mg/dl or a LDH level more than three times the upper limit of normal for serum, are indications for an invasive procedure. These characteristics result from the evolution of a not well treated parapneumonic effusion, through the three stages: (1) exsudative; (2) fibrinopurulent; (3) fibrotic. Depending on the stage therapeutic methods vary from therapeutic thoracentesis, insertion of a chest tube with or without instillation of fibrinolytics, video-assisted thoracoscopic surgery, and lung decortication. A review of all these aspects are done based on a series of three cases reports with very different clinical presentation: one patient with empyema by Streptococcus pyogenes and that died rapidly due to massive hemoptysis; a patient with empyema due to acute pneumonia developing during an airflight; a patient with empyema and bacteraemia by Streptococcus pneumonia leading to the diagnosis of an unknown HIV infection.

[Open pleural window at treatment of the advanced thoracic empyema: 20 high-risk patients' treatment experience]

The aim of the retrospective clinical study was the analysis of the 20 high-risk patients operated in our department within years 2000-2008 by the modified Eloesser procedure for the serious thoracic empyema.

MATERIAL AND METHODS

We have analyzed the data of the 17 men and 3 women. The most important objectives were the cause of the disease, type of procedure, perioperative mortality, length of stay and subsequent procedures. The underlying disease was the malignant intrathoracic disease in 40%, diabetes mellitus was found in 25%. The cause of empyema was pleuropneumonia in 45%, postresectional empyema occurred in 35%.

RESULTS

There were two perioperative deaths (10%), remaining patients were all dismissed in a stabilized condition the 22nd postoperative day at average. Six subsequent reconstructive procedures were performed. There was no early death for the postpneumonectomy empyema.

CONCLUSION

In case of the serious pleural empyema in a high-risk patient is the modified Eloesser procedure safe and life saving surgical operation. The timing of the procedure and correct indication for surgery are essential.

[Two cases of anaerobic empyema including Actinomyces]

We report 2 cases of empyema including Actinomyces spp. Case 1 was a 66-year-old man with fever and left pleural effusion, Actinomyces israelii and 2 other microbes were isolated. Case 2 was a 52-year-old male inpatient who developed empyema during treatment of upper gastrointestinal bleeding. Actinomyces odontolyticus and 3 other microbes were cultured in pleural effusion. Empyema caused by Actinomyces spp. is rare, in particular Actinomyces odontolyticus is rarely isolated and only 4 cases have been reported in Japan.

Open thoracic window: a useful alternative for retained infected pleural collections in critically ill trauma patients

Historically, tube thoracostomy, image-guided drainage, or an open thoracotomy has been indicated as the standard procedure for the management of patients with retained infected pleural collections (RIPC). These infections can be a debilitating and potentially lethal complication in already critically ill trauma patients. The purpose of this review was to evaluate the usefulness of an open thoracic window (OTW) as definitive therapy for the management of RIPC refractory to conventional therapies. The medical records of patients who underwent an OTW for RIPC were reviewed for the following: demographic data, primary diagnosis, clinical findings that explained the failure of the conventional management, bacteriology of the retained collection, and final outcome. Over a 3-year period, eight critically ill trauma patients who had sustained multiple system trauma and developed a RIPC were identified (six males and two females; average age, 47 years). Of the eight patients identified, six collections were in the right and two in the left pleural cavity. Staphylococcus aureus and Acinetobacter were the two most common bacterial isolates from these collections. All patients had undergone multiple and unsuccessful drainage attempts by thoracostomy tubes. Additionally, two of the patients also underwent image-guided drainage procedures, which proved to be unsuccessful. After creation of the OTW, all patients had complete resolution of the RIPC, and all were discharged alive from the hospital. During outpatient follow up, the OTW was found to have completely healed and required no further surgical intervention. The creation of long-term pleural drainage, with an OTW, facilitates and expedites the resolution of persistent infected pleural collections by providing more efficient surgical drainage and mechanical débridement. Our experience also shows this uncommon operation to be an effective alternative when conventional measures have failed.

Clinical analysis of cases of empyema due to Streptococcus milleri group

In this study we analyzed 15 cases of empyema due to Streptococcus milleri group treated between January 2000 and December 2007. The majority (87%) were men, and the mean patient age was 62 years (range 36 to 83). An underlying disease was present in 14 of 15 cases. Six cases were complicated by pneumonia. Polymicrobial infection with S. milleri group was recognized in four patients. Most patients underwent chest tube drainage (87%), and all received antibiotic treatment (100%). The average duration of chest tube drainage was 8.4 days and that of antibiotic treatment was 14.0 days. Six cases (40%) underwent video-assisted thoracoscopic surgery for decortication. The duration of hospitalization was 19.6 days. The clinical effect of treatment was comparatively good (93%), and the prognosis was also good (mortality rate 7%).

[Pleural empyema caused by Gemella species: a rare condition]

Three cases of pleural empyema caused by Gemella species--2 caused by Gemella morbillorum and 1 caused by G haemolysansare reported. Microbiological characteristics, predisposing factors, and treatment are reviewed and all cases published in the literature are analyzed.

Recombinant tissue plasminogen activator in the treatment of pleural infections in adults

BACKGROUND

Intrapleural recombinant tissue plasminogen activator (r-TPA) has been successfully evaluated in pediatric patients with complicated parapneumonic pleural effusion (CPE) and pleural empyema (PE). Yet, there is no data concerning r-TPA in adults with CPE/PE. The aim of our study was to investigate the efficacy and complications of r-TPA in adult patients with CPE/PE.

METHODS

Twenty consecutive patients (mean age 50+/-18.9 years) with pleural infection (14 CPE and 6 PE) were included. Chest tube was inserted under guidance of chest ultrasound and/or computed tomography. After failure of pleural fluid drainage, 25mg of r-TPA was administered intrapleurally in a single daily dose. The evaluation was made according to imaging and clinical status.

RESULTS

The mean volume of fluid increased significantly after r-TPA administration (p<0.0001). White blood cells count (WBC) and C-reactive protein (CRP) were significantly improved after r-TPA instillations (both p<0.0001). Significant clinical and imaging improvement was noted in all but one patient after r-TPA administration (overall p<0.0001). Complications observed were mild: pain in 4 (25%) and local bleeding in 3 (15%) patients. The median number of r-TPA instillations was 3 (range 2-5).

CONCLUSION

Intrapleural instillation of r-TPA at a dose of 25 mg is a well-tolerated and effective treatment in 95% of our adult patients with CPE/PE.

[Videothoracoscopic interventions in the treatment of pleural empyema]

The experience of treatment of patients, suffering an acute or chronic pleural empyema (PE), using modern videothoracoscopic technique, was presented. The methods of operative interventions performance, using general narcosis or local anesthesia, in different severity of affection and etiology of purulent process were depicted. Comparative estimation of videothoracoscopic operations vs other methods, performed for PE, was performed. Intraoperative AIG-laser coagulation and electrocoagulation of pleural fistulas were applied for the treatment efficacy rising. There were noted the treatment efficacy rising, relatively low rate of postoperative complications (7.5%), the shortening of the patients stationary treatment period as well as postoperative rehabilitation and disability periods. All the patients are alive.

[Treatment-refractory-dental-extraction-associated pyothorax involving infection by 2 species of oral originated bacteria requires surgical debridement by video assisted thoracoscopic surgery (VATS)]

Cases of septic pulmonary embolism (SPE) diagnosed clinically by CT after dental extraction rarely include verification of bacteria from the local infection site. We report the case of a 70-year-old man without background disease suffering severe pyothrax after dental extraction. We detected two species of oral bacteria from his pleural effusion. Treatment was so difficult that it required surgical debridement by video assisted thoracoscopic surgery (VATS), even after the appropriate administration of antibiotics. According to the American Heart Association (AHA) prophylaxis guidelines for preventing infective endocarditis indicate that it is uncommon to prescribe antibiotics to patients without background disease after dental extraction. No appropriate Japanese guidelines exist considering the prevention of SPE causing severe pyothorax as in our case. The hematogenous spread of bacteria such as SPE caused by sepsis after tooth extraction thus requires more attended careful consideration in clinical practice if patients are to be properly protected against potentially serious complications.

[Endovascular management of a left subclavian artery lesion following thoracoplasty for bronchopleural fistula and empyema secondary to aspergillus fumigatus]

Massive and/or recurrent hemoptysis is a clear indication for surgical treatment of pleuropulmonary aspergilloma, despite the incidence of postoperative morbidity and mortality. Thoracoplasty has been widely used for 20 years and is still indicated in these cases, following lobectomy, even though the procedure is not free of complications. We report the case of a patient who required thoracoplasty to treat a pleuropulmonary aspergilloma invading the chest wall. Subsequent placement of an aortic stent-graft was required due to tearing of the left subclavian artery.

Direct detection of Clostridium sordellii in pleural fluid of a patient with pneumonic empyema by a broad-range 16S rRNA PCR

We report the case of a 56-y-old male admitted with a left-sided post-pneumonic empyema. Clostridium sordellii DNA was directly detected in its pleural fluid by a broad-range 16S rRNA PCR, after 24 h of specimen collection. This is the third case of pleural infection caused by C. sordellii in the literature.

Development of parapneumonic empyema in children

AIM

The aim of the study was to find clinical predictors for parapneumonic empyema in children.

METHODS

Thirty-seven children treated for parapneumonic empyema at the Department of Pediatrics, Turku University Hospital, were retrospectively evaluated. Two distinct comparison groups of children with uncomplicated community-acquired pneumonia with alveolar consolidation (n = 37 in both groups) were included. Clinical and laboratory data on admission as well as fever kinetics and inflammatory markers during hospitalization were analyzed.

RESULTS

In a multivariate analysis, a history of prolonged fever, tachypnoea and pain on abdominal palpation on admission were the most significant clinical predictors for empyema. On admission, serum C-reactive protein levels were higher among children with empyema than among those with uncomplicated pneumonia (means, 234 mg/L vs. 178 mg/L; p = 0.037). During hospitalization, prolonged fever and persistence of high serum C-reactive protein levels were associated with empyema. At the initial evaluation, pleural fluid was not reported in 35% of children with empyema.

CONCLUSIONS

Early recognition of developing empyema is challenging. Children with pneumonia presenting with prolonged fever, tachypnoea, pain on abdominal palpation and high serum C-reactive protein levels are at risk for parapneumonic empyema.

[Successful treatment applied to methicillin-resistant Staphylococcus aureus (MRSA) empyema after the operation for lung cancer; report of a case]

Empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) remains an intractable infection producing high mortality. The authers report a case of MRSA empyema following video-assisted thoracic surgery (VATS) for lung cancer. The case was 73-year-old male with some risks such as pulmonary emphysema, decreased renal function, and previous history of brain infarction. He received wedge resection and the staple lines were wrapped with polyglycolic acid (PGA) felt. Ten days after the operation, he was complicated MRSA pyothorax. By thoracoscopic procedures under local anesthesia, fibrinopurulent tissues were cleaned and 3 of chest tubes were replaced. Intrathoracic infected space was cleaned with physiological saline solution. The patient made favorable progress and recovered. Further empyema has not been developed for 24 months. VATS under local anesthesia and irrigation technique was safe and so useful. Nowadays, PGA felt is often used to reinforce the staple lines of lung. PGA felt is an absorbable but artificial material. We have to care about infectious problems. However, we could control the MRSA pyothrax without removing the PGA felt.

Different bacteriology and prognosis of thoracic empyemas between patients with chronic and end-stage renal disease

BACKGROUND

Bacterial infections are a well-documented complication in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, there are no previous studies of the empyemas that can develop in these patients.

METHODS

This retrospective study investigated the bacteriology and outcomes of empyema in stage 4 CKD (predialysis) and ESRD patients receiving long-term dialysis and treated in a tertiary university hospital from January 2001 to March 2006.

RESULTS

Eighty-four stage 4 CKD patients and 40 ESRD patients had empyemas. Most empyemas (n = 77, 62%) were secondary to pneumonia. Empyema culture findings were positive in 102 patients (82%): 87 microorganism were isolated in pleural fluid from 67 stage 4 CKD patients, and 39 microorganisms were isolated in pleural fluid from 35 ESRD patients. Aerobic Gram-negative organisms (n = 58, 67%), especially Klebsiella pneumoniae (n = 20, 34%), were the predominant pathogens in stage 4 CKD patients; aerobic Gram-positive organisms (n = 21, 54%), especially Staphylococcus aureus (n = 14, 67%), were the main pathogens in ESRD patients. Compared to stage 4 CKD patients, ESRD patients had a significantly higher percentage of catheter infections (p = 0.002) and aerobic Gram-positive organism bacteremia (p = 0.001), as well as a lower aerobic Gram-negative organism infection rate (p < 0.001) and a lower infection-related mortality rate (p = 0.022).

CONCLUSION

Stage 4 CKD patients and ESRD patients with empyema have different causative pathogens and outcomes. In ESRD patients, the dialysis catheter or the dialysis process appear to alter the microbiological flora responsible for empyema. This finding has clinical implications that clinicians need to consider.

A comparative study of community- and nursing home-acquired empyema thoracis

OBJECTIVES

To compare the clinical presentation, microbiological features, and outcomes of patients with community-acquired empyema (CAE) with those of patients with nursing home-acquired empyema (NHAE).

DESIGN

A retrospective observational study.

SETTING

Three tertiary care centers.

PARTICIPANTS

One hundred fourteen patients admitted from the community and 55 patients transferred from nursing homes.

MEASUREMENTS

Baseline sociodemographic information, activities of daily living, Charlson Comorbidity Index score, and clinica, and microbiologic data were obtained. Outcome was assessed at hospital discharge and 6 months postdischarge.

RESULTS

Patients admitted from nursing homes had a delayed presentation, with dyspnea, weight loss, and anemia as the predominant manifestation. Patients with CAE presented more acutely, with fever, cough, and chest pain. Anaerobic organisms were more commonly isolated from patients with NHAE. The success rate of nonsurgical intervention was significantly lower for the NHAE patients than for the CAE group (39% vs 63; P=.01). In-hospital mortality was not significantly different between the two groups (NHAE, 18%; CAE, 8%; P=.09). In a Cox regression analysis, preadmission functional status (hazard ratio (HR)=1.26, 95% confidence interval (CI)=1.19-1.4; P<.001) and surgical intervention (HR=0.47, 95% CI=0.24-0.92; P=.03) were the only variables highly correlated with long-term outcome.

CONCLUSION

Patients admitted with NHAE have distinctly different clinical and microbiological presentation from that of patients with CAE. Because of the delayed presentation in patients with NHAE, medical treatment alone may be associated with higher rate of failure. Surgical therapy should be considered for selected cases, with the aim of improving long-term survival.

[Usefulness of the thoracoscopic surgery under local anesthesia and irrigation for the patient with Bacillus cereus empyema; report of a case]

The case was 54-year-old male with some risks such as chronic heart failure, atrial fibrillation, and liver chirrhosis. He was admitted because of severe back pain and diagnosed as empyema by preoperative thoracentesis. By thoracoscopic procedures under local anesthesia, fibrinopurulent tissues were cleaned as much as possible and 3 of chest tubes were replaced. The final diagnosis was Bacillus cereus pyothorax by bacterial cultures of pleural effusion. Intrathoracic cavity was cleaned with physiological saline solution. The patient made favorable progress and recovered. Thoracoscopic surgery under local anesthesia with thoracic irrigation was so effective and safe methods to control the infection.

IκB Genetic Polymorphisms and Invasive Pneumococcal Disease

RATIONALE

Increasing evidence supports a key role for the transcription factor nuclear factor (NF)-kappaB in the host response to pneumococcal infection. Control of NF-kappaB activity is achieved through interactions with the IkappaB family of inhibitors, encoded by the genes NFKBIA, NFKBIB, and NFKBIE. Rare NFKBIA mutations cause immunodeficiency with severe bacterial infection, raising the possibility that common IkappaB gene polymorphisms confer susceptibility to common bacterial disease.

OBJECTIVES

To determine whether polymorphisms in NFKBIA, NFKBIB, and NFKBIE associate with susceptibility to invasive pneumococcal disease (IPD) and thoracic empyema.

METHODS

We studied the frequencies of 62 single-nucleotide polymorphisms (SNPs) across NFKBIA, NFKBIB, and NFKBIE in individuals with IPD and control subjects (n=1,060). Significantly associated SNPs were then studied in a group of individuals with thoracic empyema and a second control group (n=632).

MEASUREMENTS AND MAIN RESULTS

Two SNPs in the NFKBIA promoter region were associated with protection from IPD in both the initial study group and the pneumococcal empyema subgroup. Significant protection from IPD was observed for carriage of mutant alleles at these two loci on combining the groups (SNP rs3138053: Mantel-Haenszel 2x2 chi2=13.030, p=0.0003; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.45-0.79; rs2233406: Mantel-Haenszel 2x2 chi2=18.927, p=0.00001; OR, 0.55; 95% CI, 0.42-0.72). An NFKBIE SNP associated with susceptibility to IPD but not pneumococcal empyema. None of the NFKBIB SNPs associated with IPD susceptibility.

CONCLUSIONS

NFKBIA polymorphisms associate with susceptibility to IPD. Genetic variation in an inhibitor of NF-kappaB therefore not only causes a very rare immunodeficiency state but may also influence the development of common infectious disease.

[Epidemiology and clinical characteristics of childhood parapneumonic empyemas]

Several studies have reported an increasing incidence of childhood parapneumonic empyemas in various countries.

AIM OF THE STUDY

The aim of our study was to estimate the annual incidence of complicated community-acquired pneumonias in children during a 9-year period in a French area and to describe the epidemiological and clinical characteristics of these complications.

POPULATION AND METHODS

We have listed the children from 28 days to 15 years old, hospitalized in the 2 children hospitals of the Isere district for a community-acquired pneumonia complicated with a pleural empyema or a pulmonary abscess from 1995 to 2003.

RESULTS

During the study period, 90 children were hospitalized for a complicated pneumonia including 83 pleural empyemas and 7 isolated lung abscess. The average number of cases was 4 per year from 1995 to 1998 then increased since 1999 to reach 34 cases in 2003, according to a linear model (P<0,001). The incidence of the complicated pneumonia, plotted to the paediatric population of the area has gone up from 0.5 per 100000 to 13 per 100000 children between 1995 and 2003.

CONCLUSION

The incidence of the complicated pneumonias in children increased since 1999 in a French area. Additional investigations are necessary to identify the causes of this increase.

Complicated parapneumonic effusion and empyema thoracis: microbiology and predictors of adverse outcomes

OBJECTIVES

To describe the microbiological characteristics of a cohort of patients with complicated parapneumonic effusion and empyema thoracis, and to identify the potential risk factors for adverse outcomes, with particular reference to the choice of empirical antibiotics, intrapleural fibrinolytics, adherence to management guidelines, and input from pulmonologists.

DESIGN

Retrospective review.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All patients with a diagnosis of complicated parapneumonic effusion/empyema thoracis admitted between January 2003 and June 2005.

MAIN OUTCOME MEASURES

Microbiological characteristics, mortality, and surgery-free survival. RESULTS. There were 63 patients, with a mean age of 64 (standard deviation, 16) years and a male-to-female ratio of 45:18. The pleural fluid culture positivity rate was 68%; Streptococcus milleri (19%), Bacteroides (14%), Klebsiella pneumoniae (12%), and Peptostreptococcus (7%) were the most common organisms. Thirteen (21%) patients died during their index admission. Use of intrapleural fibrinolytics according to the guideline was associated with survival (P=0.001) while discordant initial antibiotic use was associated with mortality (P=0.002). Discordant initial antibiotic use was also independently associated with reduced surgery-free survival (P<0.001). Subgroup analysis showed that early intrapleural fibrinolytic use (within 4 days of diagnosis) was associated with decreased mortality (P<0.001), increased surgery-free survival (P=0.005), and shorter hospital stay (P=0.039).

CONCLUSION

Organisms identified from complicated parapneumonic effusion and empyema thoracis differ from those giving rise to community-acquired pneumonia. In these patients, adherence to guidelines, early concordant antibiotic treatment, intrapleural fibrinolytics, and input from a pulmonologist were associated with improved outcomes.