Unusual presentation of empyema necessitans: case report and review of the literature

Empyema Necessitatis Caused by Prevotella melaninogenica and Dialister pneumosintes Resolved with Vacuum-Assisted Closure System: A Case Report

Empyema necessitatis is a rare complication of an untreated or inadequately controlled empyema. We present the case of an 11-year-old female adolescent living in precarious conditions, overcrowding, incomplete vaccinations, irregular dental hygiene, and no significant family or personal medical history. The patient started with symptoms one week prior to her hospitalization, presenting a persistent sporadic dry cough, and was later diagnosed with complicated pneumonia, resulting in the placement of an endopleural tube. Vancomycin (40 mg/kg/day) and ceftriaxone (75 mg/kg/day) were administered. However, the clinical evolution was unfavorable, with fever and respiratory distress, so a right jugular catheter was placed. The CT scan showed a loculated collection that occupied the entire right lung parenchyma and pneumothorax at the right upper lobe level. After four days of treatment, the patient still presented purulent drainage with persistent right pleural effusion syndrome. P. melaninogenica and D. pneumosintes were identified from the purulent collection on the upper right lobe, so the antimicrobial treatment was adapted to a glycopeptide, Teicoplanin, at a weight-based dosing of 6 mg/kg/day and Metronidazole at a weight-based dosing of 30 mg/kg/day. In addition, VAC therapy was used for 26 days with favorable resolution.

Beyond the Liver: A Unique Case of Pyogenic Liver Abscess Caused by Peptostreptococcus micros Penetrating the Chest Wall

Liver abscesses are uncommon pyogenic infections with diverse microbiology, often involving enteric gram-negative bacilli such as Escherichia coli and Klebsiella pneumoniae. Standard management includes antibiotic therapy and abscess drainage. We present a case of a 37-year-old male with chronic right upper quadrant abdominal pain, who was found to have an enlarging liver mass infiltrating the chest wall and right-side chest ribs, ultimately diagnosed as a large pyogenic liver abscess (PLA) extending into the chest wall. Notably, the abscess was attributed to Peptostreptococcus micros, a rarely isolated pathogen in liver abscesses. Despite initial unsuccessful percutaneous drainage, surgical intervention proved necessary for definitive treatment. This case underscores the diagnostic challenge posed by uncommon pathogens in liver abscesses and emphasizes the effectiveness of surgical drainage in managing refractory cases.

Empyema necessitans as a rare manifestation of Staphylococcus aureus

Empyema necessitans (EN) is a rare complication of empyema, in which pus accumulates within the pleural space and spreads through the chest wall, leading to the formation of a subcutaneous abscess. This condition presents significant diagnostic and therapeutic challenges due to its rarity and potential for serious complications. Here, we present the case of an 8-year-old boy with a history of parapneumonic effusion that was incompletely treated due to a lack of fibrinolytic agent injection. He presented with fever, chills, a productive cough, and left-sided chest pain with yellowish purulent secretions from the left chest wall. The patient was diagnosed with EN caused by Staphylococcus aureus, which has occurred due to inadequate treatment and the lack of administration of a fibrinolytic agent injection for the patient. He was treated with broad-spectrum antibiotics, video-assisted thoracic surgery, and a chest tube for complete drainage. The patient showed a smooth and uneventful recovery, highlighting the importance of early diagnosis and prompt treatment of EN to avoid further complications. This case report aims to increase awareness among clinicians about the importance of early recognition and appropriate management of EN to improve patient outcomes.

Empyema necessitans (EN) as a rare complication of tuberculosis - A case report

INTRODUCTION

Empyema necessitans (EN) is an uncommon condition where an intrathoracic empyema extends into surrounding extra-thoracic tissues. This case report presents a rare instance of tuberculous EN in an immunocompetent individual.

PRESENTATION OF CASE

We present a case of a healthy young male with complaints of weight loss and a chest wall swelling, initially treated as a subcutaneous abscess. He had a history of TB contact and initial laboratory tests showed elevated CRP and ESR, with no bacterial growth on initial culture from FNAC sample. Subsequent imaging revealed the presence of pleural empyema. Following surgical intervention, a connection between fluid collection outside the thoracic wall and the pleural cavity was identified. Diagnosis of tuberculous EN was made on results of second culture of the fluid collection. The patient was further treated with anti-tuberculous treatment.

DISCUSSION

EN, rare extrapulmonary complication of tuberculosis, is challenging to diagnose due to nonspecific symptoms and paucibacillary nature of extrapulmonary TB. Imaging plays a crucial role in diagnosis. A multidisciplinary approach involving surgery and anti-tuberculous treatment is effective in managing EN.

CONCLUSION

This case underscores the scarcity of EN occurrences and emphasizes the potential for latent TB to surface as atypical complications. Accurate diagnosis requires a combination of clinical insight, imaging, and laboratory tests. EN should be considered in individuals with chest wall masses, particularly in TB endemic areas, and those with a history of TB contact. Treatment involves surgical intervention and anti-tuberculous therapy.

Esophagopleural fistula due to empyema necessitans

Empyema necessitans is a rare entity that consists on the development of an abscess that begins in the pleural space and then extends to the adjacent tissues. This case shows a rare and very late complication of a total pneumonectomy, emphasizing the importance of the multidisciplinary approach and the potential of endoscopic therapy with over-the-scope clips.

Empyema necessitans: After recent thoracostomy in an immunocompromised patient

This paper consists of a clinical image of an unexpected complication of a pleural space infection that dissects through the pleura into the soft tissues of the chest in an immunocompromised patient.