Surgical treatment of pleural empyema in Coronavirus disease 19 patients: the Southern Switzerland experience

CT features of acute COVID-19 and long-term follow-up

Since the first few cases of pneumonia attributed to infection with the highly contagious novel coronavirus 2 (SARs-CoV-2) were detected in Wuhan, China, in December 2019, imaging has proven an invaluable diagnostic tool throughout the resulting global pandemic. This review describes the imaging features of severe pulmonary disease caused by SARs-CoV-2, named COVID-19 by the World Health Organization (WHO), particularly focussing on computed tomography (CT). CT plays an important role in understanding the pathology behind the progression of disease, as well as helping to identify the potential complications of COVID-19 pneumonia and recognising possible alternative or concurrent diagnoses. This review also focusses on follow-up imaging of survivors of COVID-19, which continues to contribute substantially to our understanding of the longer-term pulmonary changes in patients who have survived severe COVID-19 pneumonia.

Surgical Interventions in Coronavirus Disease 2019 Pleural and Pulmonary Complications: A Case Series of the Tertiary Thoracic Surgery Center Experience

Background: In most cases of pulmonary or pleural post-coronavirus disease 2019 (COVID-19) complications, surgical interventions are performed to treat these complications, but the method of the surgery and its outcome in these patients is not clearly defined. We present 40 patients with pulmonary and pleural complications after COVID-19 who required surgical intervention. Patients and Methods: In this case series, patients' data were prospectively collected from April to August 2022 at Masih Daneshvari Hospital. Inclusion criteria were patients with COVID-19 who were referred to the thoracic surgery department because of pleural effusion, pneumothorax, empyema, infected or non-infected pneumatocele, and lung cavity with suspected fungal infections. The required intervention for each patient was assessed. Results: Patients' mean age was 49.21 ± 11.5 (30-69 years). Nine patients (22.5%) were female. Pure pleural effusion was reported in five (12.5 %), pneumothorax in eight (20%), empyema in 29 (72.5%), and infected pneumatocele in two patients (5%). Twelve patients had bronchial fistulas that were clarified at the time of surgery that needed repair after resection. In 13 patients (32.5%) because of pleural effusion or pneumothorax, a chest tube was inserted and after two weeks lungs were fully expanded. All patients with pneumothorax were managed by chest tube initially but in the presence of continuous air leakage and non-expanding lungs surgical thoracotomy or video-assisted thoracoscopic surgery (VATS) were considered for correction. In 10 patients who required thoracotomy, the chest tube was necessary for more than one month. In most of the patients, there were small cystic lesions or peripheral bronchopleural fistula. In 17 (42.5%) cases of empyema, necrotic pneumonia was documented and eight patients (20%) had aspergillus infection in the pathology report and two patients had a pulmonary abscess. Conclusions: Pleural COVID-19 complications can be treated with conventional surgical methods such as chest tube insertion, and debridement of infected tissue with no mortality and further complications.

Empyema thoracic in a neonate co-infected with SARS-CoV-2 and staphylococcus arouse successfully treated with fibrinolysis: a brief report

BACKGROUND

Empyema as a rare cause of respiratory distress in neonatal period has not yet been reported after Corona virus disease 2019 (COVID-19) and even rarely in the context of bacterial infections is age group.

CASE PRESENTATION

The first neonate of quadruplets, resulting from Cesarean-Section of a 30-year-old mother without a history of previous illness, born at 34 weeks of gestation with a birth weight of 1600 gram. All four newborns were hospitalized; while the first one underwent nasal continuous positive airway pressure (N-CPAP) with a positive end-expiratory pressure of 6 and fractional inspired oxygen of 0.6, due to respiratory distress, noting a respiratory score of five out of 12.She was resuscitated one hour later due to bradycardia and underwent ventilator support. She received a single dose of pulmonary surfactant, intravenous paracetamol, and phenobarbital due to respiratory distress syndrome, Pectus Ductus Arteriosus, and unilateral clonic movements, respectively. In the lack of positive blood culture, she extubated two days later and breast-feeding was started. On day eight, she underwent high flow nasal cannula. On day 12, she suddenly developed respiratory distress, mottling, and abdominal distension, leading to N-CPAP and re-evaluation. The nasopharyngeal sampling for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) real time Polymerase chain reaction and the blood culture for staphylococcus aurous became positive. A large volume pleural effusion including septa and loculation in right hemi-thorax on chest computerized tomography scan and ultrasound was seen, necessitating to thoracotomy, which was not possible due to her general condition. Remdesivir was started and antibiotics changed to a more broad-spectrum coverage. Chest tube was inserted and Alteplase was injected for three consecutive days with beneficial effects. She had no problem for six-month follow up.

CONCLUSION

This was a case of empyema thoracic in the context of SARS-CoV-2 and Staphylococcus arouses co-infection. In our experience, it can be treated by chest drainage and fibrinolysis in neonatal period.

Lung decortication for spontaneous hydropneumothorax in post COVID patients: A case series

Hydropneumothorax is an abnormal collection of air and fluid in the pleural space. As it is a rare complication of COVID-19 pneumonia, we report a case series of spontaneous hydropneumothorax converted to pus collection that was resistant to medical management and treated as decortication and pleurectomy.

Tracheo-esophageal fistula and pleural empyema in the course of SARS-CoV-2 infection-A case report

We report a 49-year-old patient with COVID-19 who developed lung abscess, pleural empyema, and tracheo-esophageal fistula. He underwent cervicotomy, segmental tracheal resection, esophageal-tracheal fistula excision, and suturing the esophagus, and a classic thoracotomy was performed. Despite the severe infection, the patient was discharged home after successful surgical treatment.

A rare case of empyema due to Cutibacterium acnes in the setting of COVID-19

Introduction

Cutibacterium acnes is a Gram-positive anaerobic rod that is part of the normal skin flora, as well as the oral cavity, genitourinary and gastrointestinal tracts. When detected, it is usually considered contaminant; but it is infrequently responsible for invasive infections, mainly neurosurgical and joint infections. It is rarely found as a pathogen responsible for lung infections or empyema.

Case report

We present a unique case of C. acnes empyema following severe COVID-19, making this the first documented case of empyema due to this bacterium following COVID-19. The microorganism was identified by 16S rRNA gene sequencing. The patient was treated with a combination of antibiotics and surgical intervention.

Conclusions

This case demonstrates the potential severity of C. acnes empyema. Further studies are needed to establish management guidance.

The Role of Surgery in Patients with COVID-19-Related Thoracic Complications

Objective

Patients with several thoracic complications induced by SARS-CoV-2 infection may benefit from surgery, but its role in this condition is largely unknown, and many surgeons’ advice against any surgical referrals. Our aim is to investigate the efficacy and safety of surgery in COVID-19 patients with thoracic complications requiring surgery.

Methods

We designed a multicenter observational study, involving nine thoracic surgery departments, evaluating patients who developed thoracic complications in hospital, surgically managed from March 1, 2020, to May 31, 2021. An overall 30-day mortality was obtained by using the Kaplan–Meier method. Multivariable Cox regression model and logistic models were applied to identify the variables associated with mortality and postoperative complications.

Results

Among 83 patients, 33 (40%) underwent surgery for complicated pneumothorax, 17 (20.5%) for pleural empyema, 13 (15.5%) for hemothorax, 8 (9.5%) for hemoptysis, 5 patients (6%) for lung abscess, 4 (5%) for infected pneumatoceles, and 3 (3.5%) for other causes. Within 30 days of surgery, 60 patients (72%) survived. At multivariable analysis, age (HR 1.05 [95% CI, 1.01, 1.09], p = 0.022), pulmonary hypertension (HR 3.98 [95% CI, 1.09, 14.5], p = 0.036), renal failure (HR 2.91 [95% CI, 1.19, 7.10], p-value 0.019), thoracotomy (HR 4.90 [95% CI, 1.84, 13.1], p-value 0.001) and infective affections (HR 0.17 [95% CI, 0.05, 0.58], p-value 0.004) were found to be independent prognostic risk factors for 30-day mortality. Age (OR 1.05 [95% CI, 1.01, 1.10], p = 0.023) and thoracotomy (OR 3.85 [95% CI, 1.35, 12.0] p = 0.014) became significant predictors for 30-day morbidity.

Conclusion

Surgical management of COVID-19-related thoracic complications is affected by high mortality and morbidity rates, but a 72% survival rate still seems to be satisfactory with a rescue intent. Younger patients without pulmonary hypertension, without renal insufficiency and undergoing surgery for infectious complications appear to have a better prognosis.

Bilateral parapneumonic pleural effusion with pneumothorax in a patient with covid 19 pneumonia: case report

Recurrent pyogenic effusion combined with bilateral pneumothorax is a rare complication associated with the COVID−19 infection. Current article presents the case report of a 68-year-old male with the severe community-acquired bilateral polysegmental viral COVID−19 pneumonia. Chest radiography on the 15th day after admission to the hospital showed the presence of air and pleural effusion in the right pleural cavity with collapse of the right lung. Thoracentesis and thoracostomy in the sixth intercostal space on the mid-axillary line were performed. About 1400 ml of a yellowish opaque liquid were evacuated from the pleural cavity. Pleural fluid analysis confirmed an exudative lymphocytic-rich effusion with no growth of acid-fast bacteria (AFB). In the pleural fluid such gram-negative bacteria as Acinetobacter baumannii and Pseudomonas aeruginosa were cultured. Chest computed tomography obtained on the third day after thoracentesis showed radiological sings of bilateral hydropneumothorax. Needle thoracocentesis and new pleural drainage in the second intercostal space on the right midclavicular line were established. Five days later after the second drainage of the pleural space was initiated the patient was diagnosed with pleural empyema and transferred to the Surgical Clinic. This case report highlights that in patients with COVID-19 recurrent pyogenic effusion combined with bilateral pneumothorax may occur.

The analysis of pleural complications of COVID-19 pneumonia

Background/aim

As the number of case reports related to the new type of coronavirus (COVID-19) increases, knowledge of and experience with the virus and its complications also increase. Pleural complications are one relevant issue. We aimed in this study to analyze pleural complications, such as pneumothorax, pneumomediastinum, and empyema, in patients hospitalized with the diagnosis of COVID-19 pneumonia.

Materials and methods

The files of patients who have pleural complications of COVID-19 pneumonia and were consulted about thoracic surgery between March 2020 and December 2020 were retrospectively reviewed. The data of the patients were analyzed according to age, sex, length of stay, treatment method for pleural complications, mortality, severity of COVID-19 pneumonia, tube thoracostomy duration, and presence of a mechanical ventilator.

Results

A total of 31 patients fulfilling the inclusion criteria were included in the study. There were 11 female (35.5%) and 20 male (65.5%) patients. The most common complication was pneumothorax in 20 patients (65%). The median duration of hospitalization was 22 days and the mortality rate was 71%. Mortality was significantly higher in patients on mechanical ventilation (p = 0.04).

Conclusion

The mortality rate is very high in patients with pleural complications of COVID-19 pneumonia. Pneumothorax is a fatal complication in critically ill patients with COVID-19 pneumonia.

Post COVID-19 pulmonary complications; a single center experience

INTRODUCTION

Although the rate and severity of complications after coronavirus 2019 disease (COVID-19) resolution is currently unknown, evidence regarding their presence is increasing in the literature. This study presents a series of cases with post COVID-19 short-term pulmonary complications.

METHODS

This is a single center retrospective case series study. The demographic and clinical data were collected from the center's electronic records. All the included cases were confirmed COVID-19 patients who had pulmonary complications even after their recovery.

RESULTS

Nineteen COVID-19 patients were involved in this study. Fourteen of them were male (73.7%) and only 5 (26.3%) cases were female, with a mean age of 52.05 years (26-77). All of the patients developed severe COVID-19 and were admitted to intensive care unit (ICU). The average infection duration was 13.5 days (10-21). The most common complaints after recovery from COVID-19 were shortness of breath, fever, and hemoptysis. Computed tomography scan showed different pulmonary abnormalities between the cases. Different surgical procedures were performed for the patients according to their conditions, such as decortications, lobectomy, and bullectomy. More than half of the patients (n = 10) recovered and were discharged from hospital without complications, five patients were admitted to the ICU, 3 cases developed mucormycosis, and one case passed away.

CONCLUSION

Following the resolution of COVID-19, patients may experience severe pulmonary complications that may last for months and can affect quality of life, ICU admission, or even death.

Management of pleural empyema in a 12-year-old obese patient with COVID-19: a pediatric case report

BACKGROUND

With the ongoing coronavirus disease (COVID-19) pandemic, along with the development of new mutations of the virus and an increase in the number of cases among pediatrics, physicians should be aware and alerted on the atypical presentations of the disease, especially in less expected individuals.

CASE PRESENTATION

Here we present a 12-year-old obese boy (BMI = 37.5 kg/m2) who presented with empyema, which was following SARS-CoV-2 infection. The patient had no history of fever. Due to the onset of dyspnea, a chest tube was inserted for him which was later altered to a pleural drainage needle catheter.

CONCLUSION

Our case is the first report of COVID-19 presenting as empyema among pediatrics. Pleural empyema should be considered as a rare complication of COVID-19. Since there is still no guideline in the management of empyema in the context of COVID-19, delay in diagnosis and intervention may cause morbidity and mortality in children.

An empyema caused by Streptococcus constellatus in an older immunocompetent patient: Case report

RATIONALE

Empyema caused by Streptococcus constellatus is rare in patients without underlying diseases. However, the importance of the Streptococcus anginosus group, which consists of S constellatus, S anginosus, and Streptococcus intermedius, as causative organisms of empyema has been increasing.

PATIENT CONCERNS

A 78-year-old man initially presented with dyspnea and chills for 4 days. He had no medical history.

DIAGNOSIS

Chest X-ray and chest computed tomography showed a large and multiloculated pleural effusion with an air bubble on the right side. Cultivation of the pleural effusion using clone library analysis of the 16S rRNA gene revealed S constellatus positivity.

INTERVENTIONS

The patient was treated by drainage of the pleural effusion and intravenous ceftriaxone and clindamycin for the possibility of anaerobes, followed by 10 weeks of oral antibiotics.

OUTCOMES

On the 11th day of admission, the thoracic drainage tube was removed. After 1 year of treatment, there were no sequelae of empyema.

LESSONS

Although S constellatus can cause serious infections in patients with underlying diseases and immunosuppression, physicians need to consider S constellatus infection in community-acquired empyema in elderly individuals. It should be treated with early pleural drainage and antibiotics to avoid surgical decortication and prolonged hospitalization.

Loculated Empyema and SARS-CoV-2 Infection: A Report of Two Cases and Review of the Literature

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clinical manifestations are diverse and can vary from mild respiratory symptoms to severe hypoxic respiratory failure. In severe cases, infection can cause gastrointestinal, renal, cardiac, neurological and haematological complications and result in multi-organ failure. There are very few reports of parapneumonic effusion in patients with COVID-19. We describe two patients with COVID-19 who had loculated empyema and discuss the clinical course and therapeutic options.

LEARNING POINTS

The clinical manifestations of COVID-19 vary from mild to severe disease and can result in multi-organ failure.Pleural empyema is usually treated with a combination of antibiotics and surgical drainage of the pleural cavity.

Anesthetic Management for Thoracic Surgery During the COVID-19 Pandemic

Purpose of Review

This review explores recent international guidance on the anesthetic management of patients undergoing thoracic surgery during the COVID-19 pandemic: those with suspected or confirmed COVID-19 requiring urgent thoracic surgery and those presenting for elective procedures.

Recent Findings

A significant mortality risk is associated with patients with COVID-19 undergoing thoracic surgery; therefore, where possible, it should be avoided. Thoracic surgery also carries a significant risk of viral transmission to healthcare workers due to the necessarily high frequency of intraoperative aerosol-generating procedures involved, such as lung isolation, one-lung ventilation, and flexible bronchoscopy.

Summary

Guidelines recommend appropriate personal protective equipment and numerous procedural modifications to prevent viral transmission to staff and other patients. With appropriate disease mitigation strategies in place, elective thoracic surgery, in particular for lung cancer, has been able to continue safely in many centres.

Successful endobronchial occlusion in empyema with broncho-pleural fistula secondary to COVID-19 pneumonia: a case report and literature review

A few cases of empyema secondary to coronavirus disease 2019 (COVID-19) pneumonia have been reported. Here, we report our experience of a successful endobronchial occlusion using endobronchial Watanabe spigots (EWSs) for empyema with broncho-pleural fistula secondary to COVID-19 pneumonia. A 62-year-old man was diagnosed with COVID-19 and progressed to empyema with broncho-pleural fistula. Computed tomography (CT) imaging showed cyst formation and the right B5b was presumed to be a branch dependent on the cyst. The effusion and air in the pleural cavity were well drained, although the air leak persisted. Endobronchial occlusion was performed for right B5a and B5b using 7- and 5-mm EWSs (Novatech, France), respectively, and the air leak ceased. This is the first report of successful treatment of empyema with bronchial fistula with endobronchial occlusion. Air leak secondary to COVID-19 pneumonia with a limited number of air cysts may be a good indication for endobronchial occlusion.