1
|
Toor A, De Freitas G, Torras J. Necrotizing pneumonia in a patient with untreated Mycobacterium kansasii infection. Respir Med Case Rep 2019; 27:100849. [PMID: 31193426 PMCID: PMC6529402 DOI: 10.1016/j.rmcr.2019.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/19/2019] [Accepted: 04/19/2019] [Indexed: 11/16/2022] Open
Abstract
Mycobacterium kansasii is the second most commonly occurring Non-Tuberculous Mycobacteria (NTM) in the United States. Infection is typically seen in middle aged males, and the risk of infection is greatly increased in immunocompromised hosts. Pulmonary infection presents in clinical parallel to that of Mycobaterium tuberculosis (TB) and is therefore often misdiagnosed. A combination of clinical, radiological, and microbiological evidence of infection is generally required to clinch the diagnosis. Treatment of such cases include prolonged courses of rifampin in combination with 2 other antimicrobial agents. The overall prognosis with appropriate treatment is good with the exception of disseminated disease in severely immunocompromised hosts. In patients who are misdiagnosed or undertreated, there is progressive destruction of the lung parenchyma with distortion of lung architecture. This can in-turn lead to bronchiectatic changes leaving the airways exposed to devastating superimposed bacterial pneumonia. We describe a case of a patient with untreated M. kansasii infection who developed superimposed necrotizing pneumonia and respiratory failure requiring prolonged ventilatory support.
Collapse
|
2
|
Molnar TF. Tuberculosis: mother of thoracic surgery then and now, past and prospectives: a review. J Thorac Dis 2018; 10:S2628-S2642. [PMID: 30345099 PMCID: PMC6178290 DOI: 10.21037/jtd.2018.04.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 04/19/2018] [Indexed: 11/06/2022]
Abstract
Knowledge on ontogenesis of thoracic surgery is essential not only for understanding present concepts and debates on surgery for tuberculosis, but it also contributes to the further developments in operative treatment of lung cancer. Both diseases have been the leading cause of death in their respective ages. History of tuberculosis follows the classic algorithm: diagnostic, casuistic and therapeutical stages. Villemin followed by Virchow, and, finally, Koch revealed the pathoanatomy and the cause of tuberculosis. The therapeutic phase of lung cancer has been reached without identified cause of the disease. Chest surgery, eradication of the macroscopic focus by physical interference with the involved tissue mass, in both diseases preceded medical treatment. Identification of phenotypes of lung cancer-if it is a single disease at all-does not contravene the concept: the tumor mass should been eliminated. However, causation is not an absolute sine qua non of an effective treatment, as the tuberculosis-lung cancer analogy also proves. Surgical approach of both diseases suffered from the same paraoxon: eradication without direct interference with the causative factor. While lung cancer seems to be controlled by an emerging array of new drugs, tuberculosis poses a new challenge, as multidrug resistant and extensively drug resistant Koch bacteria are emerging and fragile societies' immunity is weakening. Thoracic surgery has a significant share in the fight against tuberculosis, when drugs and/or society fail. Palliative and radical adjuvant surgery multiplies the chance of cure in those cases, where not much hope is left. The jury is still out in a series of questions, but it is obvious, that surgery is only an option and not a panacea where medicines and their providers fail. Deeper understanding of our past and present failures with tuberculosis and its surgery might contribute to new concepts in coping with lung cancer as well.
Collapse
Affiliation(s)
- Tamas F. Molnar
- Department of Operational Medicine, Medical Humanities Unit, University of Pécs, Pécs, Hungary
- Department Surgery, St Sebastian Thoracic Surgery Unit, Petz A University Teaching Hospital, Győr, Hungary
| |
Collapse
|
3
|
Seo H, Cha S, Shin K, Lim J, Yoo S, Lee J, Lee S, Kim C, Park J, Lee W. Clinical relevance of necrotizing change in patients with community-acquired pneumonia. Respirology 2017; 22:551-558. [PMID: 27862706 PMCID: PMC7169103 DOI: 10.1111/resp.12943] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/22/2016] [Accepted: 08/22/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Few studies have analysed a large number of patients with necrotizing pneumonia (NP) diagnosed based on computed tomography (CT) scans. The aim of the present study was to document the incidence and clinical features of NP in patients with community-acquired pneumonia (CAP). METHODS This retrospective study was conducted on CAP patients who had been admitted to a tertiary referral centre and who had available enhanced CT scan images. Patients were allocated into NP and non-NP groups, and they were compared with respect to various clinical variables. RESULTS Of the 830 patients included in the present study, necrotizing change was observed in 103 patients (12%). Patients with NP experienced more symptoms of pneumonia, had higher blood levels of inflammatory markers and more often required pleural drainage compared to patients with non-NP. Although the use of mechanical ventilation, vasopressor infusion, 30-day mortality, in-hospital mortality and clinical deterioration did not differ between the NP and non-NP groups, the median length of hospital stay (LOS) was significantly longer in the NP group. Multivariate analysis using Cox proportional hazards model showed that necrotizing change independently predicted LOS in patients with CAP. CONCLUSION NP affects approximately one-tenth of hospitalized CAP patients. It may be associated with more severe clinical manifestations and may increase the need for pleural drainage. NP was found to be an independent predictor of LOS, but not of mortality in CAP patients.
Collapse
Affiliation(s)
- Hyewon Seo
- Department of Internal MedicineKyungpook National University School of MedicineDaeguKorea
| | - Seung‐Ick Cha
- Department of Internal MedicineKyungpook National University School of MedicineDaeguKorea
| | - Kyung‐Min Shin
- Department of RadiologyKyungpook National University School of MedicineDaeguKorea
| | - Jae‐Kwang Lim
- Department of RadiologyKyungpook National University School of MedicineDaeguKorea
| | - Seung‐Soo Yoo
- Department of Internal MedicineKyungpook National University School of MedicineDaeguKorea
| | - Jaehee Lee
- Department of Internal MedicineKyungpook National University School of MedicineDaeguKorea
| | - Shin‐Yup Lee
- Department of Internal MedicineKyungpook National University School of MedicineDaeguKorea
| | - Chang‐Ho Kim
- Department of Internal MedicineKyungpook National University School of MedicineDaeguKorea
| | - Jae‐Yong Park
- Department of Internal MedicineKyungpook National University School of MedicineDaeguKorea
| | - Won‐Kee Lee
- Department of Preventive MedicineKyungpook National University School of MedicineDaeguKorea
| |
Collapse
|
4
|
Emergent Pneumonectomy for Lung Gangrene: Does the Outcome Warrant the Procedure? Ann Thorac Surg 2014; 98:265-70. [DOI: 10.1016/j.athoracsur.2014.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 02/19/2014] [Accepted: 03/05/2014] [Indexed: 11/22/2022]
|
5
|
Management of necrotizing pneumonia and pulmonary gangrene: a case series and review of the literature. Can Respir J 2014; 21:239-45. [PMID: 24791253 DOI: 10.1155/2014/864159] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Necrotizing pneumonia is an uncommon but severe complication of bacterial pneumonia, associated with high morbidity and mortality. The availability of current data regarding the management of necrotizing pneumonia is limited to case reports and small retrospective observational cohort studies. Consequently, appropriate management for these patients remains unclear. OBJECTIVE To describe five cases and review the available literature to help guide management of necrotizing pneumonia. METHODS Cases involving five adults with respiratory failure due to necrotizing pneumonia admitted to a tertiary care centre and infected with Streptococcus pneumoniae (n=3), Klebsiella pneumoniae (n=1) and methicillin-resistant Staphylococcus aureus (n=1) were reviewed. All available literature was reviewed and encompassed case reports and retrospective reviews dating from 1975 to the present. RESULTS All five patients received aggressive medical management and consultation by thoracic surgery. Three patients underwent surgical procedures to debride necrotic lung parenchyma. Two of the five patients died in hospital. CONCLUSIONS Necrotizing pneumonia often leads to pulmonary gangrene. Computed tomography of the thorax with contrast is recommended to evaluate the pulmonary vascular supply. Further study is necessary to determine whether surgical intervention, in the absence of pulmonary gangrene, results in better outcomes.
Collapse
|
6
|
|
7
|
Tsai YF, Tsai YT, Ku YH. Surgical Treatment of 26 Patients with Necrotizing Pneumonia. Eur Surg Res 2011; 47:13-8. [DOI: 10.1159/000327684] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 03/18/2011] [Indexed: 11/19/2022]
|
8
|
Macedo M, Meyer KF, Oliveira TCM. Necrotizing pneumonia in children submitted to thoracoscopy due to pleural empyema: incidence, treatment and clinical evolution. J Bras Pneumol 2010; 36:301-5. [PMID: 20625666 DOI: 10.1590/s1806-37132010000300006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 01/19/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the incidence of necrotizing pneumonia (NP) in children submitted to thoracoscopy, comparing patients with and without NP in terms of the presentation and clinical evolution. METHODS A retrospective study of children with pleural empyema submitted to thoracoscopy. Thoracoscopy was performed in patients not previously submitted to thoracic drainage and in whom there was evidence of loculated effusion or pneumothorax, as well as in those previously submitted to thoracic drainage and in whom there was persistent pneumothorax or fever with purulent discharge. On the basis of the thoracoscopy findings, patients were distributed into two groups: those with NP (NP group) and those without (no-NP group). RESULTS The study sample comprised 52 patients. Of the 24 patients with NP, 19 (79%) had undergone thoracic drainage prior to thoracoscopy, 11 (46%) presented with pneumothorax, and 16 (67%) developed bronchopleural fistula. In the NP group, the median drainage time and the median length of hospital stay were 18 and 19 days, respectively. Of the 28 patients without NP, 10 (36%) had undergone thoracic drainage prior to thoracoscopy, 9 (32%) presented pneumothorax, and 5 (18%) developed bronchopleural fistula. In the no-NP group, the median drainage time and the median length of hospital stay were 6 and 10 days, respectively. CONCLUSIONS Pneumothorax should raise the suspicion of NP. Early thoracoscopy can be a valuable treatment option for NP in children because it hastens recovery in comparison with the medical treatment alone and avoids extensive late thoracotomy lung resections.
Collapse
Affiliation(s)
- Maurício Macedo
- Department of Surgery, Hospital Estadual Infantil Darcy Vargas, São Paulo, Brazil.
| | | | | |
Collapse
|
9
|
Westphal FL, Lima LCD, Netto JCL, Tavares E, Andrade EDO, Silva MDSD. Tratamento cirúrgico de crianças com pneumonia necrosante. J Bras Pneumol 2010. [DOI: 10.1590/s1806-37132010000600008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Descrever os resultados do tratamento cirúrgico de crianças com pneumonia necrosante. MÉTODOS: Análise retrospectiva dos prontuários de 20 crianças diagnosticadas com pneumonia necrosante e submetidas ao tratamento cirúrgico nos serviços de cirurgia torácica de dois hospitais na cidade de Manaus (AM) entre março de 1997 e setembro de 2008. Dados referentes a idade, sexo, agente etiológico, motivos da indicação cirúrgica, tipo de ressecção cirúrgica realizada e complicações pós-operatórias foram compilados. RESULTADOS: Dos 20 pacientes analisados, 12 (60%) eram do sexo feminino. A média de idade dos pacientes foi de 30 meses. Os agentes etiológicos mais encontrados foram Staphylococcus aureus, em 5 pacientes (25%), e Klebsiella sp., em 2 (10%). Os motivos de indicação cirúrgica foram sepse, em 16 pacientes (80%), e fístula broncopleural, em 4 (20%). Os tipos de procedimentos cirúrgicos realizados foram lobectomia, em 12 pacientes (60%), segmentectomia, em 7 (35%), e bilobectomia, em 1 (5%). Além desses procedimentos, 8 pacientes (40%) foram submetidos à descorticação pulmonar. As complicações pós-operatórias foram as seguintes: fístula broncopleural, em 4 pacientes (20%); empiema, em 1 (5%); pneumatocele, em 1 (5%); e flebite em membro superior esquerdo, em 1 (5%). Quatro pacientes (20%) morreram. CONCLUSÕES: Pacientes com evidências de necrose pulmonar devem ser considerados para a ressecção cirúrgica, que está indicada em casos graves de sepse, fístula broncopleural de alto débito ou insuficiência respiratória aguda que não respondem ao tratamento clínico.
Collapse
|
10
|
Reimel BA, Krishnadasen B, Cuschieri J, Klein MB, Gross J, Karmy-Jones R. Surgical management of acute necrotizing lung infections. Can Respir J 2007; 13:369-73. [PMID: 17036090 PMCID: PMC2683290 DOI: 10.1155/2006/760390] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Surgical resection for acute necrotizing lung infections is not widely accepted due to unclear indications and high risk. OBJECTIVE To review results of resection in the setting of acute necrotizing lung infections. METHODS A retrospective review of patients who underwent parenchymal resection between January 1, 2000, and January 1, 2006, for management of necrotizing pneumonia or lung gangrene. RESULTS Thirty-five patients underwent resection for lung necrosis. At the time of consultation, all patients presented with pulmonary sepsis, and also had the following: empyema (n = 17), hemoptysis (n = 5), air leak (n = 7), septic shock requiring pressors (n = 8) and inability to oxygenate adequately (n = 7). Twenty-four patients were ventilated preoperatively. Eleven patients had frank lobar gangrene, and the other patients had combinations of necrotizing pneumonia and abscesses. In 10 patients, preresection procedures were performed, including percutaneous drainage of an abscess (n = 4), thoracoscopic decortication (n = 4) and open decortication (n = 2). Procedures included pneumonectomy (n = 4), lobectomy (n = 18), segmentectomy (n = 2), wedge resection (n = 4) and debridement (n = 7). There were three (8.5%) postoperative deaths--two due to multiple organ failure and one due to anoxic brain injury. All patients not ventilated preoperatively were weaned from ventilatory support within three days. Of those ventilated preoperatively, three died, while four remained chronically ventilator dependent. CONCLUSIONS Surgical resection for necrotizing lung infections is a reasonable option in patients with persistent sepsis who are failing medical therapy. Ventilated patients have a worse prognosis but can still be candidates for resection. Patients who are hemodynamically unstable appear to have better outcomes if they can be stabilized before resection.
Collapse
Affiliation(s)
- Beth Ann Reimel
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Baiya Krishnadasen
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Joseph Cuschieri
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Matthew B Klein
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Joel Gross
- Department of Radiology, Harborview Medical Center, Seattle, Washington, USA
| | - Riyad Karmy-Jones
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
- Department of Surgery, Southwest Washington Medical Center, Vancouver, Washington, USA
- Correspondence: Dr Riyad Karmy-Jones, Southwest Washington Medical Center, Physicians’ Pavilion, 200 NE Mother Joseph Place, Suite 300, Vancouver, Washington 98664, USA. Telephone 360-514-1854, fax 360-514-6063, e-mail
| |
Collapse
|
11
|
Kalfa N, Allal H, Lopez M, Counil FO, Forgues D, Guibal MP, Galifer RB. An Early Thoracoscopic Approach in Necrotizing Pneumonia in Children: A Report of Three Cases. J Laparoendosc Adv Surg Tech A 2005; 15:18-22. [PMID: 15772471 DOI: 10.1089/lap.2005.15.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Cavitary necrosis remains a rare complication of bacterial pneumonia in children. Conservative medical treatment and radical surgical treatment with lung resection are the current therapeutic choices. Evaluation of thoracoscopy for this pathology has not yet been reported. We describe 3 cases. MATERIALS AND METHODS Between January 2001 and January 2002, 3 children (1, 2, and 3 years old) were admitted to our institution with necrotizing pneumonia. The diagnosis was based on injected computed tomography (CT) scan showing pulmonary condensation, intra-parenchymal bullae, and hypovascularization. In addition to an adapted antibiotic therapy, a thoracoscopic approach was decided on within 24 hours of diagnosis, with extensive decortication, ablation of superficial necrotic debris, irrigation, and drainage. RESULTS No conversion to open thoracotomy or lung resection was needed. Admission to the intensive care unit was unnecessary. On average, apyrexia was reached on postoperative day (POD) 2 and tube drainage was removed on POD 15. Mean follow-up at 16 months showed excellent lung re-expansion with no relapse. CONCLUSION On the condition that the decision is made quickly, thoracoscopy may be a valuable treatment option in childhood necrotizing pneumonia, as it hastens recovery and avoids lung resection. Injected CT scan allows an early diagnosis and we propose the first 24 hours after diagnosis as the optimal period for thoracoscopy because of the rapid natural course of lung gangrene.
Collapse
Affiliation(s)
- Nicolas Kalfa
- Department of Visceral Pediatric Surgery, Lapeyronie-Arnaud de Villeneuve Hospital, 34295 Montpellier Cedex 5, France.
| | | | | | | | | | | | | |
Collapse
|
12
|
|