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Di Mitri M, Thomas E, Capano E, Bisanti C, D'Antonio S, Libri M, Gargano T, Lima M. The role of the early video-assisted thoracoscopic surgery in children with pleural empyema. Pediatr Surg Int 2024; 40:134. [PMID: 38761186 PMCID: PMC11102380 DOI: 10.1007/s00383-024-05715-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE Pleural empyema (PE) is a collection of purulent material in the pleural space. PE's management in children is a challenge and an inappropriate diagnostic-therapeutic work up can lead to serious short and long-term complications. The aim of this study is to define the correct timing to approach a pediatric PE by video-assisted thoracoscopic surgery (VATS). METHODS A retrospective observational study was conducted including pediatric patients who underwent video-assisted thoracoscopy for pleural empyema between May 2005 and September 2022. RESULTS 62 patients were subjected to VATS for PE (32 in Group Early VATS, 30 in Group Late VATS). It emerged that the elapsed period between the onset of symptoms and surgery correlates in a statistically significant way with the post-operative stay in intensive care (z score 4.3 and p value < 0.0001) and the analysis between early VATS, late VATS and postoperative hospitalization showed a statistically significant reduction of the post-operative hospitalization in the early VATS groups (p value < 0.02). CONCLUSIONS VATS resulted to be safe and effective for the treatment of PE in children, and an early minimally invasive thoracoscopic intervention (early VATS) correlates with better outcomes, specifically in terms of intensive care hospitalization and overall hospitalization.
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Affiliation(s)
- Marco Di Mitri
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Eduje Thomas
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Eleonora Capano
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Cristian Bisanti
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy.
| | - Simone D'Antonio
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Michele Libri
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Tommaso Gargano
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Mario Lima
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
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Chaudhary KR, Singh K, Singh C. Recent Updates in Inhalable Drug Delivery System against Various Pulmonary Diseases: Challenges and Future Perspectives. Curr Drug Deliv 2024; 21:1320-1345. [PMID: 37870055 DOI: 10.2174/0115672018265571231011093546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 08/22/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023]
Abstract
In the current scenario, pulmonary disease has become a prime burden for morbidity and mortality alongside tremendous social and economic crises throughout the world. Numerous conventional drug delivery system and treatment approach targeting the respiratory region has been driven out. However, effective and accurate recovery has not been achieved yet. In this regard, nanotechnological- based inhalable drug delivery strategy including polymeric, lipidic, or metallic-based respirable microparticles plays an indispensable role in circumventing numerous challenges faced during traditional treatment. Excellent aerodynamic performance leads to enhanced lung targetability, reduced dosing frequency and hence systemic toxicities, as well as improved pharmaceutical attributes, and therefore pharmacokinetic profiles are interminable factors associated with nanotechnologicalbased inhalable delivery. In this review, we comprehensively explored recent advancements in nanotechnologically engineered inhalable formulations targeting each of the mentioned pulmonary diseases. Moreover, we systematically discussed possible respiratory or systemic toxicities about the indeterminate and undefined physicochemical characteristics of inhaled particles.
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Affiliation(s)
- Kabi Raj Chaudhary
- Department of Pharmaceutics, ISF College of Pharmacy, Ghal Kalan, Ferozpur G.T Road, Moga, Punjab 142001, India
- Department of Research and Development, United Biotech [P] Ltd. Bagbania, Nalagarh, Solan, Himachal Pradesh, India
| | - Karanvir Singh
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab 143005, India
| | - Charan Singh
- Department of Pharmaceutics, ISF College of Pharmacy, Ghal Kalan, Ferozpur G.T Road, Moga, Punjab 142001, India
- Department of Pharmaceutical Sciences HNB Garhwal University, Madhi Chauras, Srinagar, Uttarakhand 246174, India
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Inflammation of the Pleural Cavity: A Review on Pathogenesis, Diagnosis and Implications in Tumor Pathophysiology. Cancers (Basel) 2022; 14:cancers14061415. [PMID: 35326567 PMCID: PMC8946533 DOI: 10.3390/cancers14061415] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 12/12/2022] Open
Abstract
Simple Summary The pleura is a cavity whose pathology ranges from simple fluid accumulation to tumor development, all inducing important consequences in patents health, and usually having an important association with local inflammation. Understanding the pathophysiology of pleural inflammation helps the development of the correct treatment strategies and opens new windows in pleural research. Thus, the aim of this review is to present the etiologies and the pathophysiological mechanisms of pleural inflammation with a special interest in their role on tumor development and diagnosis. Abstract Pleural effusions are a common respiratory condition with many etiologies. Nonmalignant etiologies explain most pleural effusions and despite being nonmalignant, they can be associated with poor survival; thus, it is important to understand their pathophysiology. Furthermore, diagnosing a benign pleural pathology always harbors the uncertainty of a false-negative diagnosis for physicians and pathologists, especially for the group of non-specific pleuritis. This review aims to present the role of the inflammation in the development of benign pleural effusions, with a special interest in their pathophysiology and their association with malignancy.
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Basnet A, Chaulagain S, Thapa A, Khadka M, Khadka M, Shrestha DB. Empyema Thoracis in a Patient Admitted with COVID-19: A Case Report. JNMA J Nepal Med Assoc 2021; 59:1313-1315. [PMID: 35199793 PMCID: PMC9200044 DOI: 10.31729/jnma.6473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 12/08/2021] [Indexed: 11/01/2022] Open
Abstract
After almost a year of declaring COVID-19 a global pandemic, unusual presentations of the disease continue to be reported. Very little is known about its association with pleural disease. Here, we present a case of empyema thoracis in a 39-year-old male admitted with COVID-19. The pleural fluid later turned serosanguinous and eventually bleeding from other sites also occurred. During his treatment, antibiotics were given, thoracocentesis was performed and later thoracotomy was done. He died on the 19th day of admission following a hemorrhagic stroke. Pleural disease, although considered atypical and unusual presentation of COVID-19, needs careful and prompt diagnosis and earliest intervention. COVID-19, being a disease that involves multiple systems, and presentation of the disease may eventually lead to circulatory dysfunction and hence should be kept under consideration.
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Affiliation(s)
- Angela Basnet
- Department of Internal Medicine, Scheer Memorial Adventist Hospital, Banepa, Kavrepalanchok, Nepal
| | - Sabin Chaulagain
- Department of Internal Medicine, Scheer Memorial Adventist Hospital, Banepa, Kavrepalanchok, Nepal
| | - Ashok Thapa
- Department of Internal Medicine, Scheer Memorial Adventist Hospital, Banepa, Kavrepalanchok, Nepal
| | - Manita Khadka
- Nepalese Army Institute of Health Sciences, Sanobharyang, Kathmandu, Nepal,Correspondence: Ms. Manita Khadka, Nepalese Army Institute of Health Sciences, Sanobharyang, Kathmandu, Nepal. , Phone: +977-9861319454
| | - Manoj Khadka
- Nepalese Army Institute of Health Sciences, Sanobharyang, Kathmandu, Nepal
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Hu K, Chopra A, Kurman J, Huggins JT. Management of complex pleural disease in the critically ill patient. J Thorac Dis 2021; 13:5205-5222. [PMID: 34527360 PMCID: PMC8411157 DOI: 10.21037/jtd-2021-31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2021] [Indexed: 11/08/2022]
Abstract
Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.
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Affiliation(s)
- Kurt Hu
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| | - Jonathan Kurman
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Terrill Huggins
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
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Matuchova I, Kelbich P, Kubalik J, Hanuljakova E, Stanek I, Maly V, Karpjuk O, Krejsek J. Cytological-energy analysis of pleural effusions with predominance of neutrophils. Ther Adv Respir Dis 2021; 14:1753466620935772. [PMID: 32600177 PMCID: PMC7328477 DOI: 10.1177/1753466620935772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: The predominance of neutrophils in pleural effusions of patients with
different serious impairments of the pleural cavity organs is often found.
The aim of this study was to identify the type of injury using the
cytological-energy analysis of pleural effusions. Methods: We analysed 635 samples of pleural effusions with predominance of
neutrophils. We compared the values of the coefficient of energy balance
(KEB), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST)
catalytic activities in the following subgroups of patients: with
transudative effusions, purulent pneumonia, chest empyema and after chest
surgery with and without purulent complications. Statistical analysis was
performed using the ANOVA Kruskal–Wallis test (p < 0.05
was considered as significant). Results: We found the lowest KEB values in pleural effusions of patients with chest
empyema and their gradual increases in patients with purulent pneumonia and
with transudative effusions. We observed the highest LDH and AST enzymes
activity in patients with chest empyema and their gradual decrease in
patients with purulent pneumonia and with transudative effusions. LDH and
AST enzymes activity was significantly higher in pleural effusions of
patients after chest surgery with purulent complications compared with
non-purulent cases. Conclusion: The most intensive inflammation and the most extensive tissue destruction in
the pleural cavity were found in patients with chest empyema. Significantly
better parameters were observed in patients with purulent pneumonia. The
absence of serious inflammation and the absence of tissue destruction were
typical for patients with transudative effusions. Finally, our results
confirmed an anticipated higher tissue destruction in patients after chest
surgery. Significantly worse injury was found in surgical patients with
purulent complications compared with non-purulent ones. The reviews of this paper are available via the supplemental
material section.
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Affiliation(s)
- Inka Matuchova
- Biomedical Centre, Masaryk Hospital in Usti nad Labem, Usti nad Labem, Czech Republic.,Faculty of Medicine and University Hospital in Hradec Kralove, Department of Clinical Immunology and Allergology, Charles University in Prague, Hradec Kralove, Czech Republic.,Laboratory for Cerebrospinal Fluid, Neuroimmunology, Pathology and Special Diagnostics Topelex, Prague, Czech Republic
| | - Petr Kelbich
- Biomedical Centre, Masaryk Hospital in Usti nad Labem, Socialni pece 3316/12A, 401 13, Usti nad Labem, Czech Republic.,Faculty of Medicine and University Hospital in Hradec Kralove, Department of Clinical Immunology and Allergology, Charles University in Prague, Hradec Kralove, Czech Republic.,Laboratory for Cerebrospinal Fluid, Neuroimmunology, Pathology and Special Diagnostics Topelex, Prague, Czech Republic
| | - Jan Kubalik
- Faculty of Medicine and University Hospital in Hradec Kralove, Department of Clinical Immunology and Allergology, Charles University in Prague, Hradec Kralove, Czech Republic.,Department of Thoracic Surgery, Masaryk Hospital in Usti nad Labem, Usti nad Labem, Czech Republic
| | - Eva Hanuljakova
- Biomedical Centre, Masaryk Hospital in Usti nad Labem, Usti nad Labem, Czech Republic.,Laboratory for Cerebrospinal Fluid, Neuroimmunology, Pathology and Special Diagnostics Topelex, Prague, Czech Republic
| | - Ivan Stanek
- Department of Thoracic Surgery, Masaryk Hospital in Usti nad Labem, Usti nad Labem, Czech Republic
| | - Vilem Maly
- Department of Thoracic Surgery, Masaryk Hospital in Usti nad Labem, Usti nad Labem, Czech Republic
| | - Ondrej Karpjuk
- Department of Thoracic Surgery, Masaryk Hospital in Usti nad Labem, Usti nad Labem, Czech Republic
| | - Jan Krejsek
- Faculty of Medicine and University Hospital in Hradec Kralove, Department of Clinical Immunology and Allergology, Charles University in Prague, Hradec Kralove, Czech Republic
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Chatziparasidis G, Kantar A. Calprotectin: An Ignored Biomarker of Neutrophilia in Pediatric Respiratory Diseases. CHILDREN-BASEL 2021; 8:children8060428. [PMID: 34063831 PMCID: PMC8223968 DOI: 10.3390/children8060428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/20/2022]
Abstract
Calprotectin (CP) is a non-covalent heterodimer formed by the subunits S100A8 (A8) and S100A9 (A9). When neutrophils become activated, undergo disruption, or die, this abundant cytosolic neutrophil protein is released. By fervently chelating trace metal ions that are essential for bacterial development, CP plays an important role in human innate immunity. It also serves as an alarmin by controlling the inflammatory response after it is released. Extracellular concentrations of CP increase in response to infection and inflammation, and are used as a biomarker of neutrophil activation in a variety of inflammatory diseases. Although it has been almost 40 years since CP was discovered, its use in daily pediatric practice is still limited. Current evidence suggests that CP could be used as a biomarker in a variety of pediatric respiratory diseases, and could become a valuable key factor in promoting diagnostic and therapeutic capacity. The aim of this study is to re-introduce CP to the medical community and to emphasize its potential role with the hope of integrating it as a useful adjunct, in the practice of pediatric respiratory medicine.
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Affiliation(s)
| | - Ahmad Kantar
- Pediatric Asthma and Cough Centre, Instituti Ospedalieri Bergamaschi, University and Research Hospitals, 24046 Bergamo, Italy
- Correspondence:
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8
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Mohanty S, Bhuniya S. Pleural empyema due to Enterococcus species: An uncommon etiology. Respir Med Case Rep 2021; 32:101375. [PMID: 33732614 PMCID: PMC7940993 DOI: 10.1016/j.rmcr.2021.101375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/01/2021] [Accepted: 02/25/2021] [Indexed: 11/28/2022] Open
Abstract
We report a case of empyema due to Enterococcus faecium in a 50-year-old woman with no apparent severe immune system impairment, except for underlying thyroid disorder and hypochromic anaemia. Appropriate antibiotic therapy with parenteral amoxicillin-clavulanate with gentamicin, tube drainage and other supportive therapy resulted in a favourable outcome and the patient was discharged after 3 weeks of hospitalization. Though uncommon, the possibility of Enteroccus species should be kept in mind as a causative agent of thoracic empyema, especially in adults presenting from the community.
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Affiliation(s)
- Srujana Mohanty
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, 751019, Odisha, India
| | - Sourin Bhuniya
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, 751019, Odisha, India
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Pleural cytokines MIF and MIP-3α as novel biomarkers for complicated parapneumonic effusions and empyema. Sci Rep 2021; 11:1763. [PMID: 33469074 PMCID: PMC7815762 DOI: 10.1038/s41598-021-81053-6] [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: 04/09/2020] [Accepted: 12/02/2020] [Indexed: 11/20/2022] Open
Abstract
Patients with complicated parapneumonic effusion (CPPE)/empyema have high morbidity and mortality, particularly when adequate management is delayed. We aimed to investigate novel dysregulated cytokines that can be used as biomarkers for infectious pleural effusions, especially for CPPE/empyema. Expression of 40 cytokines in parapneumonic effusions (PPE) was screened in the discovery phase, involving 63 patients, using a multiplex immunobead-based assay. Six cytokines were subsequently validated by enzyme-linked immunosorbent assays (ELISAs). We then used ELISA to further evaluate the diagnostic values and cutoff values of these cytokines as potential biomarkers in an expanded group that included 200 patients with uncomplicated parapneumonic effusion (UPPE), CPPE, empyema, transudates, other exudates, and malignant pleural effusion (MPE). The pleural levels of four cytokines (MIF, MIP-3α, IL-1β, ENA-78) were highest and significantly increased in CPPE/empyema compared with those in other etiologies. According to receiver operating characteristic curve analysis, the four cytokines (MIF, MIP-3α, IL-1β, and ENA-78) had areas under the curve (AUCs) greater than 0.710 for discriminating parapneumonic pleural effusion from noninfectious pleural effusions. In a comparison of nonpurulent CPPE with UPPE, logistic regression analysis revealed that pleural fluid MIF ≥ 12 ng/ml and MIP-3α ≥ 4.3 ng/ml had the best diagnostic value; MIF also displayed the highest odds ratio of 663 for nonpurulent CPPE, with 97.5% specificity, 94.44% sensitivity, and an AUC of 0.950. In conclusion, our results show that elevated MIF and MIP-3α may be used as novel biomarkers for PPE diagnosis, particularly in patients with CPPE/empyema; the findings indicate that dysregulated cytokine expression may provide clues about the pathogenesis of pleural infection.
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Earasi K, Welch C, Zelickson A, Westover C, Ramani C, Sumner C, Davis EM. Proteus empyema as a rare complication from an infected renal cyst, a case report. BMC Pulm Med 2020; 20:314. [PMID: 33246448 PMCID: PMC7694313 DOI: 10.1186/s12890-020-01346-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 11/12/2020] [Indexed: 11/30/2022] Open
Abstract
Background The most commonly isolated organisms in a parapneumonic effusion include S. pneumoniae, H. influenzae, and S. aureus. If unusual organisms are isolated from the pleural space, further investigation is warranted to locate the primary source. We present a patient with an infected chronic renal cyst found to have an empyema secondary to Proteus mirabilis to highlight the importance of further diagnostic workup when encountering unusual organisms in the pleural space. Case presentation A 40-year-old African-American female, with a past medical history of asthma and sickle cell trait, presented with 5 weeks of upper respiratory tract symptoms and chest pain. A computed tomography angiogram (CTA) of the chest was negative for a pulmonary embolism but revealed a loculated left sided pleural effusion with associated left-lower lobe consolidation. She was started on empiric antibiotics, and a chest tube was inserted with drainage of frank pus. Fluid gram stain was positive for gram negative rods. Intrapleural fibrinolytics were administered for 72 h given the presence of loculations. With no improvement following fibrinolytics, she was taken to the operating room for large bore chest tube placement and left visceral pleura decortication. Pleural fluid cultures speciated to Proteus mirabilis, so further cross-sectional imaging of her abdomen/pelvis was pursued to evaluate for a primary source. A complex cystic lesion in the upper pole of the left kidney that communicated with the ipsilateral diaphragm was identified. Subsequent drainage and culture of the renal cyst was positive for Proteus mirabilis. Given clinical improvement following these interventions she was discharged with an extended course of antibiotics with plans for repeat imaging following completion of treatment. Conclusions While cases of Proteus mirabilis empyema have previously been reported as a consequence of conditions such as pyelonephritis, we present, to our knowledge, the first case of a Proteus mirabilis empyema as a consequence of an infected renal cyst communicating with the pleural space. This study highlights that further evaluation with cross-sectional imaging is warranted when unusual organisms are found in the pleural space. Anatomic abnormalities that become apparent on imaging may help elucidate the source of infection.
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Affiliation(s)
- Kranthikiran Earasi
- Department of Medicine, University of Virginia, 1714 Calvary Circle, Apt. 302, Charlottesville, VA, 22911, USA.
| | - Caitlin Welch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Adam Zelickson
- Department of Radiology, University of Virginia, Charlottesville, VA, USA
| | - Clinton Westover
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | - Chintan Ramani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Cameron Sumner
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Eric M Davis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA, USA
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11
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Pleural empyema in children - benefits of primary thoracoscopic treatment. Wideochir Inne Tech Maloinwazyjne 2020; 16:264-272. [PMID: 33786143 PMCID: PMC7991945 DOI: 10.5114/wiitm.2020.97443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 04/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Pleural empyema is the condition of the pleural cavity when initially sterile pleural effusion has become infected. In the majority of cases, it is of parapneumonic origin. Parapneumonic effusions and pleural empyemata usually continuously progress in severity. The American Thoracic Society divides them into three stages: exudative, fibrinopurulent and organizing. The therapy depends on the stage. Aim To assess whether thoracoscopy should be considered better than conservative treatment and to assess the feasibility of the thoracoscopic approach to the 3rd phase of pleural empyema. Material and methods The clinical course of 115 patients treated from 1996 to 2017 was analyzed. 45 patients operated on thoracoscopically after the failure of conventional treatment were compared with 70 patients treated by primary thoracoscopic drainage and decortication. Results The results of the study demonstrated that patients treated primarily by thoracoscopy had a shortened length of hospital stay (16.6 vs. 19.3 days), reduced drainage time (7.9 vs. 9.8 days), and shorter time of general therapy (31.8 vs. 38.0 days). They required fibrinolysis less frequently (12.8 vs. 26.7% of patients) and had reduced risk of reoperation (10 vs. 15.6% of cases). Operation time in the 3rd stage was only 15 min longer. The difference in length of hospital stay was only 0.8 days in favor of less severe cases. Conclusions The thoracoscopic approach is safely feasible in the 3rd stage of pleural empyema and should be considered as the preferred approach. Furthermore, the post-operative stay and general course of the disease are milder whenever surgery would not be delayed by prolonged conservative treatment attempts.
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12
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Dual RNA-seq in Streptococcus pneumoniae Infection Reveals Compartmentalized Neutrophil Responses in Lung and Pleural Space. mSystems 2019; 4:4/4/e00216-19. [PMID: 31409659 PMCID: PMC6697439 DOI: 10.1128/msystems.00216-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The factors that regulate the passage of bacteria between different anatomical compartments are unclear. We have used an experimental model of infection with Streptococcus pneumoniae to examine the host and bacterial factors involved in the passage of bacteria from the lung to the pleural space. The transcriptional profile of host and bacterial cells within the pleural space and lung was analyzed using deep sequencing of the entire transcriptome using the technique of dual RNA-seq. We found significant differences in the host and bacterial RNA profiles in infection, which shed light on the key factors that allow passage of this bacterium into the pleural space. Streptococcus pneumoniae is the dominant cause of community-acquired pneumonia worldwide. Invasion of the pleural space is common and results in increased mortality. We set out to determine the bacterial and host factors that influence invasion of the pleural space. In a murine model of pneumococcal infection, we isolated neutrophil-dominated samples of bronchoalveolar and pleural fluid containing bacteria 48 hours after infection. Using dual RNA sequencing (RNA-seq), we characterized bacterial and host transcripts that were differentially regulated between these compartments and bacteria in broth and resting neutrophils, respectively. Pleural and lung samples showed upregulation of genes involved in the positive regulation of neutrophil extravasation but downregulation of genes mediating bacterial killing. Compared to the lung samples, cells within the pleural space showed marked upregulation of many genes induced by type I interferons, which are cytokines implicated in preventing bacterial transmigration across epithelial barriers. Differences in the bacterial transcripts between the infected samples and bacteria grown in broth showed the upregulation of genes in the bacteriocin locus, the pneumococcal surface adhesin PsaA, and the glycopeptide resistance gene vanZ; the gene encoding the ClpP protease was downregulated in infection. One hundred sixty-nine intergenic putative small bacterial RNAs were also identified, of which 43 (25.4%) small RNAs had been previously described. Forty-two of the small RNAs were upregulated in pleura compared to broth, including many previously identified as being important in virulence. Our results have identified key host and bacterial responses to invasion of the pleural space that can be potentially exploited to develop alternative antimicrobial strategies for the prevention and treatment of pneumococcal pleural disease. IMPORTANCE The factors that regulate the passage of bacteria between different anatomical compartments are unclear. We have used an experimental model of infection with Streptococcus pneumoniae to examine the host and bacterial factors involved in the passage of bacteria from the lung to the pleural space. The transcriptional profile of host and bacterial cells within the pleural space and lung was analyzed using deep sequencing of the entire transcriptome using the technique of dual RNA-seq. We found significant differences in the host and bacterial RNA profiles in infection, which shed light on the key factors that allow passage of this bacterium into the pleural space.
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13
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Mohajerzadeh L, Lotfollahzadeh S, Vosoughi A, Harirforoosh I, Parsay S, Amirifar H, Farahbakhsh N, Atqiaee K. Thoracotomy versus Video-Assisted Thoracoscopy in Pediatric Empyema. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 52:125-130. [PMID: 31236371 PMCID: PMC6559187 DOI: 10.5090/kjtcs.2019.52.3.125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 02/27/2019] [Accepted: 03/07/2019] [Indexed: 11/17/2022]
Abstract
Background To compare the outcomes of video-assisted thoracoscopic surgery (VATS) in comparison to open thoracic surgery in pediatric patients suffering from empyema. Methods A prospective study was carried out in 80 patients referred to the Department of Pediatric Surgery between 2015 and 2018. The patients were randomly divided into thoracotomy and VATS groups (groups I and II, respectively). Forty patients were in the thoracotomy group (16 males [40%], 24 females [60%]; average age, 5.77±4.08 years) and 40 patients were in the VATS group (18 males [45%], 22 females [55%]; average age, 6.27±3.67 years). There were no significant differences in age (p=0.61) or sex (p=0.26). Routine preliminary workups for all patients were ordered, and the patients were followed up for 90 days at regular intervals. Results The average length of hospital stay (16.28±7.83 days vs. 15.83±9.44 days, p=0.04) and the duration of treatment needed for pain relief (10 days vs. 5 days, p=0.004) were longer in the thoracotomy group than in the VATS group. Thoracotomy patients had surgical wound infections in 27.3% of cases, whereas no cases of infection were reported in the VATS group (p=0.04). Conclusion Our results indicate that VATS was not only less invasive than thoracotomy, but also showed promising results, such as an earlier discharge from the hospital and fewer postoperative complications.
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Affiliation(s)
- Leily Mohajerzadeh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Iran
| | - Saran Lotfollahzadeh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Iran
| | - Armin Vosoughi
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Iran.,Neurosciences Research Center, Iran
| | - Iman Harirforoosh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Iran
| | - Sina Parsay
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Iran.,Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hesam Amirifar
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Iran.,Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nazanin Farahbakhsh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Iran
| | - Khashayar Atqiaee
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Iran
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14
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Wu KA, Wu CC, Liu YC, Hsueh PC, Chin CY, Wang CL, Chu CM, Shih LJ, Yang CY. Combined serum biomarkers in the noninvasive diagnosis of complicated parapneumonic effusions and empyema. BMC Pulm Med 2019; 19:108. [PMID: 31215423 PMCID: PMC6582530 DOI: 10.1186/s12890-019-0877-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/12/2019] [Indexed: 01/30/2023] Open
Abstract
Background We previously demonstrated that the pleural levels of proteins (neutrophil gelatinase-associated lipocalin/NGAL, calprotectin, bactericidal permeability-increasing/BPI, azurocidin 1/AZU-1) were valuable markers for identifying complicated PPE (CPPE). Herein, this study was performed to evaluate whether these proteins are useful as serological markers for identifying CPPE and empyema. Methods A total of 137 participates were enrolled in this study. The levels of NGAL, calprotectin, BPI and AZU-1 were measured in serum and pleural fluid by enzyme-linked immunosorbent assay. We also characterized the diagnostic values of these markers between different groups. Results The serum levels of NGAL, calprotectin, and BPI in PPE patients were significantly higher than those in transudates, noninfectious exudates, and healthy controls. The area under the curve (AUC) values of NGAL, calprotectin, and BPI for distinguishing PPE from transudates or noninfectious exudates were around 0.861 to 0.953. In PPE group, serum NGAL and calprotectin levels were significantly elevated in patients with CPPE and empyema than in those with UPPE, whereas the serum BPI levels were similar between these two groups. In CPPE and empyema patients, the serum NGAL showed a positive correlation with the pleural fluid NGAL (r = 0.417, p < 0.01). When combined with serum CRP, the sensitivity and specificity of serum calprotectin for identifying CPPE and empyema were the highest at 73.52% and 80.55%, respectively. Conclusions We concluded that serum calprotectin and NGAL were adjuvant serological markers for CPPE and empyema diagnosis. Patients present with pneumonia and pleural effusion signs in the chest x-ray and the combination of serum calprotectin and CRP constitutes a more highly sensitive and specific assay for identifying CPPE and empyema. Electronic supplementary material The online version of this article (10.1186/s12890-019-0877-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kuo-An Wu
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan.,School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Chih-Ching Wu
- Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Ching Liu
- Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Chun Hsueh
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Yin Chin
- Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Liang Wang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pulmonary Oncology and Interventional Bronchoscopy, Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chi-Ming Chu
- Division of Biomedical Statistics and Informatics, School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Li-Jane Shih
- Department of Medical Laboratory, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Chia-Yu Yang
- Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan. .,Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan. .,Department of Microbiology and Immunology, College of Medicine, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Taoyuan, 33302, Taiwan. .,Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
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15
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Abstract
CLINICAL ISSUE Despite a considerable number of antimicrobial agents and interdisciplinary treatment options, lower respiratory tract infections are still associated with high morbidity and mortality rates. Infections of the respiratory tract can lead to severe complications, such as empyema, lung abscesses and acute respiratory distress syndrome (ARDS). Besides intrapulmonary complications pneumonia can also impair other organs due to a systemic inflammatory response. Underlying cardiovascular diseases, such as chronic heart failure, arteriosclerosis and dysrhythmia can either deteriorate due to infections or be newly manifested as a result of pneumonia. Early diagnosis and therapy of these sometimes life-threatening complications are crucial and can have a severe impact on disease outcome. STANDARD RADIOLOGICAL METHODS The most important imaging techniques include chest X‑ray and computed tomography (CT) of the chest. Although a definite diagnosis is sometimes difficult or even impossible to establish using chest X‑ray or CT, there are several findings indicative of intrapulmonary or extrapulmonary complications of pneumonia. Another useful and portable tool is thoracic ultrasound directly on the patient, which can be used to further define the underlying disease or as guidance during procedures. PRACTICAL RECOMMENDATIONS The chest X‑ray is useful in initial diagnosis and follow-up. If complications or disease progression are suspected or the clinical course differs from the X‑ray interpretation, a subsequent CT of the chest should be performed.
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16
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Lai SW, Lin CL, Liao KF. Population-based cohort study investigating the correlation of diabetes mellitus with pleural empyema in adults in Taiwan. Medicine (Baltimore) 2017; 96:e7763. [PMID: 28885331 PMCID: PMC6392655 DOI: 10.1097/md.0000000000007763] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/23/2017] [Accepted: 07/24/2017] [Indexed: 12/13/2022] Open
Abstract
We assessed the association between diabetes mellitus and the risk of pleural empyema in Taiwan.A population-based retrospective cohort study was conducted using the database of the Taiwan National Health Insurance Program. There were 28,802 subjects aged 20 to 84 years who were newly diagnosed with diabetes mellitus from 2000 to 2010 as the diabetes group and 114,916 randomly selected subjects without diabetes mellitus as the non-diabetes group. The diabetes group and the non-diabetes group were matched by sex, age, comorbidities, and the year of index date. The incidence of pleural empyema at the end of 2011 was estimated. A multivariable Cox proportional hazards regression model was used to estimate the hazard ratio (HR) and 95% confidence interval (95% CI) for pleural empyema associated with diabetes mellitus.The overall incidence of pleural empyema was 1.65-fold higher in the diabetes group than that in the non-diabetes group (1.58 vs 0.96 per 10,000 person-years, 95% CI 1.57-1.72). After adjusting for confounders, a multivariable Cox proportional hazards regression model revealed that the adjusted HR of pleural empyema was 1.71 in subjects with diabetes mellitus (95% CI 1.16-2.51), compared with those without diabetes mellitus. In further analysis, even in the absence of any comorbidity, the adjusted HR was 1.99 for subjects with diabetes mellitus alone (95% CI 1.18-3.38).Diabetic patients confer a 1.71-fold increased hazard of developing pleural empyema. Even in the absence of any comorbidity, the risk remains existent.
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Affiliation(s)
- Shih-Wei Lai
- College of Medicine
- Department of Family Medicine
| | - Cheng-Li Lin
- College of Medicine
- Management Office for Health Data, China Medical University Hospital, Taichung
| | - Kuan-Fu Liao
- College of Medicine, Tzu Chi University, Hualien
- Department of Internal Medicine, Taichung Tzu Chi General Hospital
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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17
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Wiese AD, Griffin MR, Zhu Y, Mitchel EF, Grijalva CG. Changes in empyema among U.S. children in the pneumococcal conjugate vaccine era. Vaccine 2016; 34:6243-6249. [PMID: 27832918 DOI: 10.1016/j.vaccine.2016.10.062] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Parapneumonic empyema, a serious complication of pneumonia, started increasing among U.S. children before the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) in 2000, and continued afterwards. This increase was due in part to pneumococcal serotypes not included in PCV7 that were included in the new 13-valent (PCV13) vaccine introduced in 2010. We assessed changes in the incidence of empyema hospitalizations among U.S. children after PCV13 introduction. METHODS We calculated annualized empyema hospitalization rates among U.S. children <18years using Nationwide Inpatient Sample and Census data (1997-2013) for four periods based on PCV7 and PCV13 introductions. Relative rates (RR) and 95% confidence intervals (CI) were calculated by age group and sex, comparing PCV7 [early-PCV7 (2001-2005) and late-PCV7 (2006-2009)] and PCV13 (2011-2013) periods with the pre-PCV7 period (1997-1999). Secondary analyses examined changes in pneumococcal, streptococcal, staphylococcal and unspecified empyema. RESULTS Among children <18years of age, annualized empyema hospitalization rates peaked at 3.6 per 100,000 in the late-PCV7 period compared with 2.1 per 100,000 in the pre-PCV7 period [RR: 1.70 (95% CI: 1.11-2.60)]. However, annualized rates in the post-PCV13 period declined to 2.0 per 100,000, similar to rates in the pre-PCV7 period. Empyema rates among children <2years were lower in the post-PCV13 period compared to the pre-PCV7 period [RR: 0.77 (95% CI: 0.61-0.96)], but rates in the two periods among children 2-4 and 5-17years were similar. Most empyema were of unspecified etiology. Pneumococcal and unspecified empyema declined after PCV13 introduction. CONCLUSIONS Although empyema hospitalization rates among U.S. children peaked after PCV7 introduction, rates decreased substantially following the introduction of PCV13.
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Affiliation(s)
- Andrew D Wiese
- Department of Health Policy, Vanderbilt University, Nashville, USA.
| | - Marie R Griffin
- Department of Health Policy, Vanderbilt University, Nashville, USA; Department of Medicine, Vanderbilt University, Nashville, USA; VA TN Valley Health Care System, Nashville, USA
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University, Nashville, USA
| | - Edward F Mitchel
- Department of Health Policy, Vanderbilt University, Nashville, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University, Nashville, USA; VA TN Valley Health Care System, Nashville, USA
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18
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Petrusevska-Marinkovic S, Kondova-Topuzovska I, Milenkovic Z, Kondov G, Anastasovska A. Clinical, Laboratory and Radiographic Features of Patients with Pneumonia and Parapneumonic Effusions. Open Access Maced J Med Sci 2016; 4:428-434. [PMID: 27703568 PMCID: PMC5042628 DOI: 10.3889/oamjms.2016.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/08/2016] [Accepted: 08/22/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND: Parapneumonic effusions complicating pneumonia are associated with increased morbidity and mortality. AIM: To determine the role of the clinical, laboratory and radiographic features to the differential diagnosis of patients with community- acquired pneumonia (CAP) without effusion, uncomplicated parapneumonic effusion (UCPPE) and complicated parapneumonic effusion (CPPE). MATERIAL AND METHODS: We analysed 148 patients with CAP without effusion, 50 with UCPPE and 44 with CPPE. In three groups of patients, the majority was male patients (58.11%, 58%, 61.36%) consequently. RESULTS: The chronic heart failure was the most common comorbidity in a group with CAP (28; 18.92%) and UCPPE (7; 14%), alcoholism (12;12.77%) in a group with CPPE. Patients with CPPE had significantly longer fever compared to patients with CAP without effusion (p = 0.003). Pleuritic chest pain (86.36%) and dyspnea (88.64%) were the most common symptoms in CPPE, then to group with UCPPE (60%; 52%), and in CAP without effusion (25.68%; 47,97%). Diffuse pulmonary changes were detected more frequently in the group with CAP without effusion compared with the group with CPPE (64.86 % vs. 27.27 %), while the segment lung changes were more common in patients with CPPE (50% vs. 20.27%). Patients with CPPE were significant with higher erythrocytes sedimentation rate (ESR), white blood cells (WBC) and serum C- reactive protein (CRP) than it the other two groups (p = 0.00090, p = 0.01, p= 0.000065). CONCLUSION: Proper analysis of clinical, laboratory and radiographic features of patients with CAP and parapneumonic effusion can prevent mismanagement in these patients and will reduce morbidity and mortality.
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Affiliation(s)
- Sanja Petrusevska-Marinkovic
- University Infectious Diseases Clinic, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Irena Kondova-Topuzovska
- University Infectious Diseases Clinic, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Zvonko Milenkovic
- University Infectious Diseases Clinic, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Goran Kondov
- University Thoracocardiovascular Surgery Clinic, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Ankica Anastasovska
- University Infectious Diseases Clinic, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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19
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Affiliation(s)
- A Schattner
- From the Department of Medicine, Laniado Hospital, Sanz Medical Center, Netanya, Israel The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - I Dubin
- From the Department of Medicine, Laniado Hospital, Sanz Medical Center, Netanya, Israel
| | - M Gelber
- From the Department of Medicine, Laniado Hospital, Sanz Medical Center, Netanya, Israel
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20
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Dean NC, Griffith PP, Sorensen JS, McCauley L, Jones BE, Lee YCG. Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia. Chest 2016; 149:1509-15. [PMID: 26836918 DOI: 10.1016/j.chest.2015.12.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/23/2015] [Accepted: 12/29/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pleural effusions are present in 15% to 44% of hospitalized patients with pneumonia. It is unknown whether effusions at first presentation to the ED influence outcomes or should be managed differently. METHODS We studied patients in seven hospital EDs with International Statistical Classification of Disease and Health Related Problems-Version 9 codes for pneumonia, or empyema, sepsis, or respiratory failure with secondary pneumonia. Patients with no confirmatory findings on chest imaging were excluded. Pleural effusions were identified with the use of radiographic imaging. RESULTS Over 24 months, 4,771 of 458,837 adult ED patients fulfilled entry criteria. Among the 690 (14.5%) patients with pleural effusions, their median age was 68 years, and 46% were male. Patients with higher Elixhauser comorbidity scores (OR, 1.13 [95% CI, 1.09-1.18]; P < .001), brain natriuretic peptide levels (OR, 1.20 [95% CI, 1.12-1.28]; P < .001), bilirubin levels (OR, 1.07 [95% CI, 1.00-1.15]; P = .04), and age (OR, 1.15 [95% CI, 1.09-1.21]; P < .001) were more likely to have parapneumonic effusions. In patients without effusion, electronic version of CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years accurately predicted mortality (4.7% predicted vs 5.0% actual). However, eCURB underestimated mortality in those with effusions (predicted 7.0% vs actual 14.0%; P < .001). Patients with effusions were more likely to be admitted (77% vs 57%; P < .001) and had a longer hospital stay (median, 2.8 vs 1.3 days; P < .001). After severity adjustment, the likelihood of 30-day mortality was greater among patients with effusions (OR, 2.6 [CI, 2.0-3.5]; P < .001), and hospital stay was disproportionately longer (coefficient, 0.22 [CI, 0.14-0.29]; P < .001). CONCLUSIONS Patients with pneumonia and pleural effusions at ED presentation in this study were more likely to die, be admitted, and had longer hospital stays. Why parapneumonic effusions are associated with adverse outcomes, and whether different management of these patients might improve outcome, needs urgent investigation.
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Affiliation(s)
- Nathan C Dean
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Paula P Griffith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Jeffrey S Sorensen
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Lindsay McCauley
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Barbara E Jones
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City VA Health System, Salt Lake City, UT
| | - Y C Gary Lee
- Pleural Diseases Unit, Sir Charles Gairdner Hospital, University of Western Australia-Perth, Western Australia
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21
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Porcel JM, Statophoulos G, Lee YCG. Advances and controversies in pleural diseases. J Thorac Dis 2015; 7:961-3. [PMID: 26150909 DOI: 10.3978/j.issn.2072-1439.2015.04.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 04/09/2015] [Indexed: 12/12/2022]
Affiliation(s)
- José M Porcel
- 1 Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Biomedical Research Institute of Lleida, Lleida, Spain ; 2 Laboratory for Molecular Respiratory Carcinogenesis, Department of Physiology, Faculty of Medicine, University of Patras, Patras, Greece ; 3 Respiratory Department, Sir Charles Gairdner Hospital, & Centre for Asthma, Allergy & Respiratory Research, University of Western Australia, Perth, Australia
| | - Georgios Statophoulos
- 1 Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Biomedical Research Institute of Lleida, Lleida, Spain ; 2 Laboratory for Molecular Respiratory Carcinogenesis, Department of Physiology, Faculty of Medicine, University of Patras, Patras, Greece ; 3 Respiratory Department, Sir Charles Gairdner Hospital, & Centre for Asthma, Allergy & Respiratory Research, University of Western Australia, Perth, Australia
| | - Yun Chor Gary Lee
- 1 Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Biomedical Research Institute of Lleida, Lleida, Spain ; 2 Laboratory for Molecular Respiratory Carcinogenesis, Department of Physiology, Faculty of Medicine, University of Patras, Patras, Greece ; 3 Respiratory Department, Sir Charles Gairdner Hospital, & Centre for Asthma, Allergy & Respiratory Research, University of Western Australia, Perth, Australia
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