[Complications after conservative vs. operative treatment of severe thoracic trauma]

BACKGROUND

Thoracic trauma is a frequent injury in the routine treatment of injured patients. Due to the increasing demographic changes a further increase is to be expected, especially after low-energy trauma.

OBJECTIVE

Expected complications after conservative vs. operative treatment of various injury patterns of thoracic trauma.

MATERIAL AND METHODS

Evaluation of a selective literature search regarding possible complications after thoracic trauma and formulation of instructions for action as expert recommendations.

CONCLUSION

Both conservative and operative treatment of thoracic trauma have their specific complications, which have to be known to the treating physician. Lung contusions are often underestimated in the initial radiological diagnostics but often lead to relevant problems during the further course of treatment. After conservative treatment of rib fractures persistent pain, functional limitations or even relevant deformities due to secondary dislocation, can remain. There is a significant risk of overlooking or underestimating relevant injuries during the initial diagnostics which then leads to secondary complications. By far the most frequent risk of surgical treatment is an incorrect positioning of chest tubes. Overall, postoperative infections after chest trauma are relatively rare.

Pleural empyema with endobronchial mass due to Rhodococcus equi infection after renal transplantation: A case report and review of literature

BACKGROUND

Kidney transplantation is the best option for patients with end-stage renal disease. However, the need for lifelong immunosuppression results in renal transplant recipients being susceptible to various infections. Rhodococcus equi (R. equi) is a rare opportunistic pathogen in humans, and there are limited reports of infection with R. equi in post-renal transplant recipients and no uniform standard of treatment. This article reports on the diagnosis and treatment of a renal transplant recipient infected with R. equi 21 mo postoperatively and summarizes the characteristics of infection with R. equi after renal transplantation, along with a detailed review of the literature.

CASE SUMMARY

Here, we present the case of a 25-year-old man who was infected with R. equi 21 mo after renal transplantation. Although the clinical features at the time of presentation were not specific, chest computed tomography (CT) showed a large volume of pus in the right thoracic cavity and right middle lung atelectasis, and fiberoptic bronchoscopy showed an endobronchial mass in the right middle and lower lobe orifices. Bacterial culture and metagenomic next-generation sequencing sequencing of the pus were suggestive of R. equi infection. The immunosuppressive drugs were immediately suspended and intravenous vancomycin and azithromycin were administered, along with adequate drainage of the abscess. The endobronchial mass was then resected. After the patient's clinical symptoms and chest CT presentation resolved, he was switched to intravenous ciprofloxacin and azithromycin, followed by oral ciprofloxacin and azithromycin. The patient was re-hospitalized 2 wk after discharge for recurrence of R. equi infection. He recovered after another round of adequate abscess drainage and intravenous ciprofloxacin and azithromycin.

CONCLUSION

Infection with R. equi in renal transplant recipients is rare and complex, and the clinical presentation lacks specificity. Elaborate antibiotic therapy is required, and adequate abscess drainage and surgical excision are necessary. Given the recurrent nature of R. equi, patients need to be followed-up closely.

Pleural penetration of amoxicillin and metronidazole during pleural infection: An ambispective cohort study

OBJECTIVES

The pharmacokinetics of antibiotics in pleural fluid during pleural infections has been poorly described. This study aimed to explore amoxicillin and metronidazole diffusion into the pleural space.

METHODS

This was an ambispective, single-centre study that included patients with complicated parapneumonic effusion or pleural empyema managed with repeated therapeutic thoracentesis as first-line treatment between 2014 and 2022. Pleural steady-state or trough concentrations of amoxicillin and metronidazole were measured, with a lower limit of quantification of 5 mg/L.

RESULTS

Seventy paired blood and pleural samples were analysed from 40 patients. The median (interquartile range) patient age was 55 years (45-67 years) and 88% were male. The median patient weight was 65.8 kg (57.3-82 kg) and median plasma albumin concentration was 29.7 g/L (23.7-33.9 g/L). Median creatinine clearance was 106 mL/min (95-117 mL/min). Median amoxicillin pleural concentrations in patients treated with oral, bolus and continuous intravenous administrations (6 g/day) were, respectively, 5.2 (<5-6.4), 9.4 (8-13.1) and 10.8 (7.1-13.1) mg/L. Pleural concentrations were <5 mg/L in 5/11 samples (45%) with oral treatment and 6/59 (10%) with intravenous treatment. Median metronidazole pleural concentrations were 18.4 (15.7-22.8) mg/L, with all patients being treated orally (1.5 g/day).

CONCLUSIONS

Oral metronidazole (1.5 g/day) and intravenous amoxicillin (6 g/day) achieved therapeutic targets in pleural fluid in most cases, but oral amoxicillin did not.

A case of severe bilateral empyema due to Streptococcus pyogenes

Bilateral empyema is a rare and severe condition and deciding on a treatment is quite difficult. Additionally, infections caused by group A Streptococcus (GAS [Streptococcus pyogenes]) are known to be invasive. We successfully treated without surgery a previously healthy 59-year-old woman with bilateral empyema due to GAS, with repeated drainages, antibiotics, and fibrinolytic therapy. To our knowledge, there have not been any published reports on cases of bilateral empyema due to GAS infection. In rare, severe cases of bilateral empyema caused by organisms such as GAS, physicians managing the condition should consider the overall condition of the patient.

Intrathoracic vacuum therapy for the therapy of pleural empyema-a systematic review and analysis of the literature

Background

Pleural empyema is a serious and potentially deadly disease leading to a significant burden on health care systems. Conservative and surgical treatment results remain poor, with high morbidity and mortality rates. Patients with pleural empyema are often multimorbid and poor candidates for surgery. Therefore, it appears sensible to explore alternative, less invasive treatment options. Recently, the well-established vacuum sponge therapy has been adopted in the treatment of pleural infections. The goal of this systematic review was to identify the existing literature and reported results of vacuum therapy for pleural empyema.

Methods

A systematic search of MEDLINE and the Cochrane Database was performed independently by two reviewers using predefined criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. In addition, abstracts from selected conference proceedings were screened and reference scanning of the search results was performed. Single case reports were excluded.

Results

Fourteen studies met the selection criteria and were reviewed. A total of 165 patients were treated with vacuum therapy in the studies reviewed. 61.2% of the patients had pleural empyema secondary to thoracic surgery. In 71.5% of the patients, vacuum therapy was applied following open window thoracostomy (OWT). Mortality rates of 0-33% were reported for vacuum therapy after OWT and 0-9.3% for vacuum therapy without OWT. Length of hospital stay (LOHS) ranged from 44-217 days for patients after OWT and could not be analysed for vacuum therapy without OWT due to lacking data. Median treatment time was 7-14 days. Treatment related complications were rare overall. Success rates defined as infection resolution were high irrespective of previous treatment and cause of empyema.

Conclusions

The current literature shows that pleural vacuum therapy is a promising, safe, and feasible treatment alternative to existing treatment modalities for pleural empyema. However, the evidence for vacuum therapy without OWT is poor, and further data, optimally prospective or randomised control trials comparing the conventional surgical approach of video-assisted thoracoscopic surgery (VATS) decortication and minimally invasive vacuum therapy, are needed.

Massive pleural empyema secondary to amoebic liver abscess in a child

BACKGROUND

Pleural empyema secondary to a ruptured amoebic liver abscess is a rare complication in the pediatric population.

CASE REPORT

We report the case of a 13-year-old male with right flank abdominal pain, productive cough with foul-smelling sputum, fever, and respiratory distress. Physical examination revealed breathlessness, decreased vesicular murmur in the right hemithorax, abdominal distension, hepatomegaly, and lower limb edema. Laboratory tests revealed mild anemia, leukocytosis without eosinophilia, elevated alkaline phosphatase, hypoalbuminemia, and positive immunoglobulin G antibodies against Entamoeba histolytica in pleural fluid. He required a chest tube and treatment with metronidazole. After 2 months of follow-up, the abscesses disappeared, and the empyema decreased.

CONCLUSIONS

Massive pleural empyema secondary to a ruptured liver abscess is a rare complication. The epidemiological link associated with the symptoms and serological tests can help in the diagnosis.

Does the time to diagnosis and treatment influence outcome in adults with pleural infections

Objective

To investigate the effect of early diagnosis and intervention in adult patients with complicated parapneumonic pleural effusion or pleural empyema and the impact on outcomes.

Methods

A systematic review based on a literature search of the PubMed database was performed.

Results

Eleven eligible studies were included; nine observational studies and two randomised controlled trials totalling a study population of 10,717 patients. The studies were conducted from 1992 to 2018, all in Europe and Northern America except one. Results varied between studies, but a trend towards better outcome in patients with shorter duration of symptoms and quicker initiation of treatment was found. We found that duration of symptoms before treatment may affect length of hospital stay, rate of conversion to open surgery, and frequency of complications.

Conclusion

We found that an earlier intervention in adults suffering from complicated parapneumonic pleural effusion and pleural empyema may potentially improve the outcome of patients in terms of length of stay, conversion to open surgery, and general complications following treatment, but not regarding mortality. Further studies are required to specify the timing of each intervention, and direct comparison in early management of interventions.

The rare thoracic complication: perforation of gastric fundus ulcer: a case report

BACKGROUND

Gastropleural fistula is an exceptionally rare condition, the incidence of which is currently unknown (Kunieda et al. in Intern Med 51(3):331, 2012,  https://doi.org/10.2169/internalmedicine.51.6823 , Iqbal et al. in Cureus 11(2):e4136, 2019, https://doi.org/10.7759/cureus.4136 , Kathayanatt et al. in Lung India 37(2):174-175, 2020, https://doi.org/10.4103/lungindia.lungindia_242_17 ). The etiology varies from traumatic or iatrogenic injury to perforation in a herniated stomach due to ischemia, ulceration, or malignancy.

CASE PRESENTATION

A 27-year-old European male presented to our hospital with complaints of general weakness and shortness of breath. The patient had a single episode of hemoptysis before admission. A computed tomography scan demonstrated a left-sided pyopneumothorax, a defect in the left main bronchus, and signs of pneumonia in the lower sections of the right lung. Therefore, a rare complication of perforation of a gastric fundus ulcer with the formation of a subdiaphragmatic abscess, gastropleural fistula, gangrene of the left lung with circular necrosis of the left main bronchus and diastasis of its edges, and pleural empyema on the left is presented in this report.

CONCLUSIONS

Although, a radical surgery may be preferable for this suspected malignancy; it should be weighed carefully against the risk of sepsis and the morbidity associated with a prolonged procedure in a sick patient. Damage-control surgery may be a viable option for a very sick patient, with more extensive resection reserved for later, provided the risk of infection and bleeding has been mitigated.

Medical Thoracoscopy and Intrapleural Fibrinolytic Therapy for the Management of Pleural Empyema: A Cohort Study

BACKGROUND

Pleural empyema is associated with relevant morbidity and mortality, and it may be classified, according to evolution and ultrasound, into three stages: stage I (free-flowing effusion), stage II (viscous effusion with the tendency to loculate), and stage III (organizing phase). According to guidelines, antibiotic therapy and pleural drainage are recommended, with surgery being performed when patients fail and/or in case of organized empyema.

OBJECTIVES

The aim of the study was to report the efficacy and safety of medical thoracoscopy in patients with pleural empyema stratified by chest ultrasound.

METHOD

Observational retrospective cohort study analyzing patients with pleural empyema treated with medical thoracoscopy. Procedure success and mortality were evaluated at 30 days and 90 days after the procedure; complications were also reported.

RESULTS

131 patients were included. Intrapleural fibrinolytic therapy was performed thereafter in the majority of cases. Medical thoracoscopy was considered successful without subsequent intervention in 99 patients (76%); 19 patients (15%) underwent a second procedure (drainage, thoracoscopy, video-assisted thoracic surgery, or thoracotomy); and 6 patients (5%) died of the evolution of empyema. Patients treated in stages I and II showed significantly better post-procedure results compared with patients treated in stage III (100%, 83.3%, and 58.1%, respectively). Thoracoscopy complications were observed in 18 patients and were reversible in all cases.

CONCLUSIONS

Patients with pleural empyema treated in earlier stages (free-flowing or multiloculated effusion) with medical thoracoscopy show significantly better results than patients treated in later stages (organized empyema). This approach is safe, minimally invasive, and efficient in these patients with disease having relevant mortality; however, patient selection remains essential.

A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: results from the ACTion trial

BACKGROUND

Pleural infection is a complex condition with a considerable healthcare burden. The average hospital stay for pleural infection is 14 days. Current standard of care defaults to chest tube insertion and intravenous antibiotics. There have been no randomised trials on the use of therapeutic thoracentesis (TT) for pleural fluid drainage in pleural infection.

AIMS AND OBJECTIVES

To assess the feasibility of a full-scale trial of chest tube vs TT for pleural infection in a single UK centre. The primary outcome was defined as the acceptability of randomisation to patients.

METHODS

Adult patients admitted with a pleural effusion felt to be related to infection and meeting criteria for drainage (based on international guidelines) were eligible for randomisation. Participants were randomised (1:1) to chest tube insertion or TT with daily review assessing need for further drainages or other therapies. Neither participant nor clinician were blinded to treatment allocation. Patients were followed up at 90 days post-randomisation.

RESULTS

From September 2019 to June 2021, 51 patients were diagnosed with pleural infection (complex parapneumonic effusion/empyema). Eleven patients met the inclusion criteria for trial and 10 patients were randomised (91%). The COVID-19 pandemic had a substantial impact on recruitment. Data completeness was high in both groups with no protocol deviations. Patients randomised to TT had a significantly shorter overall mean hospital stay (5.4 days, SD 5.1) compared to the chest tube control group (13 days, SD 6.0), p = 0.04. Total number of pleural procedures required per patient were similar, 1.2 in chest tube group and 1.4 in TT group. No patient required a surgical referral. Adverse events were similar between the groups with no readmissions related to pleural infection.

CONCLUSIONS

The ACTion trial met its pre-specified feasibility criteria for patient acceptability but other issues around feasibility of a full-scale trial remain. From the results available the hypothesis that TT can reduce length of stay in pleural infection should be explored further.

TRIAL REGISTRATION

ISRCTN: 84674413.

The uniportal VATS in the treatment of stage II pleural empyema: a safe and effective approach for adults and elderly patients-a single-center experience and literature review

Background

Pleural empyema (PE) is a frequent disease, associated with a high morbidity and mortality. Surgical approach is the standard of care for most patients with II-III stage PE. In the last years, the minimally invasive surgical revolution involved also thoracic surgery allowing the same outcomes in terms of safety and effectiveness combined to better pain management and early discharge. The aim of this study is to demonstrate through our experience on uniportal-video-assisted thoracoscopy (u-VATS) the effectiveness and safety of its approach in treatment of stage II PE. As secondary endpoint, we will evaluate the different pattern of indication of u-VATS in adult and elderly patients with literature review.

Methods

We retrospectively reviewed our prospectively collected database of u-VATS procedures from November 2018 to February 2022, in our regional referral center for Thoracic Surgery of Regione Molise General Surgery Unit of “A. Cardarelli” Hospital, in Campobasso, Molise, Italy.

Results

A total of 29 patients underwent u-VATS for II stage PE. Fifteen (51.72%) patients were younger than 70 years old, identified as “adults,” 14 (48.28%) patients were older than 70 years old, identified as “elderly.” No mortality was found. Mean operative time was 104.68 ± 39.01 min in the total population. The elderly group showed a longer operative time (115 ± 53.15 min) (p = 0.369). Chest tube was removed earlier in adults than in elderly group (5.56 ± 2.06 vs. 10.14 ± 5.58 p = 0.038). The Length of Stay (LOS) was shorter in the adults group (6.44 ± 2.35 vs. 12.29 ± 6.96 p = 0.033). Patients evaluated through Instrumental Activities of Daily Living (IADL) scale returned to normal activities of daily living after surgery.

Conclusion

In addition, the u-VATS approach seems to be safe and effective ensuring a risk reduction of progression to stage III PE with a lower recurrence risk and septic complications also in elderly patients. Further comparative multicenter analysis are advocated to set the role of u-VATS approach in the treatment of PE in adults and elderly patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00438-8.

Epidemiology of pediatric parapneumonic pleural effusion during 13-valent pneumococcal conjugate vaccine implementation

INTRODUCTION

The reported incidence of parapneumonic pleural effusion, including empyema, has shown fluctuations in the last decades. It has been related to the implementation of different types of conjugate pneumococcal vaccines.

METHODS

We have retrospectively reviewed data from all 10 public hospitals in Alicante Province (Spain) covering a population of 279,000 children under 15 years of age, between 2010 and 2018. Effusions less than 10 mm (PE-) and those of 10 mm or more (PE+) were separated.

RESULTS

A total of 366 episodes of parapneumonic pleural effusion have been analyzed, 178 PE- (48.6%) and 188 PE+ (51.4%), with a median age of 4 years (interquartile range: 2-7 years) and marked seasonality with the maximum in winter and the minimum in summer. A culture proven bacterial agent was identified in 34 patients (9.3%), mainly Streptococcus pneumoniae (24 patients) followed by Streptococcus pyogenes (7 patients). The most frequent S. pneumoniae serotype was 19A (6 patients) and 3 vaccine failures were observed. The mean annual incidence rate was 14.3 cases per 100,000 children under 15 years of age (7.0 for PE- and 7.3 for PE+). No significant changes were observed in incidence over time, but noticeable differences in incidence were observed in different health departments.

CONCLUSIONS

We have not found temporal variations in incidence of parapneumonic effusion despite the implementation of the 13-valent pneumococcal conjugate vaccine. The unexplained disparity in incidence between close departments is noteworthy.

Interventional closure of a bronchopleural fistula in a 2 year old child with detachable coils

Background

Bronchopleural fistula (BPF) is a severe complication following pneumonia or pulmonary surgery, resulting in persistent air leakage (PAL) and pneumothorax. Surgical options include resection, coverage of the fistula by video-assisted thoracoscopic surgery (VATS), or pleurodesis. Interventional bronchoscopy is preferred in complex cases and involves the use of sclerosants, sealants and occlusive valve devices.

Case presentation

A 2.5-year-old girl was admitted to our hospital with persistent fever, cough and dyspnoea. Clinical and radiological examination revealed right-sided pneumonia and pleural effusion. The child was started on antibiotics, and the effusion was drained by pleural drainage. Following removal of the chest tube, the child developed tension pneumothorax. Despite insertion of a new drain, the air leak persisted. Thoracoscopic debridement with placement of another new drain was performed after 4 weeks, without abolishment of the air leak. Bronchoscopy with bronchography revealed a BPF in right lung segment 3 (right upper-lobe anterior bronchus). We opted for an interventional approach that was performed under general anaesthesia during repeat bronchoscopy. Following bronchographic visualisation of the fistula, a 2.7 French microcatheter was placed in right lung segment 3 (upper lobe), allowing occlusion of the fistula by successive implantation of 4 detachable high-density packing volume coils, which were placed into the fistula. Subsequent bronchography revealed no evidence of residual leakage, and the chest tube was removed 2 days later. The chest X-ray findings normalized, and follow-up over 4 years was uneventful.

Conclusions

Bronchoscopic superselective occlusion of BPF using detachable high-density packing large-volume coils was a successful minimally invasive therapeutic intervention performed with minimal trauma in this child and has not been reported thus far. In our small patient, the short interventional time, localized intervention and minimal damage in the lung seemed superior to the corresponding outcomes of surgical lobectomy or pleurodesis in a young growing lung, enabling normal development of the surrounding tissue. Follow-up over 4 years did not show any side effects and was uneventful, with normal lung-function test results to date.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03298-y.

Pleural empyema caused by dropped gallstones after laparoscopic cholecystectomy for acute cholecystitis: a case report

BACKGROUND

Dropped gallstones during laparoscopic cholecystectomy (LC) sometimes induce postoperative infectious complications. However, pleural empyema rarely occurs as a complication of LC.

CASE PRESENTATION

We present the case of a 66-year-old woman with right pleural empyema. She previously underwent LC for acute gangrenous cholecystitis 11 months ago. The operative report revealed iatrogenic gallbladder perforation and stone spillage. The bacterial culture of the gallbladder bile was positive for Escherichia coli. Chest and abdominal computed tomography revealed right pleural effusion, perihepatic fluid collection, and multiple small radiopaque density masses. Although ultrasound-guided transthoracic drainage was performed, the drainage was incomplete, and systemic inflammatory reaction persisted. Consequently, thoracotomy and laparotomy with gallstone retrieval were performed, and the patient recovered completely. The patient has remained well without complications after 14 months of follow-up.

CONCLUSIONS

We report a rare case of pleural empyema caused by dropped gallstones after LC. This case emphasized the importance of completely retrieving the dropped gallstones to prevent late infectious complications after LC.

Boerhaave syndrome with double esophageal perforation. About a case

INTRODUCTION

Boerhaave syndrome consists of a spontaneous perforation of the esophagus, with high mortality.

OBJECTIVE

To describe a case with Boerhaave syndrome with double esophageal perforation.

CASE REPORT

33-year-old female who came to the hospital for emetic symptoms, followed by retrosternal chest pain; chest drainage is performed. Esophageal perforation was diagnosed late and he was transferred to a tertiary level institution. Successive treatments were performed: videothoracoscopy and pleural decortication; alimentary jejunostomy; esophageal stent placement, diagnosis of new perforation, pyloric exclusion, new stent placement, and esophageal exclusion.

CONCLUSIONS

The delay in diagnosis contributed to the fatal outcome of the patient.

Actinomyces meyeri pleural empyema: A case report

We report the case of a man with intense cough for several months and a few days of severe dyspnea. A massive pleural empyema due to Actinomyces meyeri was diagnosed by radiological, microbiological and thoracoscopic means. Pleural infections caused by this anaerobic bacterium are very rare and should be considered when risk factors like male gender, chronic alcohol abuse, and poor oral hygiene are present. Penicillin-based antibiotic treatment and surgical decortication led to recovery.

Pleural empyema secondary to nephropleural fistula in complicated pyonephrosis

Pleural empyema of extra pulmonary origin is uncommon and empyema secondary to a fistula between the urinary tract and thorax is extremely rare. We report a case of nephropleural fistula causing massive pleural empyema in a 64-year-old woman with a long history of urological problems, including nephrolitiasis and urinary tract infection. She was admitted with sepsis, fever, chills, tachypnea, productive cough and pyuria. At clinical examination, breath sounds were reduced over the left hemithorax. CT revealed a fistulous connection from the upper left calyceal group and the pleural space. Drainage of thoracic and perinephric collection was carried out, but nephrectomy and pleural decortication were required due to haemopurulent urine and decreased hemoglobin levels during the hospitalization. This case demonstrates the unusual and prolonged evolution of an obstructive hydroureteronephrosis complicated by pyonephrosis, culminating in retroperitoneal abscess that fistulized into the pleural space, leading to empyema.

Intrapleural Foreign Body: Case Report

The detection of foreign bodies in the pleural cavity is rare and mostly consequent to iatrogenic or traumatic events. The migration of an inhaled foreign body from the airways to the pleural space through a bronchopleural fistula is an exceptional event. We report a case of a pleural empyema consequent to an inhaled wooden skewer. CT scan and bronchoscopy were unable to identify the foreign body, due to its migration in the peripheral airways. The thin and pointed foreign body perforated the visceral pleural surface emerging in the pleural cavity.

Thoracomyoplasty for Chronic Empyema and Osteoradionecrosis of the Chest Wall

Herein, we report a case in which thoracomyoplasty was performed to manage chronic postlobectomy empyema (PLE). A 54-year-old male patient with a surgical history of right upper lobectomy and thymectomy 35 years previously who had undergone adjuvant radiotherapy presented with purulent discharge on the anterior chest wall. The patient was diagnosed with chronic PLE with ascending infection and concurrent osteonecrosis of the parasternum. Proper drainage was performed for local infection control and the dead spaces were successfully closed with muscle flaps. There have been no complications to date.

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

We report the first surgical series of patients developing pleural empyema after severe bilateral interstitial lung disease in confirmed severe acute respiratory syndrome coronavirus 2 infection. The empyema results in a complex medical challenge that requires combination of medical therapies, mechanical ventilation and surgery. The chest drainage approach was not successful to relieve the symptomatology and to drain the excess fluid. After multidisciplinary discussion, a surgical approach was recommended. Even though decortication and pleurectomy are high-risk procedures, they must be considered as an option for pleural effusion in Coronavirus disease-positive patients. This is a life-treating condition, which can worsen the coronavirus disease manifestation and should be treated immediately to improve patient’s status and chance of recovery.

Diagnosis of pleural empyema/parapneumonic effusion by next-generation sequencing

BACKGROUND

Although a microbiological diagnosis of pleural infection is clinically important, it is often complicated by prior antibiotic treatment and/or difficulties with culturing some bacterial species. Therefore, we aimed to identify probable causative bacteria in pleural empyema/parapneumonic effusions by combining 16S ribosomal RNA (rRNA) gene amplification and next-generation sequencing (NGS).

METHODS

Pleural fluids were collected from 19 patients with infectious effusions and nine patients with non-infectious malignant effusions. We analysed DNA extracted from the pleural fluid supernatant by NGS using the Genome Search Toolkit and GenomeSync database, either directly or after PCR amplification of the 16S rRNA gene. Infectious and non-infectious effusions were distinguished by semi-quantitative PCR of the 16S rRNA gene.

RESULTS

Only 8 (42%) effusions were culture-positive, however, NGS of the 16S rRNA gene amplicon identified 14 anaerobes and 7 aerobes/facultative anaerobes in all patients, including Streptococcus sp. (n = 6), Fusobacterium sp. (n = 5), Porphyromonas sp. (n = 5), and Prevotella sp. (n = 4), accounting for >10% of the total genomes. The culture and NGS results were discordant for 3 out of 8 patients, all of whom had previously been treated with antibiotics. Total (2^ΔCT value in semi-quantitative PCR of the 16S rRNA gene) and specific (total bacterial load multiplied by the proportion of primary bacteria in NGS) bacterial loads could efficiently distinguish empyema/parapneumonic effusion from non-infectious effusion.

CONCLUSION

Combining NGS with semi-quantitative PCR can facilitate the diagnosis of pleural empyema/parapneumonic effusion and its causal bacteria.

Empyema thoracis presented as giant back abscess

Empyema thoracis (ET) is defined as pus in the pleural space, either localized or involving the entire pleural cavity, due to diverse etiologies. In severe form, it may infiltrate the extrapulmonary region. Clinical guideline describes 3 stages of parapneumonic effusion before developing into an ET, namely the exudative stage, the fibrinopurulent stage, and the organizing/late stage. We highlight a 59-year-old gentleman who presented a back swelling masquerading as a deep-seated abscess, in which the diagnosis of ET had not been established early. The principles of treatment are treating the underlying condition such as pneumonia, pleural drainage and debridement, full re-expansion of the collapsed lung by performing chest physiotherapy, and improving nutrition. ET is a condition with a dynamic process due to diverse etiologies, either localized or involving the entire pleural cavity. The gold standard in diagnosing ET is the pleural aspiration of fluid from the pleural space, whereas the management of ET may include non-surgical and/or surgical treatments based on the basic principles of ET treatment.

Grave thoraco-intestinal complication secondary to an undetected traumatic rupture of the diaphragm: a case report

BACKGROUND

Diaphragmatic lesions as a result of blunt or penetrating trauma are challenging to detect in the initial trauma setting. This is especially true when diaphragmatic trauma is part of a polytrauma. Complications of undetected diaphragmatic defects with incarcerating bowel are rare, but as in our patient can be serious.

CASE PRESENTATION

A 57-year-old female presented to the Emergency Room of our Hospital in a critical condition with 3 days of increasing abdominal pain. The initial clinical examination showed peritonism with tinkling peristaltic bowel sounds of mechanical obstruction. A thoraco-abdominal CT scan demonstrated colon prolapsed through the left diaphragmatic center with a large sero-pneumothorax under tension. As the patient was hemodynamically increasingly unstable with developing septic shock, an emergency laparotomy was performed. After retraction of the left colon, which had herniated through a defect of the tendinous center of the left diaphragm and was perforated due to transmural ischemia, large amounts of feces and gas discharged from the left thorax. A left hemicolectomy resulting in a Hartmann-type procedure was performed. A fully established pleural empyema required meticulous debridement and lavage conducted via the 7-10 cm in diameter phrenic opening followed by a diaphragmatic defect reconstruction. Due to pneumonia and recurring pleural empyema redo-debridement of the left pleural space via thoracotomy were required. The patient was discharged on day 56. A thorough history of possible trauma revealed a bicycle-fall trauma 7 months prior to this hospitalization with a surgically stabilized fracture of the left femur and conservatively treated fractures of ribs 3-9 on the left side.

CONCLUSION

This is the first report on a primarily established empyema at the time of first surgical intervention for feco-pneumothorax secondary to delayed diagnosed diaphragmatic rupture following abdomino-thoracic blunt trauma with colic perforation into the pleural space, requiring repetitive surgical debridement in order to control local and systemic sepsis. Thorough investigation should always be undertaken in cases of blunt abdominal and thoracic trauma to exclude diaphragmatic injury in order to avoid post-traumatic complications.

Cryotherapy in Semirigid Thoracoscopy for Debridement of Multiloculated Empyema

Surgical intervention is occasionally required for the treatment of pleural empyema. Semirigid thoracoscopy is a safe and successful surgical approach utilized by interventional pulmonologists, conventionally utilizing flexible forceps and suction as the main tools, but they can sometimes be inefficient for more complicated cases. In debriding a case of multiloculated empyema with semirigid thoracoscopy, we report the novel use of cryotherapy in clearing adhesions from the pleural cavity. We found using the cryoprobe to be more efficient than using forceps and suggest further investigation into its use in medical thoracoscopy.

Multiplex bacterial polymerase chain reaction in a cohort of patients with pleural effusion

Background

The identification of the pathogens in pleural effusion has mainly relied on conventional bacterial culture or single species polymerase chain reaction (PCR), both with relatively low sensitivity. We investigated the efficacy of a commercially available multiplex bacterial PCR assay developed for pneumonia to identify the pathogens involved in pleural infection, particularly empyema.

Methods

A prospective, monocentric, observational study including 194 patients with pleural effusion. Patients were evaluated based on imaging, laboratory values, pleura ultrasound and results of thoracentesis including conventional microbiology studies during hospitalisation. Multiplex bacterial PCR (Curetis Unyvero p55) was performed in batch and had no influence on therapeutic decisions.

Results

Overall, there were 51/197 cases with transudate and 146/197 with exudate. In 42% (n = 90/214) there was a clinical suspicion of parapneumonic effusion and the final clinical diagnosis of empyema was made in 29% (n = 61/214) of all cases. The most common microorganisms identified in the cases diagnosed with empyema were anaerobes [31] followed by gram-positive cocci [10] and gram-negative rods [4]. The multiplex PCR assay identified more of the pathogens on the panel than the conventional methods (23.3% (7/30) vs. 6.7% (2/30), p = 0.008).

Conclusion

The multiplex PCR-based assay had a higher sensitivity and specificity than conventional microbiology when only the pathogens on the pneumonia panel were taken into account. A dedicated pleural empyema multiplex PCR panel including anaerobes would be needed to cover most common pathogens involved in pleural infection.

Evaluation of clinical risk factors for developing pleural empyema secondary to liver abscess

BACKGROUND

The aim of this study was to investigate the clinical manifestation and predictive risk factors of pleural empyema developing during treatment of the pyogenic liver abscess.

METHODS

Medical records of patients with the liver abscess in our institution were reviewed retrospectively. Enrolled patients were classified into four groups; Group 1: patients without pleural effusion, Group 2: patients with pleural effusion and who were treated noninvasively, Group 3: patient with pleural effusion and who were treated with thoracentesis, and Group 4: patients with pleural effusion that developed into empyema. Patient characteristics, clinical manifestation, and possible risk factors in development of empyema were analyzed.

RESULTS

A total of 234 patients was enrolled in this study. The incidence rate of empyema was 4.27% (10 patients). The mean interval for developing pleural effusion was 5.6 ± 6.35 days. In multivariate analysis, risk factors for developing pleural effusion included the location of the liver abscess near the right diaphragm (segment 7 and 8, OR = 2.30, p = 0.048), and larger diameter of the liver abscess (OR = 1.02, p = 0.042). Among patients who developed pleural effusions, presences of mixed microorganisms from culture of liver aspirates (OR = 10.62, p = 0.044), bilateral pleural effusion (OR = 46.72, p = 0.012) and combined biliary tract inflammation (OR = 21.05, p = 0.040) were significantly associated with the need for invasive intervention including surgery on effusion.

CONCLUSION

The location of the liver abscess as well as pleural effusion, elevated inflammatory markers, and combined biliary tract inflammation may be important markers of developing pleural complication in patients with pyogenic liver abscess.

Increase in Streptococcus pneumoniae serotype 3 associated parapneumonic pleural effusion/empyema after the introduction of PCV13 in Germany

INTRODUCTION

Pediatric pneumococcal pneumonia complicated by parapneumonic pleural effusion/empyema (PPE/PE) remains a major concern despite general immunization with pneumococcal conjugate vaccines (PCVs).

METHODS

In a nationwide pediatric hospital surveillance study in Germany we identified 584 children <18 years of age with bacteriologically confirmed PPE/PE from October 2010 to June 2018. Streptococcus pneumoniae was identified by culture and/or PCR of blood samples and/or pleural fluid and serotyped.

RESULTS

S. pneumoniae was identified in 256 of 584 (43.8%) children by culture (n = 122) and/or PCR (n = 207). The following pneumococcal serotypes were detected in 114 children: serotype 3 (42.1%), 1 (25.4%), 7F (12.3%), 19A (7.9%), other PCV13 serotypes (4.4%) and non-PCV13 serotypes (7.9%). Between October 2010 and June 2014 serotype 1 (38.1%) and serotype 3 (25.4%) were most prevalent, whereas between July 2014 and June 2018 serotype 3 (62.7%) and non-PCV13 serotypes (15.7%) were dominant. Compared to children with other pneumococcal serotypes, children with serotype 3 associated PPE/PE were younger (median 3.2 years [IQR 2.1-4.3 years] vs. median 5.6 years [IQR 3.8-8.2 years]; p < 0.001) and more frequently admitted to intensive care (43 [89.6%] vs. 48 [73.8%]; p = 0.04). Seventy-six of 114 (66.7%) children with pneumococcal PPE/PE had been vaccinated with pneumococcal vaccines. Thirty-nine of 76 (51.3%) had received a vaccine covering the serotype detected. Thirty of these 39 breakthrough cases were age-appropriately vaccinated with PCV13 and considered vaccine failures, including 26 children with serotype 3, three children with serotype 19A and one child with serotype 1.

CONCLUSION

Following the introduction of PCV13 in general childhood vaccination we observed a strong emergence of serotype 3 associated PPE/PE in the German pediatric population, including a considerable number of younger children with serotype 3 vaccine breakthrough cases and failures. Future PCVs should not only cover newly emerging serotypes, but also include a more effective component against serotype 3.

Fatal Legionella pneumophila serogroup 1 pleural empyema: A case report

BACKGROUND

Legionella pneumophila (L. pneumophila) is a gram-negative intracellular bacillus composed of sixteen different serogroups. It is mostly known to cause pneumonia in individuals with known risk factors as immunocompromised status, tobacco use, chronic organ failure or age older than 50 years. Although parapneumonic pleural effusion is frequent in legionellosis, pleural empyema is very uncommon. In this study, we report a case of fatal pleural empyema caused by L. pneumophila serogroup 1 in an 81-year-old man with multiple risk factors.

CASE SUMMARY

An 81-year-old man presented to the emergency with a 3 wk dyspnea, fever and left chest pain. His previous medical conditions were chronic lymphocytic leukemia, diabetes mellitus, chronic kidney failure, hypertension and hyperlipidemia, without tobacco use. Chest X-ray and comouted tomography-scan confirmed a large left pleural effusion, which puncture showed a citrine exudate with negative standard bacterial cultures. Despite intravenous cefotaxime antibiotherapy, patient’s worsening condition after 10 d led to thoracocentesis and evacuation of 2 liters of pus. The patient progressively developed severe hypoxemia and multiorgan failure occurred. The patient was treated by antibiotherapy with cefepime and amikacin and with adequate symptomatic shock treatment, but died of uncontrolled sepsis. The next day, cultures of the surgical pleural liquid samples yielded L. pneumophila serogroup 1, consistent with the diagnosis of pleural legionellosis.

CONCLUSION

L. pneumophila should be considered in patients with multiple risk factors and undiagnosed pleural empyema unresponsive to conventional antibiotherapy.

Therapeutic strategy for acute pleural empyema: comparison between retrospective study and prospective study

OBJECTIVES

The purpose of this study is to investigate the efficiency of therapeutic strategy for acute pleural empyema.

METHODS

We retrospectively reviewed 121 acute empyema patients and evaluated the therapeutic strategy for acute pleural empyema. Then, we prospectively reviewed 114 acute pleural empyema patients based on the strategy.

RESULTS

The duration from onset to hospitalization in our hospital is statistically shorter, and the mortality and the rate of stage 3 empyema patients are lower in the prospective study group (PSG) than in the retrospective study group (RSG). Retrospective study and prospective study found that surgical group (SG) had more favorable outcomes than non-surgical group (NSG). Although antibiotic treatment duration, hospital stay, and entire mortality were comparable in NSG of both study groups, mortality of patients with PS grade 4 was significantly lower in PSG. SG in PSG had more favorable outcomes than that in RSG, such as antibiotic treatment duration, hospital stay, complication, and mortality.

CONCLUSIONS

The good outcomes may be mainly caused by shorter duration from onset to hospitalization and shorter duration from hospitalization to operation. Operative management is an effective procedure for selected patients, and it is important to refer for thoracic surgical consultation earlier.

A descriptive and comparative metagenomic study

OBJECTIVES

The view of pleural empyema as a complication of bacterial pneumonia is changing because many patients lack evidence of underlying pneumonia. To further our understanding of pathophysiological mechanisms, we conducted in-depth microbiological characterization of empyemas in clinically well-characterized patients and investigated observed microbial parallels between pleural empyemas and brain abscesses.

METHODS

Culture-positive and/or 16S rRNA gene PCR-positive pleural fluids were analysed using massive parallel sequencing of the 16S rRNA and rpoB genes. Clinical details were evaluated by medical record review. Comparative analysis with brain abscesses was performed using metagenomic data from a national Norwegian study.

RESULTS

Sixty-four individuals with empyema were included. Thirty-seven had a well-defined microbial aetiology, while 27, all of whom had community-acquired infections, did not. In the latter subset, Fusobacterium nucleatum and/or Streptococcus intermedius was detected in 26 patients, of which 18 had additional facultative and/or anaerobic species in various combinations. For this group, there was 65.5% species overlap with brain abscesses; predisposing factors included dental infection, minor chest trauma, chronic obstructive pulmonary disease, drug abuse, alcoholism and diabetes mellitus. Altogether, massive parallel sequencing yielded 385 bacterial detections, whereas culture detected 38 (10%) and 16S rRNA gene PCR/Sanger-based sequencing detected 87 (23%).

CONCLUSIONS

A subgroup of pleural empyema appears to be caused by a set of bacteria not normally considered to be involved in pneumonia. Such empyemas appear to have a similar microbial profile to oral/sinus-derived brain abscesses, supporting spread from the oral cavity, potentially haematogenously. We suggest reserving the term 'primary empyema' for these infections.

Uniportal video-assisted thoracic surgery in the treatment of pleural empyema

Background

The efficacy of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has recently been proven. Till today, very few works evaluated the role of uniportal-VATS (U-VATS) approach in the treatment of pleural empyema even if it currently represents the most innovative and less invasive thoracoscopic approach. We report our experience with U-VATS in the treatment of pleural empyema.

Methods

A retrospective bicentric analysis of 35 consecutive patients who underwent surgical treatment of stage II and stage III pleural empyema was performed, from January 2015 to May 2017.

Results

The mean age of patients was 57.26±18.29 years and 54.3% of them were males. In 85.7% of the cases, empyema was related to a complicated parapneumonic effusion; in only 5 cases it was a post-surgical consequence. All patients were treated with broad-spectrum antibiotics and subsequent target therapy for 14.62±21.76 days prior to operation and 23 patients needed the placement of a chest tube. Twenty patients (57.1%) presented with stage III, 11 patients (31.4%) stage II and 4 patients (11.4%) stage I empyema. Complete debridement and decortication were obtained in all patients through U-VATS approach and no conversion or further access was needed for any reason. No major complication was recorded. Only 2 cases of trapped lung were not responsive to surgical treatment. At a mean follow-up of 247.42±306.29 days, 33 patients (94.3%) were alive with no recurrence, 2 patients died for causes unrelated to the operation.

Conclusions

According to our experience, we consider U-VATS as an adequate procedure in the treatment of "stages II and III" empyemas when the necessary surgical expertise has been achieved. Indeed, U-VATS permits an easier performance and complete debridement and decortication, with a very low risk for conversion and excellent postoperative outcomes in terms of less pain, fast recovery and cosmetic results.

[Risks associated with the use of non-steroidal anti-inflammatory drugs during pneumonia]

INTRODUCTION

Outpatient treatment of community-acquired pneumonia (CAP) patients with non-steroidal anti-inflammatory drugs (NSAIDs) is frequent, although this is not based on clinical recommendations and there is no scientific evidence supporting better symptom relief in comparison to acetaminophen.

STATE OF THE ART

Experimental data suggest that NSAIDs alter the intrinsic functions of neutrophils, limit their locoregional recruitment, alter bacterial clearance and delay the resolution of inflammatory processes during acute bacterial pulmonary challenge. In hospitalized children and adults with CAP, observational data suggest a strong and independent association between the outpatient exposure to NSAIDs and the occurrence of pleuropulmonary complications (pleural empyema, excavation, and abscess). In the only study taking into account possible protopathic bias, the association still persists. Other markers of morbidity have been described, including delay in hospital management, prolonged antibiotic therapy, and higher transfer rate to an intensive care unit.

PERSPECTIVES

Data describing the role of self-medication and the biological mechanisms involved are needed.

CONCLUSIONS

Intake of NSAIDs during outpatient treatment of CAP is probably the second modifiable factor of morbidity after inadequate antibiotic therapy. In light of existing data in children and adults, health authorities should urgently reassess the risk-benefit ratio of NSAIDS in CAP.

Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion

OBJECTIVES

To evaluate the effectiveness of videothoracoscopic surgery in the treatment of complicated parapneumonic pleural effusion and to determine whether there is a difference in the videothoracoscopic surgery outcome before or after the chest tube drainage.

METHODS

The medical records of 79 children (mean age 35 months) undergoing videothoracoscopic surgery from January 2000 to December 2011 were retrospectively reviewed. The same treatment algorithm was used in the management of all patients. Patients were divided into two groups: in group 1, videothoracoscopic surgery was performed as the initial procedure; in group 2, videothoracoscopic surgery was performed after previous chest tube drainage.

RESULTS

Videothoracoscopic surgery was effective in 73 children (92.4%); the other six (7.6%) needed another procedure. Sixty patients (75.9%) were submitted directly to videothoracoscopic surgery (group 1) and 19 (24%) primarily underwent chest tube drainage (group 2). Primary videothoracoscopic surgery was associated with a decrease of hospital stay (p=0.05), time to resolution (p=0.024), and time with a chest tube (p<0.001). However, there was no difference between the groups regarding the time until fever resolution, time with a chest tube, and the hospital stay after videothoracoscopic surgery. No differences were observed between groups regarding the need for further surgery and the presence of complications.

CONCLUSIONS

Videothoracoscopic surgery is a highly effective procedure for treating children with complicated parapneumonic pleural effusion. When videothoracoscopic surgery is indicated in the presence of loculations (stage II or fibrinopurulent), no difference were observed in time of clinical improvement and hospital stay among the patients with or without chest tube drainage before videothoracoscopic surgery.

Thoracotomy versus video-assisted thoracoscopic surgery (VATS) in stage III empyema-an analysis of 217 consecutive patients

BACKGROUND

Pleural empyema is an infectious disease of the chest cavity, with a high morbidity and mortality. According to the American Thoracic Society, pleural empyema gets graduated into three stages, with surgery being indicated in intermediate stage II and chronic stage III. Evidence for the feasibility of a minimally-invasive video-assisted thoracoscopic approach in stage III empyema for pulmonary decortication is still little.

METHODS

Retrospective single-center analysis of patients conducted to surgery for chronic stage III pleural empyema from 05/2002 to 04/2014 either by video-assisted thoracoscopic surgery (VATS, n = 110) or conventional open surgery by thoracotomy (n = 107). Multiple regression analysis and propensity score matching was used to evaluate the influence of operation technique (thoracotomy versus VATS) on the length of post-operative hospitalization.

RESULTS

Operation time was longer in the thoracotomy-group (p = 0.0207). Conversion rate from VATS to open surgery by thoracotomy was 4.5%. Post-operative complication- (61 patients in thoracotomy- and 55 patients in VATS-group), recurrence- (3 patients in thoracotomy- and 5 in VATS-group) and mortality-rates (6.5% in thoracotomy- and 9.5% in VATS-group) did not differ between both groups; the length of (post-operative) stay at intensive care unit was longer in the VATS-group (p = 0.0023). Duration of chest tube drainage and prolonged air leak rate were similar among both groups, leading to a similar overall and post-operative length of hospital stay in both groups. Adjusted to clinically and statistically relevant confounders, multiple regression analysis showed an influence of the surgical technique on length of post-operative stay after pair matching of the patients (n = 84 in each group) by propensity score (B = - 0.179 for thoracotomy = 0 and VATS = 1, p = 0.032) leading to a reduction of 0.836 days after a VATS-approach compared to thoracotomy.

CONCLUSIONS

VATS in late stage (III) pleural empyema is feasible and safe. The decrease in post-operative hospitalization demonstrated by adjusted multiple regression analysis may indicate the minimally-invasive approach being safe, more tolerable for patients, and more effective.

Risk of developing pleural empyema in patients with stroke: a propensity-matched cohort study

Pleural empyema is an important complication of pneumonia. Patients with stroke are at a higher risk developing pneumonia; however, the association between stroke and pleural empyema risk is largely unknown. We used the data from the National Health Insurance Research Database of Taiwan to establish a stroke group consisting of 466,170 patients diagnosed between 2000 and 2010, and a non-stroke group consisting of the same number of individuals matched by the propensity score. Incident pleural empyema was monitored toward the end of 2011. Adjusted hazard ratios (aHRs) of pleural empyema in the stroke group, compared to the non-stroke group, were estimated using the Cox proportional hazards model. We found that the incidence of pleural empyema is 2.69-fold higher in the stroke group than in the non-stroke group (15.2 vs. 5.59/10,000 person-years, p < 0.001), with an aHR of 2.89 [95% confidence interval (CI) = 2.72-3.08]. Further analysis reveals the aHRs of pleural empyema to be 2.62 (95% CI = 2.45-2.79) in patients with ischemic stroke and 4.53 (95% CI = 4.14-4.95) in patients with hemorrhagic stroke compared with those without stroke. In addition, we observe that stroke patients with ventriculoperitoneal (VP) shunt implantation exhibit more than sevenfold risk for developing of pleural empyema. In conclusion, patients with stroke are at an elevated risk of developing pleural empyema. The risk is greater for those with hemorrhagic stroke than for those with ischemic stroke. The risk increases further for patients who undergo VP shunt implantation.

Disseminated nocardiosis complicated by multiple brain abscesses and pleural empyema in a young diabetic man: a case report

Nocardiosis is a life-threatening infection usually affecting immunocompromised patients. Very rarely it presented with intracranial abscesses and pleuro-parenchymal infections. We herein report a very challenging case of a 34-year-old obese and diabetic man affected by disseminated nocardiosis with multiple brain abscesses and pleural empyema. Despite rare, this entity should be taken into account by the pathologists and urgently communicated to clinicians in order to promptly start an effective treatment.

Uniportal thoracoscopic decortication for pleural empyema and the role of ultrasonographic preoperative staging

Objectives

The surgical approach to chronic pleural empyema is still controversial. Video-assisted thoracic surgery (VATS) debridement and decortication has shown favourable outcomes, while the uniportal VATS (U-VATS) approach is still anecdotal. We report our experience with ultrasonographic (US) preoperative staging followed by U-VATS decortication for pleural empyema.

Methods

We performed a retrospective analysis of patients who underwent surgical treatment of stage II and stage III pleural empyema from 2012 to 2015. Pre-, intra- and postoperative data were investigated to evaluate outcomes including postoperative complications and disease recurrence. Results were analysed according to preoperative US appearance of pleural space (stages A-E) and surgical approach (thoracotomy vs U-VATS).

Results

We performed 30 (47%) uniportal thoracoscopic pleural decortication and 34 (53%) open decortication for empyema in stage II (40%) or III (60%) obtaining a complete debridement and decortication in all patients. In-hospital mortality was zero and overall morbidity was 29%. U-VATS was associated with lower blood loss (118 ±  80 ml vs 247  ±  140 ml P  < 0.001), lower chest tubes duration (5.6 ±  1.4 vs 10.6  ±  4.4 days P  < 0.001), shorter hospital stay (6.7  ±  1.9 vs 12.2  ± 4.7 days, P  < 0.001) and lower complications (10% vs 16%, P  < 0.001). Elevated US patterns (D-E) are associated with thoracotomy, higher blood loss, operative time and a significant incidence of complications.

Conclusions

Uniportal thoracoscopic decortication for pleural empyema is a safe and effective approach for selected patients based on a combination of clinical and imaging staging. US patterns well corresponded with intraoperative pleural findings and showed a prognostic value.

Pleural empyema and streptococcal toxic shock syndrome due to Streptococcus pyogenes in a healthy Spanish traveler in Japan

Group A Streptococcus (GAS, Streptococcus pyogenes) causes invasive infections including streptococcal toxic shock syndrome (STSS) and local infections. To our knowledge, this is the first report of a case of an invasive GAS infection with pneumonia and pleural empyema (PE) followed by STSS (disseminated intravascular coagulation [DIC] and acute renal insufficiency) in a healthy male adult. He received combined supportive therapies of PE drainage, anti-DIC agent, hemodialysis, and antimicrobials and eventually made a clinical recovery. GAS isolated from PE was found to have emm1/speA genes, suggestive of a pathogenic strain. Clinicians should be aware of the possibility of this disease entity (pneumonia, PE, and STSS) in healthy male adults as well as children and adult women.

Prehospital NSAIDs use prolong hospitalization in patients with pleuro-pulmonary infection

OBJECTIVE

Nonsteroidal anti-inflammatory drug (NSAID) pre-hospitalization consumption might affect the course of pneumonia. We opted to assess the potential effects of pre-hospitalization use of NSAIDs in patients with pleuropulmonary infection in the context of the duration of hospitalization.

METHODS

A prospective observational study of 57 consecutive patients with a diagnosis of pneumonia and parapneumonic pleural effusion was conducted. The exact medication history the previous fifteen days was recorded.

RESULTS

Prehospital use of NSAIDs >6 days was positively associated with prolonged hospitalization extending out for approximately 10 days. Immunosuppression was an independent risk factor for prolonged hospitalization of more than 5 days. This group of patients also had more complicated pleural effusions and difficult to treat management. In the immunocompetent group of patients, there was a negative inverse correlation of duration of NSAIDs use with pleural fluid pH and glucose. The longer medication with NSAIDs correlated with lower values of C-reactive protein, and erythrocyte sedimentation rate. Importantly, the early prehospital antibiotic use significantly prevented the development of empyema.

CONCLUSION

Our findings highlight the potential complications involved with prehospital use of NSAIDs and especially that prolonged NSAID use which may lead to longer hospitalization duration and more complicated pleural effusions.

Intrapleural administration of DNase alone for pleural empyema

INTRODUCTION

Pleural empyema is a severe complication of various diseases. The essential is the inserting a drain into the pleural cavity and evacuation of the pus. Sometimes the pus is very thick and its evacuation and re-expansion of the lung is very difficult.

METHODS

We report a group of 10 patients with intrapleural administration of Pulmozyme (dornase alpha) in dosages of either 2.5 mg once or on two separate occasions. All of the patients had a chest tube inserted into the pleural cavity. Measurement of viscosity was done before and after the instillation of the dornase alpha.

RESULTS

In six patients dornase alfa was introduced into the pleural cavity once. Three of them received this on the 4th whilst the rest were treated with the agent on the 6th day. Four patients received the dornase alpha twice because of the small amount of drainage fluid after the previous instillation. Five patients were discharged from hospital with complete re-expansion of their lungs. Two patients were qualified for a surgical operation since the lung was trapped and did not re-expand. Three patients had to be discharged with a drain as a result of incomplete re-expansion of the lung. In all the patients the density of the pus after administering the dornase alpha decreased and the amount of the pus drainage increased.

CONCLUSIONS

Dornase alpha may be used in some patients with pleural empyema with good results.

[Anti-inflammatory drugs and community-acquired pneumonia]

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in ambulatory medicine for their analgesic and antipyretic properties and are often used as self-medication. Their use in community-acquired pneumonia is associated with an increased risk of loco-regional complications, especially pleural empyema. Appropriate therapeutic care and hospital admissions are often delayed because of initial improvement of symptoms with NSAIDs. Despite worrying observational data, a causal link remains to be established. Currently, there is no recommendation cautioning against the use of NSAIDs in the management of community-acquired pneumonia.

[Complicated pleural infection: Analysis of 2 consecutive cohorts managed with a different policy]

INTRODUCTION

The treatment of complicated pleural infection (CPI) is controversial. Clinical guidelines recommend drainage, but with the lowest grade of evidence. Recent reports have observed good outcomes with antibiotics alone. We retrospectively compared the outcomes in two consecutive cohorts treated with different policies: the first treated according to pleural fluid charactersitics (2005-2009, interventional-prone, group 1) and the second according to clinical assessment (2010-2013, conservative-prone, group 2).

METHODS

The clinical records of all children treated for CPI in our hospital between 2005 and 2013 were thoroughly reviewed. Primary outcomes were the proportion of children drained and the length of hospital stay (LHS).

RESULTS

One hundred and nine patients (64 group 1 and 45 group 2) were analyzed. A chest tube was placed in 83% of patients in group 1 and 47% in group 2 (P<0.001). The mean LHS was 11.4 days for patients in group 1 and 12.3 for patients in group 2 (P=0.45); no differences were observed in other outcomes.

CONCLUSION

Our results add to few recent observations reporting good outcomes in many children treated with antibiotics alone and challenge the need to drain most children with CPI. Clinical trials are now needed to identify when a drainage procedure would be useful.

[The management of complicated parapneumonic effusions in France]

INTRODUCTION

There are no French guidelines for the management of complicated parapneumonic effusions. A national observational study was carried out to assess the main features of current clinical practice for this condition.

MATERIAL AND METHODS

A questionnaire was sent by email to the 1500 members of the Société de Pneumologie de Langue Française (SPLF) between 15th November and 15th December 2012.

RESULTS

There were 92 responders, i.e. a response rate of 6%. Of these, 87 physicians mentioned that they were involved in the management of patients with complicated parapneumonic effusions with a median number of cases of 10 per year (IQR: 5-20). Chest tube drainage was the main approach used for pleural fluid aspiration (n=51/87), followed by repeated thoracentesis (n=29/87) and early surgery (1/87). Five physicians answered both chest tube drainage or repeated thoracentesis and one physician either chest tube drainage or early surgery. Pleural fibrinolytics were never used by 20% of physicians, only in case of loculations by 70% and by 10% of respondents in all cases. Only 3 physicians combined fibrinolytics with DNAse. A double antibiotic dose was used by one third of physicians. All the physicians used respiratory physiotherapy during hospitalization and to aid recovery. Follow-up practices were heterogeneous.

CONCLUSIONS

The management of complicated parapneumonic effusions varies significantly in France. National guidelines may be helpful to define best practice and aid in its implementation.

[Community acquired pneumonia in children: Treatment of complicated cases and risk patients. Consensus statement by the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Chest Diseases (SENP)]

The incidence of community-acquired pneumonia complications has increased during the last decade. According to the records from several countries, empyema and necrotizing pneumonia became more frequent during the last few years. The optimal therapeutic approach for such conditions is still controversial. Both pharmacological management (antimicrobials and fibrinolysis), and surgical management (pleural drainage and video-assisted thoracoscopic surgery), are the subject of continuous assessment. In this paper, the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases have reviewed the available evidence. Consensus treatment guidelines are proposed for complications of community-acquired pneumonia in children, focusing on parapneumonic pleural effusion. Recommendations are also provided for the increasing population of patients with underlying diseases and immunosuppression.

[Parapneumonic pleural effusions: Epidemiology, diagnosis, classification and management]

Parapneumonic pleural effusions represent the main cause of pleural infections. Their incidence is constantly increasing. Although by definition they are considered to be a "parapneumonic" phenomenon, the microbial epidemiology of these effusions differs from pneumonia with a higher prevalence of anaerobic bacteria. The first thoracentesis is the most important diagnostic stage because it allows for a distinction between complicated and non-complicated parapneumonic effusions. Only complicated parapneumonic effusions need to be drained. Therapeutic evacuation modalities include repeated therapeutic thoracentesis, chest tube drainage or thoracic surgery. The choice of the first-line evacuation treatment is still controversial and there are few prospective controlled studies. The effectiveness of fibrinolytic agents is not established except when they are combined with DNase. Antibiotics are mandatory; they should be initiated as quickly as possible and should be active against anaerobic bacteria except for in the context of pneumococcal infections. There are few data on the use of chest physiotherapy, which remains widely used. Mortality is still high and is influenced by underlying comorbidities.

Surgery for parapneumonic pleural empyema--What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?

OBJECTIVE

Pleural empyema is a critical condition. In the western world the share of sufferers with multiple comorbidities and advanced age is rapidly increasing.

METHODS

This retrospective study comprises all patients who underwent surgery for parapneumonic pleural empyema at a major center for thoracic surgery in Germany between January 2006 and April 2013.

RESULTS

A total of 335 patients (mean age 60.4 years) were included. The average ASA grade was 2.8. Empyema stage 1, 2 and 3 (classification of the American Thoracic Society) was encountered in 30, 230 and 75 cases, respectively. The most common comorbidities were cardiac disorders (124), diabetes mellitus (76), COPD (66) and alcoholism (54). The mean Charlson index of comorbidity score was 2. Minimally invasive surgery was feasible in 290 cases. A total of 88 patients sustained pulmonary sepsis. The overall mortality was 29/335 (8.7%). The occurrence of pulmonary sepsis (OR: 17.95; 95% CI: 6.38-62.69; p < 0.001), respiratory failure (OR: 23.08; 95% CI: 8.52-73.35; p < 0.001) and acute renal failure (OR: 8.20; 95% CI: 3.18-20.80; p < 0.001) and Charlson score ≥ 3 (OR: 6.65; 95% CI: 2.76-17.33; p < 0.001) were associated with higher mortality. On the other hand, very elderly sufferers (≥80 years) showed neither higher odds for pulmonary sepsis (OR: 0.78) nor for fatal outcome (OR: 0.92; 95% CI: 0.22-2.86; p = 1).

CONCLUSIONS

Parapneumonic pleural empyema is still associated with considerable morbidity and mortality. Pre-existing comorbidity, the occurrence of pulmonary sepsis and sepsis related complications have a determining influence on the results whereas advanced age itself shows no higher risk for adverse outcome. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.

Repair of Bochdalek hernia in an adult complicated by abdominal compartment syndrome, gastropleural fistula and pleural empyema: Report of a case

INTRODUCTION

Bochdalek's diaphragmatic hernia (BDH) rarely developed symptomatic in adulthood but mostly required an operation. In adult BDH cases, long-term residing of the massive intraabdominal organs in the thoracic cavity passively causes loss of domain for abdominal organs (LOD).

PRESENTATION OF CASE

A 63-year-old man presented at our institution complaining of sudden left upper quadrant abdominal pain. Chest radiography showed a hyperdense lesion containing bowel gas in the left pleural space. Computed tomography revealed a dilated bowel above the diaphragm and intestinal obstruction suggestive of gangrenous changes. These findings were consistent with the diagnosis of incarcerated BDH and an emergency laparotomy was performed. Operative findings revealed the hypoplastic lung, lack of hernia sac, and location of the diaphragmatic defect, which indicated that his hernia was true congenital. Organs were reduced into the abdominal cavity, and large defect of the diaphragm was repaired with combination of direct vascular closure and intraperitoneal onlay mesh reinforcement using with expanded polytetrafluoroethylene (ePTFE) mesh. On the postoperative day 1, the patient fell into the shock and was diagnosed to have abdominal compartment syndrome (ACS). Conservative therapies were administered, but resulted in gastropleural fistula and pleural empyema, which required an emergency surgery. Mesh extraction and fistulectomy were performed.

DISCUSSION

A PubMed search for the case of ACS after repair of the adult BDH revealed only three cases, making this very rare condition.

CONCLUSION

In dealing with adult BDH, possible post-repair ACS should be considered.

Management of pleural empyema with a vacuum-assisted closure device and reconstruction of open thoracic window in a patient with liver cirrhosis

The patient is a 21-year-old female, diagnosed with cryptogenic cirrhosis at the age of 9. She presented with left post-pneumonic empyema that did not remit with conventional medical management and evolved with fistulization to the skin in the 7th intercostal space in the left subscapular region. We performed an open thoracic window procedure, and on the 6th day the patient was sent home with a portable vacuum-assisted closure device, with changes of the material every 4 days until the cavity was completed obliterated (92 days). Imaging tests showed full expansion of the lung, and chest wall reconstruction was performed with titanium rods. The high mortality of empyema in patients with liver disease requires both implementing and searching for new adjuvant therapies, like the use of vacuum-assisted closure systems and reconstruction with titanium rods. Controlled studies with a wide range of cases are needed for proper evaluation.

Langerhans cell histiocytosis presenting with complicated pneumonia, a case report

We describe a 2 ½ year old boy presenting with fever, abdominal pain and splinter haemorrhages of the nails. On further examination there were signs of pneumonia with pleural effusion. This was treated with mini-thoracotomy, drainage and intravenous antibiotics. Further diagnostic workup for underlying causes showed diffuse cystic lung disease, suggestive of Langerhans cell histiocytosis. This was confirmed on pathology specimens, which showed Langerhans cells in lung tissue, nail bed and skin biopsy samples, indicating multisystem Langerhans cell histiocytosis. The patient was treated with Prednisone and Vinblastin according to the LCH-III guidelines. In this case report we give a brief description on cystic lung disease in children, Langerhans cell histiocytosis and associated nail abnormalities.