Aggressive Presentation of Streptococcus constellatus

The Streptococcus anginosus group (SAG) consists of three bacteria (Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus) that are known commensals of the upper respiratory, digestive, and reproductive tracts. While a rare occurrence, these bacteria have the capability of causing devastating pyogenic infections and ensuing abscess formations. It is often difficult to distinguish this group as a contaminant or the offending organism (as it is often cultured in respiratory specimens); therefore, it is important to understand the risk factors, clinical presentation, and diagnostic findings that can provide a more accurate picture to identify the organism. Published literature pertaining to the SAG group has rarely documented any invasive surgical intervention that was undertaken for treatment. We describe a case of a 59-year-old male who presented for persistent chest pain and profuse productive cough weeks after he was diagnosed with a left lower extremity deep vein thrombosis and right-sided pulmonary embolism. The patient was found to have a rapidly evolving Streptococcus constellatus right middle lobe lung abscess complicated by a right hemithorax empyema. Management included an exploration of the right chest, decortication, parietal pleurectomy, and partial excision of the right middle lobe. Subsequently, the patient completed four weeks of antibiotics with ertapenem.

Prosthesis for open pleurostomy (POP): management for chronic empyemas

OBJECTIVES

We developed a prosthesis for open pleurostomy cases where pulmonary decortication is not indicated, or where post-pneumonectomy space infection occurs. The open pleural window procedure not only creates a large hole in the chest wall that is shocking to patients, also results in a permanent deformation of the thorax. prosthesis for open pleurostomy is a self-retained silicone tube that requires the removal of 3 cm of one rib for insertion, and acts as a mature conventional open pleural window. Herein, we report our 13-year experience with this device in the management of different kinds of pleural empyema.

METHODS

Forty-four consecutive patients with chronic empyema were treated. The etiology of empyema was diverse: pneumonia, 20; lung resections, 12 (pneumonectomies, 7; lobectomies, 4; non-anatomical, 1); mixed-tuberculous, 6; and mixed-malignant pleural effusion, 6. After debridement of both pleural surfaces, the prosthesis for open pleurostomy was inserted and attached to a small recipient plastic bag.

RESULTS

Infection control was achieved in 20/20 (100%) of the parapneumonic empyemas, in 3/4 (75%) of post-lobectomies, in 6/7 (85%) of post-pneumonectomies, in 6/6 (100%) of mixed-tuberculous cases, and in 4/6 (83%) of mixed-malignant cases. Lung re-expansion was also successful in 93%, 75%, 33%, and 40% of the groups, respectively

CONCLUSIONS

Prosthesis for open pleurostomy insertion is a minimally invasive procedure that can be as effective as conventional open pleural window for management of chronic empyemas. Thus, we propose that the use of prosthesis for open pleurostomy should replace the conventional method.

A Case of Inadequately Treated Bacterial Pneumonia Leading to Bronchopleural Fistula

Bronchopulmonary fistula (BPF) is an abnormal connection between the pleural space and bronchial tree, potentially leading to fatal outcomes if untreated. While BPF commonly arises following lung surgery, it can also be linked to infections. This report details the case of a 47-year-old male with recent untreated bacterial pneumonia, who developed bilateral pneumothoraces with persistent air leaks, Pseudomonas and Aspergillus empyema, culminating in a right-sided BPF necessitating video-assisted thoracic surgery (VATS) decortication. The agenda of this presentation is to enhance early recognition of BPF, which can be presented subtly, to avert severe complications.

Early Functional Results of Surgery for Organizing Phase of Empyema Thoracis in a High Output Centre for Thoracic Surgery

Objective: To determine the early functional outcome of pulmonary decortication (PD) in patients having organized empyema thoracic (ET). 

Methodology: This is a prospective study conducted at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Center, Karachi from July 2019 to June 2020. The study included 76 patients referred to the department for assessment and surgery for the indication of organized empyema thoracis. After careful assessment and evaluation of the patients’ computed tomography (CT) scans and pulmonary function tests (PFTs) in addition to their symptoms, history, etiology of empyema, physical examination and nutrition status, they were recommended pulmonary decortication to release the underlying entrapped lung. Functional improvement was measured in terms of forced vital capacity (FVC) and forced expiratory volume in one second (FEV₁) three to six months after PD.

Results: A total of 76 empyema thoracis patients were included in the study. The mean age of participants was 33.4±11.9 years. The mean duration of empyema symptoms was 7.21±3.7 months. Majority were males (n=61; 80.3%). The full-lung expansion was achieved in 43 patients and partial lung expansion was achieved in 27 patients. The lung failed to expand in five patients. There was one death (lung failed to expand) due to respiratory failure as a result of septicemia. Most of the patients who achieved full-lung expansion had tuberculosis (26; 60.5%), followed by penetrating lung injury (7; 16.2%) and ruptured pulmonary hydatid cysts (5; 11.6%). Statistically significant association was found between etiology and full-lung expansion (p=0.042). Early functional improvement was seen in all patients with PD as mean FEV₁ improved from 1.23±0.27 to 2.02±0.5 (63% increase; p<0.001) and FVC from 2.10±0.27 to 2.72±0.41 (29.7% increase; p<0.001).

Conclusion: Based on the results obtained in the present study, it is concluded that pulmonary decortication in carefully selected patients has a vital role in significantly improving early functional results in terms of pulmonary functions.

Empyema Necessitatis: A Rare Complication of Empyema

Empyema necessitatis (EN) is an exceedingly rare complication of empyema. EN refers to the expansion and progression of an empyema beyond the thoracic cavity toward the skin wall. Herein, we present the case of a man with EN and detail his clinical course. A 42-year-old male with a prior history of substance use presented to the emergency department with three weeks of fever, cough, and progressively worsening pain overlying the left anterior chest wall. An empiric antibiotic regimen of cefepime, metronidazole, and vancomycin was initiated. Chest X-ray, ultrasound, and chest CT demonstrated a large region of loculation suspicious for a loculated empyema. On day 4 of admission, he underwent a video-assisted thoracoscopy followed by a left minithoracotomy, which confirmed the diagnosis of EN. The patient was discharged on hospital day 16 with marked clinical improvement and monitored for a year via an outpatient clinic. Symptoms did not recur, and there was complete resolution of EN. More predominant in the pre-antibiotic era with the progression of uncontrolled infections, EN is less commonly seen today. As such, EN requires a high degree of clinical suspicion for timely detection and management. Our case illustrates the importance of early intervention with antibiotics and surgical drainage.

Clostridium perfringens Empyema: Anaerobic Invasion in an Uncommon Location

Clostridium perfringens bacteremia arises due to skin inoculation from the external environment or translocation from the gastrointestinal tract. In the event of bacteremia, it tends to colonize in anaerobic environments due to its obligatory anaerobic nature. Its inoculation in the lung, albeit rare, can occur if an anaerobic nidus is created. In the presented case, the patient developed C. perfringens bacteremia andempyema in the area of lung necrosis caused by acute pulmonary embolism. He did not have any history of chest trauma, and the source of bacteremia was deemed to be via gut translocation. The patient was noted to have multiple gastric ulcers on endoscopy and jejunal wall thickening, which likely led to the bacterial translocation into the bloodstream. He underwent video-assisted thoracoscopic surgery-assisted decortication and intravenous antibiotics, eventually leading to clinical improvement. To identify the source of Clostridium in the absence of penetrating trauma, a thorough gastrointestinal evaluation, including a colonoscopy, is warranted to identify the pathology leading to the gastrointestinal translocation.