Pharyngo-cervicospinal fistula with destructive osteomyelitis after laryngopharyngectomy and radiotherapy, managed successfully with a vascularized fibula free flap

Total laryngectomy is an operation mainly employed in recurrent laryngeal and hypopharyngeal carcinoma after previous radiotherapy. The most feared complication after this procedure is a pharyngocutaneous fistula. An extremely rare complication is the development of osteomyelitis of the cervical spine, which is associated with high rates of neurological impairment and epidural empyema, often requiring surgical treatment. This report describes the case of a patient with neck and shoulder pain and progressive motor weakness of the left deltoid and biceps muscle, caused by a pharyngo-cervicospinal fistula with spinal empyema. This condition resulted in destructive osteomyelitis of the cervical spine. A successful reconstruction of the cervical spine and neopharynx was performed using a free vascularized fibula bone and skin graft in a complex area because of previous treatments. It appears that no similar case has been described previously.

Management of an Esophago-pleural Fistula after Emergent Endoscopic Variceal Injectional Sclerotherapy: A Case Report And Literature Review

A 48-year-old man developed sudden-onset haematemesis and melena after decompensated posthepatitic cirrhosis. Endoscopic variceal injectional sclerotherapy was emergently performed. However, the patient developed esophago-pleural fistula, empyema, and liver failure. He thus received symptomatic treatments and nasojejunal feedings, which failed to restore the nutrition as the gastroesophageal reflux exacerbated the hydrothorax. Percutaneous endoscopic gastro-jejunal (PEG-J) was therefore carefully performed for enteral nutrition support. The patient had recovered from the fistula at a six-month follow-up, which allowed the resumption of an oral diet. Our literature review revealed that PEG-J is a feasible approach to treating esophago-pleural fistula, a rare but lethal complication of endoscopic sclerotherapy.

Case report of parapneumonic effusion and mesothelial subdiaphragmatic cyst: relationship or coincidence?

Parapneumonic pleural effusions are common in patients with pneumonia. When colonized by pathogenic bacteria or other microorganisms, these effusions can progress to empyema. Additionally, empyema formation may result in extension of the infection into the infradiaphragmatic region, further complicating the clinical scenario. Many subphrenic collections are found to be mesothelial cysts, which are congenital in origin. However, data regarding the potential association between mesothelial diaphragmatic cysts and parapneumonic effusions are limited. We herein describe a toddler with pneumonia complicated by parapneumonic effusion and a lung abscess with a subphrenic collection. After abscess drainage and a full course of antibiotics, imaging revealed clear lung parenchyma with an interval resolution of the effusion and a persistent unchanged subphrenic collection that was confirmed to be mesothelial diaphragmatic cyst. This case highlights the fact that not every subphrenic collection associated with parapneumonic effusion is a communicated collection formed by seeding. Such a collection can instead be an incidental cyst, which is congenital in origin and known as a mesothelial diaphragmatic cyst. A diaphragmatic mesothelial cyst is an uncommon benign congenital cyst that is unrelated to an adjacent parapneumonic effusion. It is usually incidental and can be monitored without invasive intervention.

Value of preoperative evaluation of FEV1 in patients with destroyed lung undergoing pneumonectomy - a 20-year real-world study

BACKGROUND

Clinical guidelines recommend a preoperative forced expiratory volume in one second (FEV1) of > 2 L as an indication for left or right pneumonectomy. This study compares the safety and long-term prognosis of pneumonectomy for destroyed lung (DL) patients with FEV1 ≤ 2 L or > 2 L.

METHODS

A total of 123 DL patients who underwent pneumonectomy between November 2002 and February 2023 at the Department of Thoracic Surgery, Beijing Chest Hospital were included. Patients were sorted into two groups: the FEV1 > 2 L group (n = 30) or the FEV1 ≤ 2 L group (n = 96). Clinical characteristics and rates of mortality, complications within 30 days after surgery, long-term mortality, occurrence of residual lung infection/tuberculosis (TB), bronchopleural fistula/empyema, readmission by last follow-up visit, and modified Medical Research Council (mMRC) dyspnea scores were compared between groups.

RESULTS

A total of 96.7% (119/123) of patients were successfully discharged, with 75.6% (93/123) in the FEV1 ≤ 2 L group. As compared to the FEV1 > 2 L group, the FEV1 ≤ 2 L group exhibited significantly lower proportions of males, patients with smoking histories, patients with lung cavities as revealed by chest imaging findings, and patients with lower forced vital capacity as a percentage of predicted values (FVC%pred) (P values of 0.001, 0.027, and 0.023, 0.003, respectively). No significant intergroup differences were observed in rates of mortality within 30 days after surgery, incidence of postoperative complications, long-term mortality, occurrence of residual lung infection/TB, bronchopleural fistula/empyema, mMRC ≥ 1 at the last follow-up visit, and postoperative readmission (P > 0.05).

CONCLUSIONS

As most DL patients planning to undergo left/right pneumonectomy have a preoperative FEV1 ≤ 2 L, the procedure is generally safe with favourable short- and long-term prognoses for these patients. Consequently, the results of this study suggest that DL patient preoperative FEV1 > 2 L should not be utilised as an exclusion criterion for pneumonectomy.

The importance of the bacterial spectrum in the clinical diagnostics and management of patients with spontaneous pyogenic spondylodiscitis and isolated spinal epidural empyema: a 20-year cohort study at a single spine center

BACKGROUND

Personalized clinical management of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) is challenging due to limited evidence of microbiologic findings and their clinical impact during the clinical course of the disease. We aimed to characterize clinico-microbiological and imaging phenotypes of SD and ISEE to provide useful insights that could improve outcomes and potentially modify guidelines.

METHODS

We performed chart review and collected data on the following parameters: bacterial antibiogram-resistogram, type of primary spinal infection, location of spinal infection, source of infection, method of detection, clinical complications (sepsis, septic embolism, and endocarditis), length of hospital and intensive care unit (ICU) stay, relapse rate, and disease-related mortality in patients with proven pyogenic SD and ISEE treated surgically in a university hospital in Germany between 2002 and 2022.

RESULTS

We included data from 187 patients (125 SD, 66.8% and 62 ISEE, 33.2%). Gram-positive bacteria (GPB) were overall more frequently detected than gram-negative bacteria (GNB) (GPB: 162, 86.6% vs. GNB: 25, 13.4%, p < 0.001). Infective endocarditis was caused only by GPB (GPB: 23, 16.5% vs. GNB: 0, 0.0%, p = 0.046). Methicillin-susceptible Staphylococcus aureus was the most frequently isolated strain (MSSA: n = 100, 53.5%), occurred more frequently in the cervical spine compared to other bacteria (OB) (MSSA: 41, 41.0% vs. OB: 18, 20.7%, p = 0.004) and was most frequently detected in patients with skin infection as the primary source of infection (MSSA: 26, 40.6% vs. OB: 11, 16.7%, p = 0.002). Streptococcus spp. and Enterococcus spp. (SE: n = 31, 16.6%) were more often regarded as the cause of endocarditis (SE: 8, 27.6% vs. OB: 15, 11.4%, p = 0.037) and were less frequently detected in intraoperative specimens (SE: 19, 61.3% vs. OB: 138, 88.5%, p < 0.001). Enterobacterales (E: n = 20, 10.7%) were identified more frequently in urinary tract infections (E: 9, 50.0% vs. OB: 4, 3.6%, p < 0.001). Coagulase-negative Staphylococci (CoNS: n = 20, 10.7%) were characterized by a lower prevalence of sepsis (CoNS: 4, 20.0% vs. OB: 90, 53.9%, p = 0.004) and were more frequently detected in intraoperative specimens (CoNS: 20, 100. 0% vs. OB: 137, 82.0%, p = 0.048). Moreover, CoNS-associated cases showed a shorter length of ICU stay (CoNS: 2 [1-18] days vs. OB: 6 [1-53] days, median [interquartile range], p = 0.037), and occurred more frequently due to foreign body-associated infections (CoNS: 8, 61.5% vs. OB: 15, 12.8%, p = 0.008). The presence of methicillin-resistant Staphylococcus aureus (MRSA) prolonged hospital stay by 56 [24-58] days and ICU stay by 16 [1-44] days, whereas patients with Pseudomonas aeruginosa spent only 20 [18-29] days in the hospital and no day in the ICU 0 [0-5] days.

CONCLUSIONS

Our retrospective cohort study identified distinct bacterial-specific manifestations in pyogenic SD and ISEE regarding clinical course, neuroanatomic targets, method of pathogen detection, and sources of infection. The clinico-microbiological patterns varied depending on the specific pathogens.

Intrapleural tissue plasminogen activator and deoxyribonuclease administered concurrently and once daily for complex parapneumonic pleural effusion and empyema

BACKGROUND

Pleural infection is life-threatening and increasingly prevalent. In addition to usual care, twice-daily, separate administration of tissue plasminogen activator and deoxyribonuclease (tPA-DNase) reduces radiological pleural opacity with lower surgical referral rates.

AIMS

This retrospective cohort study examines the use of once-daily, concurrent administration of tPA-DNase for complex parapneumonic pleural effusion and empyema.

METHODS

Patients with pleural infection who received intrapleural tPA-DNase between October 2014 and July 2020 at Logan Hospital, where it is given concurrently and once-daily as salvage therapy, were retrospectively identified. Radiographic opacification, inflammatory markers, clinical response and complications were examined.

RESULTS

Thirty-one patients were identified. Mean age was 48.8 years (standard deviation [SD], 17.2). Median tPA-DNase administration was 3 (interquartile range [IQR], 2-3). Chest x-ray pleural opacity decreased significantly (P = 0.047) from a median of 39.6% (IQR, 28.8-65.7%) to 9.7% (IQR, 2.5-23.2%), a median relative reduction of 75.5% (IQR, 47.7-93.9%). White cell count and C-reactive protein improved significantly (P = 0.002 and P = 0.032, respectively) from a median of 16.3 × 109 /L (IQR, 11.8-20.6 × 109 /L) to 9.9 × 109 /L (IQR, 8.0-12.3 × 109 /L) and 311.0 mg/L (IQR, 218.8-374.0 mg/L) to 69.0 mg/L (IQR, 36.0-118.0 mg/L), respectively. No patients experienced significant bleeding or died. Five patients (16.1%) were referred for surgery.

CONCLUSION

This is pilot evidence that a practical regimen of concurrent, once-daily intrapleural tPA-DNase improved pleural opacification and inflammatory markers without bleeding or mortality. The surgical referral rate was higher than in studies assessing twice-daily administration, though the validity of this outcome as a measure of treatment success is limited, and further studies are needed to assess the optimal dose and frequency of intrapleural therapy and indications for surgical referral.

Hyperammonemia Due to Empyema

A 91-year-old woman was brought to our hospital with altered consciousness. Blood tests showed an increased ammonia level of 468 μg/dL and a normal liver function. Chest computed tomography showed massive right pleural effusion with loculation. We immediately performed chest drainage using two drainage tubes. The pleural effusate pH was 8.5. We diagnosed her with right empyema leading to hyperammonemia and initiated ampicillin/sulbactam therapy. However, she developed progressive renal failure and died on the third day. Empyema caused by urease-producing bacteria can lead to hyperammonemia. This is the first report of hyperammonemia due to empyema in the English literature.

Spinal infection with intraspinal abscess or empyema and acute myelopathy: comparative analysis of diagnostics, therapy, complications and outcome in primary care

INTRODUCTION

This study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account.

METHODS

Patients were enrolled in an ambispective study (2012-2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan-Meier method and Cox regression.

RESULTS

In total, 134 patients with a median (IQR) age of 72 (61-79) years were analyzed. Baseline characteristics were similar between the SCI (n = 55) and noSCI (n = 79). A higher percentage of endocarditis (9% vs. 0%; p = 0.03) was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group (e.g., urinary tract infection, pressure ulcers). Lethality risk factors were age (HR 1.09, 95% CI 1.02-1.16, p = 0.014), and empyema/abscess extension (≥ 3 infected spinal segments, HR 4.72, 95% CI 1.57-14.20, p = 0.006), dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%.

CONCLUSION

PSI + are associated with higher in-hospital mortality, particularly when multiple spinal segments are involved. However, survival is similar with (SCI) or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates.

Continued Vaccine Breakthrough Cases of Serotype 3 Complicated Pneumonia in Vaccinated Children, Portugal (2016-2019)

We previously reported that despite the use of pneumococcal conjugate vaccines (PCVs), vaccine serotypes remained important causes of pneumonia with pleural effusion and empyema (pediatric complicated pneumococcal pneumonia [PCPP]). We cultured and performed PCR on 174 pleural fluid samples recovered from pediatric patients in Portugal from 2016 to 2019 to identify and serotype Streptococcus pneumoniae. Most PCPP cases (n = 87/98) were identified by PCR only. Serotypes 3 (67%), 14, and 8 (5% each) were the most frequent. Vaccine breakthrough cases were seen among age-appropriately, 13-valent, PCV vaccinated children (median: 3 years, range: 17 months to 7 years), mostly with serotype 3 (n = 27) but also with serotypes 14 and 19A (n = 2 each). One breakthrough was seen with serotype 14 in an age-appropriately, 10-valent, PCV-vaccinated child and another with serotype 3 in a child to whom the 23-valent polysaccharide vaccine was administered. While the relative risk of serotype 1 PCPP decreased almost 10-fold from the period of 2010 to 2015 to the period of 2016 to 2019 (relative risk [RR] = 0.106), that of serotype 3 PCPP almost doubled (RR = 1.835). Our data highlight the importance of molecular diagnostics in identifying PCPP and document the continued importance of serotype 3 PCPP, even when PCV13 use with almost universal coverage could be expected to reduce exposure to this serotype. IMPORTANCE The use of conjugate vaccines against Streptococcus pneumoniae in children has led to substantial reductions in pneumococcal invasive disease. However, the reductions seen in each of the 13 serotypes currently included in the highest-valency vaccine approved for use in children (PCV13), were not the same. It is becoming clear that most vaccine breakthroughs worldwide involve serotype 3 and are frequently associated with complicated pneumonia cases, often with empyema or pleural effusion. Here, we show that despite almost universal PCV13 use, which would be expected to reduce vaccine serotype circulation and further reinforce vaccine direct protection, pneumococci and serotype 3 remain the major causes of pediatric complicated pneumonia. Molecular methods are essential to identify and serotype pneumococci in these cases, which frequently reflect vaccine breakthroughs. A broader use of molecular diagnostics will be essential to determine the role of this important serotype in the context of PCV13 use in different geographic regions.

Clostridioides difficile Pyogenic Liver Abscess With an Empyema

INTRODUCTION

Reports of extraintestinal manifestations of Clostridioides difficile (C difficile) infections are rare. The frequency of these infections comprises approximately 0.17% to 0.6% of all C difficile infections. While they are becoming more frequent worldwide, the precise trend is unclear.

CASE PRESENTATION

An 83-year-old female patient presented with pleuritic chest pain 2 to 3 months after a needle biopsy of her liver abscess confirmed C difficile. She was found to have extension of the liver abscess into the chest cavity, leading to empyema, and was treated with intravenous antimicrobials.

DISCUSSION

This is the fifth known reported case of C difficile leading to a pyogenic liver abscess and the first case where the C difficile liver abscess was associated with an empyema. While long-term metronidazole is considered effective for managing extra intestinal C difficile infection, our patient was treated with vancomycin and meropenem.

CONCLUSION

To determine epidemiology and a proper treatment regimen for extraintestinal C difficile infection, a greater accumulation of cases is necessary.

[Effective Treatment for Empyema with Fistula by Negative Pressure Wound Therapy:Report of a Case]

A 54-year-old male with alcoholic cirrhosis and diabetes mellitus was referred to our hospital for the treatment of right pleural empyema with fistula. Despite performing a simple suture closure of the pulmonary fistula, air leakage occurred one week after surgery. Hence, we covered the fistula with a pediculed muscle flap associated with an open window thoracostomy. After 32 days of gauze drainage, negative pressure wound therapy( NPWT) was introduced for reducing the residual pleural space. A chest computed tomography( CT) scan showed almost the full expansion of the lung after undergoing 98 days of NPWT. The patient was discharged from the hospital four months after thoracostomy.

An in Depth Look Into Intracranial Abscesses and Empyemas: a Ten-year Experience in a Single Institute

Background:

As the incidence of intracranial infections increase due to diagnostic procedures improvement, more real-life data is needed to reach a more solid informed management approach.

Objective:

This study aims to describe and analyse clinical features of intracranial abscesses patients treated at a tertiary hospital in North Jordan during a 10-year period.

Methods:

We retrospectively identified 37 patients treated at King Abdullah University Hospital (KAUH) from 2011 to 2020 in Irbid, North Jordan. Treatment consisted of either aspiration, open craniotomy excision (OCE) or conservative therapy. Extracted variables included demographic data such (age, gender), clinical presentation, lab findings, radiological findings as well as management plan. Retrieved data was compared between the patients who underwent a single operation and those who underwent reoperation after the initial procedure.

Results:

Thirty-seven patients with 55 intracerebral abscesses were identified, 29 of whom had intraparenchymal brain abscesses, 4 patients had epidural empyema, and 4 had subdural empyema. The mean age was 28.8 (± 20.7) years, with a male predominance (78.4%). Sixteen patients underwent open craniotomy excision (OCE), 14 patients were treated by aspiration and 7 patients were treated conservatively. When comparing the single operation and the reoperation groups, there was no statistically significant difference across variables.

Conclusion:

Our study presents valuable insight from a tertiary hospital in north Jordan on intracranial abscesses and empyemas. Our findings confirm that good recovery can be established after aspiration or OCE in the majority of patients. Similar results were obtained when comparing the SOP and the ROP groups.

Disseminated nocardiosis caused by Nocardia farcinica in a patient with colon cancer: A case report and literature review

RATIONALE

Nocardiosis is an uncommon and potentially life-threatening infection that usually affects immunocompromised hosts. No clinical guidelines have been established for managing this rare disease, and the optimal treatment modality remains unclear. Nocardia farcinica, a relatively infrequent pathogen of nocardiosis, causes a clinically aggressive infection. In addition to our patient data, our search of the literature for patients who presented with empyema caused by N. farcinica will provide fundamental information for optimal treatment modalities.

PATIENT CONCERNS

A 64-year-old man was diagnosed with empyema, 4 days following surgery for sigmoid colon cancer. Brain lesions were evaluated only after N. farcinica was isolated and identified as the causative pathogen through repeated culture tests.

DIAGNOSES

N. farcinica was isolated from the pleural effusion and confirmed as the pathogen through 16S rRNA sequencing.

INTERVENTIONS

The patient was successfully treated with tube thoracotomy, neurosurgical evacuation, and a combination of trimethoprim/sulfamethoxazole plus imipenem. Long-term antibiotic therapy was required to prevent recurrence.

OUTCOMES

Pyothorax showed a good clinical response to antimicrobial therapy and drainage of pleural effusion, whereas brain abscess did not respond to medical therapy and required surgery. The patient eventually recovered and continued chemotherapy as treatment for sigmoid colon cancer.

LESSONS

Although extremely rare, this report demonstrates the importance of considering Nocardia infection as the differential diagnosis in immunocompromised patients who present with empyema. In particular, because of the N. farcinica infection's tendency to spread and the resistance of the organism to antibiotics, aggressive evaluation of metastatic lesions and standardized support from microbiological laboratories are important. Surgery may be required in some patients with brain abscesses to improve the chance of survival.

[Descending Necrotizing Mediastinitis with Empyema Necessitated Two Performances of Surgical Drainage for Successful Treatment:Report of a Case]

The case was a 57-year-old woman. She visited a local doctor with a chief complaint of sore throat. A retropharyngeal abscess was suspected, and she was referred to our otolaryngology. Contrast-enhanced computed tomography(CT) scan revealed continuous fluid retention from the retropharyngeal space to the neck and the superior and posterior mediastinum with bilateral pleural effusion. The patient was diagnosed with descending necrotizing mediastinitis with empyema, and on the same day cervical drainage, thoracoscopic bilateral mediastinal drainage, empyema curettage and tracheostomy was performed. Postoperative contrast-enhanced CT scan revealed a widespread residual mediastinal abscess and thoracoscopic bilateral mediastinal drainage was performed again on the 11th postoperative day. After reoperation, the inflammation gradually subsided and she was discharged 47 days after reoperation.

[Lung Cancer Complicated with Empyema Due to Intratumoral Abscess;Report of a Case]

A 73-year-old man was admitted to our hospital because of fever. A chest computed tomography (CT) scan revealed a 10-cm-sized irregular mass with air-fluid level in the left lower lobe, and sputum cytology revealed squamous cell carcinoma, which was diagnosed as a giant squamous cell carcinoma with intratumoral abscess. Later, the empyema developed and drainage was performed for empyema and intratumoral abscess. Two weeks later, left lower lobectomy and lymph node dissection were performed by posterolateral thoracotomy. After surgery, there were no serious complications or relapse of empyema.

Use of Bioglue™ to seal a difficult to treat air leak in a complicated empyema patient

Surgical sealants have been used in thoracic surgery in an effort to reduce air leak duration, intercostal drain duration, length of stay and complications. They are instilled over a defect usually treated with other means. We herein present the technique of controlling a difficult to treat defect by directly instilling Bioglue™ alone into a crater, caused during empyema Video-assisted thoracic surgery in a 50-year-old patient with a trapped lung. This deep crater had caused a significant air leak rendering intraoperative ventilation challenging. After instillation, the dependent lung was kept blocked. With this technique, the Bioglue™ polymerized and the air leak was dramatically decreased making ventilation and eventually extubation of the patient feasible. Instillation of Bioglue™ directly into a large lung defect could be a choice of action to decrease complicated air leaks, otherwise impossible to treat with other means, in patients with trapped lung.

Salmonella houtenae-induced Empyema Complicated with Chronic Tuberculous Empyema

Salmonella spp. are food-borne pathogens that usually cause gastroenteritis, although bacteremia and subsequent focal metastatic infection can also occasionally occur. Of the known Salmonella spp., Salmonella houtenae is a rare subspecies, comprising less than 1% of all Salmonella strains. We herein report the first case of S. houtenae-induced empyema complicated with chronic tuberculous empyema, which was successfully treated by antibacterial agents alone. We wish to highlight the importance of being aware that Salmonella spp. can cause empyema in cases suffering from chronic tuberculous empyema; moreover, despite the successful completion of treatment with antibacterial agents, periodical follow-up is mandatory in such cases.

Cancer Risk in Patients With Empyema: A Nationwide Population-Based Study

This study aimed to evaluate cancer risk and possible risk factors in patients diagnosed with empyema. A total of 31,636 patients with newly diagnosed empyema between January 1, 1999 and December 31, 2010 were included in this study. Standardized incidence ratios (SIRs) were calculated to compare the cancer incidence in these empyema patients to that in the general population. Adjusted hazard ratios were also calculated to investigate whether characteristics increased cancer risk. During the 12-year study period, 2,654 cancers occurred in 31,636 patients with empyema, yielding an SIR of 2.67 (95% confidence interval [CI] 2.57-2.78). We excluded cancer that occurred within 1 year to avoid surveillance bias. The cancer risk remained significantly increased (SIR 1.50, 95% CI 1.41-1.58). Specifically, patients with empyema had higher SIR of cancers of the head and neck (1.50, 95% CI 1.41-1.58), esophagus (2.56, 95% CI 1.92-3.33), stomach (1.49, 95% CI 1.16-1.89), liver and biliary tract (2.18, 95% CI 1.93-2.45), and lung and mediastinum (1.62, 95% CI 1.39-1.86). Age ≥ 60, male sex, diabetes mellitus, and liver cirrhosis were independent risk factors for cancer development. Our study demonstrates an increased incidence of cancer development in patients with empyema, and patients' age ≥ 60, men, and those with diabetes mellitus and liver cirrhosis showed a higher incidence of developing cancer compared to the general population. The association between such kind of infection and secondary malignancy may be elucidated by further study.

Comparative Effectiveness of Oral Versus Outpatient Parenteral Antibiotic Therapy for Empyema

BACKGROUND

Treatment of pediatric parapneumonic empyema (PPE) requires several weeks of antibiotic therapy that is typically completed in the outpatient setting. The route of outpatient therapy can be oral or intravenous (outpatient parenteral antibiotic therapy [OPAT]). No studies have compared outcomes between oral therapy and OPAT for PPE.

METHODS

We identified children <18 years hospitalized from 2005 to 2014 at Primary Children's Hospital with PPE and discharged with oral therapy or OPAT. The primary outcome was the percentage of children who experienced all-cause complications after discharge. Complications included those that were related to pneumonia (including treatment failure, defined as readmission with reaccumulation of pleural fluid or abscess requiring drainage) or antibiotic therapy (eg, allergy, line clot) resulting in either a hospital readmission or emergency department/urgent care visit. All-cause complications were compared between oral therapy and OPAT by using propensity score-weighted logistic regression.

RESULTS

A total of 391 children were hospitalized with PPE; 337 (86%) were discharged with OPAT; 35 (9%) children experienced an all-cause complication, including 5 with oral (9.3%) and 30 (8.9%) with OPAT. Pneumonia and treatment-related complications were comparable (P = .25 and .78, respectively). Two patients treated with OPAT (1%) experienced treatment failure. After adjustment using propensity score weighting, the frequency of complications was similar between groups (adjusted odds ratio 0.97, 95% confidence interval 0.23-4.65).

CONCLUSIONS

The frequency of complications was similar with oral therapy and OPAT for children with PPE. Oral antibiotics may be considered safe and effective for children with PPE who will be discharged to complete therapy in the outpatient setting.

Common bile duct exploration in an elderly Asian population

Common bile duct exploration (CBDE) is an accepted treatment for choledocholithiasis. This procedure is not well studied in the elderly population. Here we evaluate the results of CBDE in elderly patients (>70 years) and compare the open (group A) with the laparoscopic group (group B). A retrospective review was performed of elderly patients with proven common bile duct (CBD) stones who underwent CBDE from January 2005 to December 2009. There were 55 patients in group A and 33 patients in group B. Mean age was 77.6 years (70-91 years). Both groups had similar demographics, liver function tests, and stone size-12 mm (range, 5-28 mm). Patients who had empyema (n = 9), acute cholecystitis (n = 15), and those who had had emergency surgery (n = 28) were more likely to be in group A (P < 0.05). The mean length of stay for group A was 11.7 ± 7.3 days; for group B, 5.2 ± 6.3 days; the complication rate was higher in group A (group A, 38.2%; group B, 8.5%; P = 0.072). The overall complication and mortality rate was 29.5% and 3.4%, respectively. CBDE can be performed safely in the elderly with accepted morbidity and mortality. The laparoscopic approach is feasible and safe in elective setting even in the elderly.

Empyema due to Gemella morbillorum Is Diagnosed by 16S Ribosomal RNA Gene Sequencing and a Phylogenetic Tree Analysis: A Case Report and Literature Review

We report a case of empyema due to Gemella morbillorum. In this case, an analysis of the aspirate from the pleural effusion revealed empyema and evidence of a Gram-positive coccal bacteria. A biochemical identification system labelled the bacteria as 'unclassified', although we initially suspected the bacterium to belong to the Streptococcus species. 16S ribosomal RNA (16S rRNA) gene sequencing and a phylogenetic tree analysis of the isolated strain confirmed the presence of Gemella morbillorum. To ascertain the true incidence of Gemella species in empyema, 16S rRNA gene sequencing should be used when the standard conventional biochemical methods fail to identify the organism or it identifies it with a low degree of reliability.

[Successful treatment of chronic empyema by the omentopexy after aggressive nutritional support]

Since general thoracic surgery requires a short fasting period, the number of cases that require nutrition support after surgery is limited and few reports exist about nutrition in general thoracic surgery and chronic empyema. Here we report 2 cases of chronic empyema treated with nutritional support team (NST) followed by omentopexy. For chronic empyema, a long period is required to sterilize the thoracic cavity by closed or open drainage before radical treatment. During this period, improvement of the nutrition status is important to control local infection, and to increase the volume of the omentum or muscle flaps used for filling the empyema space effectively. In our 2 cases, radical surgeries using omental flap were successfully performed after the improvement of general condition by aggressive nutritional support.

Frontal epidural empyema (Pott's puffy tumor) associated with Mycoplasma and depression

A 37-year-old male has left exophthalmia, which gradually evolved in the last two years, finally with a deviation of left eye (LE), down side and out, with gradually decrease of visual acuity (VA). These symptoms are accompanied with headache and psychiatric manifestations with irritability, decreased attention, anxiety, insomnia, depressed mood. Brain Computed Tomography (CT) shows a tumor mass in air leakage sinus, bilateral frontal and bilateral ethmoidal, with left orbital invasion. This tumor mass lysis by pressure the supero-posterior wall of the left orbit, with the delimitation of a frontal epidural process with a capsule and calcifications. Additionally, it has been shown there is a bilateral maxillary sinusitis. The surgical intervention removed the infection focal spots rearranging the left eyeball, recovering the VA. The sinuses were drained. The psychiatric symptoms in the post operatory phase disappeared. Histopathological examination of the excised tissue revealed sinus ciliated respiratory mucosa with mixed acute and chronic inflammatory infiltrate and focal squamous metaplasia. The lamina propria is edematous and contains large numbers of neutrophils, lymphocytes and plasma cells. Histopathological diagnosis is acute and chronic sinusitis.

CONCLUSIONS

An untreated infection of the aerial sinuses can lead to a complication like Pott's puffy tumor. When signs such as ophthalmologic, psychiatric and intense headaches appear, it suggests the presence of the Pott's puffy tumor (PPT). The clinical signs are reversible once the tumor has been removed.

[Awake epidural anesthesia for thoracotomic drainage in a high-risk patient with postoperative severe pneumonia complicated with empyema]

An 84-year-old man successfully underwent thoracotomic drainage for empyema under awake epidural anesthesia. His past history had revealed significant chronic obstructive pulmonary disease due to smoking. He had undergone right lower lobectomy a month before, but his postoperative course was complicated with pulmonary leakage, severe pneumonia and empyema which required intensive care management. A thoracotomic drainage for empyema was managed under awake thoracic epidural anesthesia using fentanyl and 1% lidocaine because of concern about deterioration of respiratory status following general anesthesia. The additional small doses of fentanyl i. v. and local anesthesia infiltration were needed for resection of 9th rib, but otherwise the drainage was managed successfully. Awake epidural anesthesia was very useful for such a high-risk patient with poor respiratory status.

[Isolation of Shewanella algae from pleural exudate of patient with pneumonia]

AIM

Clinical-microbiological description of the first case in Russia of isolation of S. algae bacteria from clinical material.

MATERIALS AND METHODS

Patient P., 23 years of age, diagnosis: right-sided distal pneumonia, severe course; parapneumonic empyema of pleura. Bacteria isolation, cultural and biochemical tests differentiating S. algae and Shewanella putrefaciens were performed according to Holt H.M. et al., 2005. Identification of bacteria, tests of sensitivity to antibiotics were carried out by automatic system Vitek 2 (bioMerieux) and additionally by disc-diffusion method.

RESULTS

S. algae in association with Serratia marcescens were isolated from pleural exudate of the patient with pneumonia. S. algae bacteria had typical taxonomical features and pathogenicity factors (lipase, gelatinase, beta-hemolysin); were resistant to benzylpenicillin, amoxicillin, cefazolin and sensitive to other beta-lactam antibiotics, aminoglycosides, fluoroquinolones, macrolides, tetracycline.

CONCLUSION

S. algae bacteria isolated from pleural exudate of the patient with pneumonia are etiologically significant in parapneumonic empyema of pleura.

Actinomyces meyeri infection: case report and review of the literature

Actinomyces meyeri is an uncommon cause of actinomycosis. We present a patient with pneumonia and empyema due to A. meyeri. The patient underwent open thoracotomy with decortication and was discharged home on a twelve-month course of oral penicillin. Review of the English literature revealed thirty-two cases of infection due to A. meyeri. The majority of patients were male, and a significant number had poor dental hygiene and a history of alcoholism. More than other Actinomyces species, A. meyeri causes pulmonary infection and has a predilection for dissemination. Prognosis is favorable with prolonged penicillin therapy combined with surgical debridement, if needed.

[A case of Paragonimus westermani complicated empyema by Streptococcus pneumoniae]

A 75-year-old man, who had eaten wild boar and deer repeatedly until November 2006, visited our hospital because of a right pleural effusion on chest X-ray films after he bruised a hip in January 2007. A right thoracocentesis revealed exudative pleural effusion with many neutrophils. Ten days after his first visit, a pleural biopsy specimen suggested the existence of parasite eggs. Twenty-six days after his first visit, he was admitted to our hospital because of leukocytosis, increased systemic inflammatory markers and a right pleural effusion. We found a great number of neutrophils, eggs of the Paragonimus species and gram-positive cocci in the pleural effusion. Streptococcus pneumoniae was also identified in his pleural effusion. In addition, a diagnosis of Paragonimiasis westermani was made serological study. After the continuous drainage of the pleural effusion, the patient was treated with praziquantel and antibiotics, and he gradually improved.

[Experience of successful treatment for a case of intractable chronic empyema with a bronchopleural fistula]

We report an experience of successful treatment for a case of intractable chronic empyema complicated by bronchopleural fistula (BPF). A 75-year-old woman who had severe diabetes mellitus complained of general fatigue and anorexia. A lung abscess in the right upper lobe was diagnosed and treated with antibiotics. Regrettably, it ruptured into a pyopneumothorax. The BPF was closed primarily and covered with intercostal muscle, but the procedure was not effective. The pyopneumothorax led to the development of chronic empyema with BPF. The patient was admitted to our hospital for treatment and the BPF was managed with a Dumon stent and endobronchial Watanabe spigot (EWS) but failed to heal. Therefore, open drainage was chosen as a 1st stage treatment. After healing the infected space, closure of the BPF and a bronchial embolization by EWS was performed with a closeire of space by pediculed omentum and muscle flap and with a thoracoplasty as a 2nd stage treatment. The postoperative course was uneventful, and the patient was discharged on post-operative day 51.

[A case of Cushing syndrome presenting after pulmonary nocardiosis with pyothorax]

A 49-year-old woman visited our clinic on July 12th, 2006, complaining of discomfort in fingers of both hands, edema of both lower limbs, and pain in the right shoulder and chest. Chest X-ray examination showed an infiltrative shadow with pleural effusion and loss of lung volume in the left lower lung field. She was treated with CTRX, but it was ineffective, and she was therefore admitted to Kurume University Hospital on July 21st, 2006. Chest CT demonstrated pyothorax and loss of lung volume in the left lung. Culture of a sample obtained by thoracentesis yielded Nocardia asteroides. The pulmonary nocardiosis improved after oral administration of trimethoprim-sulfamethoxazole, and the patient was discharged on August 25th 2006. No immunological impairment was observed, and the serum levels of ACHT and cortisol were normal. In February 2007, however, she developed facial acne, facial edema ("moon" face), centripetal obesity, and weight gain. Cushing syndrome was diagnosed on the basis of tests including a low-dose dexamethasone suppression test. To the best of our knowledge, there has been no previous report of pulmonary nocardiosis with pyothorax in a patient with Cushing syndrome. We assume that the present patient had pre-(sub-) clinical Cushing syndrome when she presented with pulmonary nocardiosis and pyothorax.

Gastric perforation presenting as empyema in a patient with pancreatic cancer on bevacizumab treatment

Bowel perforation is a rare but life-threatening complication of bevacizumab, a new anticancer treatment. Patients with bowel perforation usually present with acute abdominal symptoms. Here a case history is presented to highlight a pancreatic cancer patient on bevacizumab chemotherapy who developed empyema as the first manifestation of gastric perforation. This unusual presentation warns physicians that bevacizumab-related bowel perforation can arise as a thoracic complication, without typical gastrointestinal manifestations, in an advanced cancer patient.

Malignant mesothelioma associated with chronic empyema with elevation of serum CYFRA19: A case report

Malignant neoplasms are reported to occur with long-standing tuberculous pleuritis or chronic empyema. During the clinical course of chronic empyema, subjective symptoms such as chest pain and deterioration of dyspnea and abnormal clinical signs such as increased abnormal chest shadows have frequently been found. Though difficult, differentiating the occurrence of malignant tumors from worsening chronic inflammation is crucial. We report here a case of malignant mesothelioma associated with chronic empyema with elevation of serum CYFRA19.

The yield and safety of thoracentesis in hematopoietic stem cell transplantation recipients

The aim of this study was to assess the diagnostic value and safety of thoracentesis in hematopoietic stem cell transplantation (HSCT) recipients. We identified all hospitalized HSCT recipients who underwent thoracentesis from 1998 to 2006. We collected patients' clinical characteristics, indications for thoracenstesis, the complications of the procedure, and the etiology of the pleural effusion. A total of 50 thoracentesis findings were analyzed. Twenty-six patients underwent allogeneic HSCT, while 24 patients underwent autologous HSCT. The main indications for performing thoracentesis were to rule out infection and document or diagnose malignancy. Pleural effusions were characterized as exudate in 33 patients (66%). A specific diagnosis based on the thoracentesis was made in 13 patients (26%). These were malignancy in nine patients, parapneumonic in three patients, and empyema in one patient. The only documented complication was pneumothorax in five patients. The presence of exudative effusion and underlying solid malignancy were associated with specific diagnosis by thoracentesis (p = 0.0001 and 0.013, respectively). In spite of the tendency of HSCT recipients to develop pulmonary infections, complex parapneumonic effusions are rarely diagnosed by thoracentesis. The rate of complications is comparable to other patient populations.

Evaluation of a new inflammatory molecule (triggering receptor expressed on myeloid cells-1) in the diagnosis of pleural effusion

BACKGROUND AND OBJECTIVE

The triggering receptor expressed on myeloid cell-1 (TREM-1) is a newly discovered molecule that is associated with the inflammatory response to microorganisms. We investigated the role of surface and soluble TREM-1 in differentiating different disease entities in pleural effusion formation.

METHODS

Sixty-seven patients with pleural effusion due to transudate (14), malignancy (15), tuberculous pleuritis (16), para-pneumonic effusion (10) and empyaema (12) were included in this study. Surface TREM-1 was measured by flow cytometry and was expressed as mean fluorescence intensity and soluble TREM-1 was measured by ELISA and expressed as pg/mL. Results are given as mean levels +/- SEM.

RESULTS

Surface TREM-1 was measured in 24 patients and the levels were highest in para-pneumonic effusion (30.0 +/- 8.4) and lowest in malignant pleural effusion (5.2 +/- 1.1) and tuberculous pleuritis (5.2 +/- 2.4). Soluble TREM-1 was highest in effusions of infectious aetiology (para-pneumonic effusion (979.4 +/- 229.6) and empyaema (1712.6 +/- 299.5)) and lowest in non-infectious effusions (transudate (81.2 +/- 4.5 pg/mL) and malignancy (111.3 +/- 20.7). At a cut-off value of 114 pg/mL, soluble TREM-1 yielded a sensitivity of 87.5% and a specificity of 89.7% in differentiating non-infectious effusion from tuberculous pleuritis. At a cut-off value of 374 pg/mL, sTREM-1 yielded a sensitivity of 93.8% and a specificity of 90.9 in differentiating tuberculous pleuritis from bacterial pleural effusion.

CONCLUSION

Soluble and surface TREM-1 are valuable markers in establishing the aetiology of pleural effusions.

The value of computed tomography for predicting empyema-associated malignancy

OBJECTIVE

To determine the value of computed tomography (CT) scanning in detecting associated malignancy in patients with chronic empyema.

METHODS

Two radiologists retrospectively reviewed CT scans of 112 consecutive patients with chronic empyema and arrived at a consensus about the findings. Among these patients, 6 were confirmed by pathology evaluation to have empyema-associated malignancy (EAM), including 4 lymphomas. The CT scans were evaluated for the presence of the following findings: a mass in the empyema sac; mass involvement of the extrapleural fat, chest wall, rib, and lung; bulging of the empyema sac; nodular pleural thickening; empyema involvement of the mediastinal pleura; presence of lung nodules (>1 cm); and mediastinal lymph node enlargement. The association between the CT findings and the EAM was analyzed with the Fisher exact test. A multiple logistic regression analysis was used to determine the predictive variables for EAM. Sensitivity, specificity, and positive predictive value were calculated for each finding.

RESULTS

All CT findings, except rib involvement and bulging of empyema sac, were significantly associated with EAM (P<0.05). The finding of the presence of a mass, extrapleural fat, and mediastinal involvement showed relatively high sensitivity (100%, 67%, 67%, respectively) and specificity (81%, 87%, 91%, respectively). A bulging of the empyema sac and nodular pleural thickening showed 100% sensitivity, but low specificity (39% and 44%, respectively). Findings from the multiple logistic regression analysis revealed that the presence of a mass and empyema of the mediastinal pleura were significant variables associated with EAM (P<0.05).

CONCLUSIONS

Although many CT findings are associated with EAM, most showed either low positive predictive value or low sensitivity. A variety of CT findings should be considered when evaluating CT image-based detection of EAM.

Massive concha bullosa pyocele with orbital extention

Concha bullosa is the most common anatomic variant of the middle turbinate. It remains usually asymptomatic. Pyocele occurs when concha bullosa becomes infected. In the formation of a pyocele, middle turbinate may become expanded and occupy the surrounding structures with local bone destruction. Direct extension of mass from the nose into the orbit may occur, because the orbital contents are separated from the ethmoidal labyrinth only by the thin lamina papyracea. We report a case of concha bullosa pyocele with orbital extension. Orbital involvement is also associated with ocular functional loss. In this case, ocular motion and vision remained normal despite of the presence of orbital extension for 2 years.

Pneumonectomy for unilateral destroyed lung with pulmonary hypertension due to systemic blood flow through broncho-pulmonary shunts

OBJECTIVE

Three decades ago, a few patients with pulmonary hypertension and respiratory failure associated with a unilateral destroyed lung were reported to have been treated by a pneumonectomy. In the present study, we investigated the clinical features, operative indications, and results of four cases with pulmonary hypertension that underwent a pneumonectomy for a unilateral destroyed lung.

METHODS

Four patients (three males, one female) with a destroyed lung and pulmonary hypertension (mean pulmonary arterial pressure >25 mmHg) were treated by a pneumonectomy between 1999 and 2002 at our institution. Their mean age was 59 years old (range 42-68 years). The underlying lung disease, Medical Research Council (MRC) dyspnea scale, respiratory function, arterial blood gas analysis, pulmonary arterial pressure, preoperative management, operative procedure, and postoperative course for each were reviewed retrospectively.

RESULTS

The underlying lung disease that caused the destroyed lung was bronchiectasis in two patients, chronic empyema with bronchopleural fistula in one, and necrotizing pneumonia in one. The average mean pulmonary artery pressure was 33 mmHg (range 25-42 mmHg), which decreased to 27 mmHg (range 19-36 mmHg) after occlusion of the pulmonary artery in the affected lung. Following the pneumonectomy, the average mean pulmonary artery pressure was decreased to 17 mmHg (range 11-25 mmHg). Chronic inflammatory symptoms and functional impairments (showed by blood gas analysis, pulmonary arterial pressure, or MRC dyspnea scale) improved post-pneumonectomy. There was no operative death, though postoperative cardiorespiratory failure occurred in one patient. All patients were discharged from the hospital.

CONCLUSIONS

We concluded that a pneumonectomy procedure may be indicated for selected patients with a unilateral destroyed lung and pulmonary hypertension due to systemic blood flow though broncho-pulmonary shunts.

Anaerobic pulmonary infections in children

Pulmonary infections due to anaerobic bacteria usually occur in children prone to aspiration. The source of the anaerobic bacteria is the oropharyngeal bacterial flora, where these organisms outnumber aerobic and facultative organisms in a 10:1 ratio. The most common lower respiratory tract infections where anaerobic bacteria are recovered mixed with aerobic organisms are aspiration pneumonia, lung abscess, and empyema. The predominant isolated anaerobic bacteria are Peptostreptococcus, Fusobacterium, pigmented Prevotella, and Porphyromonas spp. and Bacteroides fragilis group. Management of these infections includes the administration of antimicrobials effective against the anaerobic as well as the aerobic pathogens.