[A first case report of empyema caused by Tetratrichomonas species in Japan]

Trichomonad is a type of flagellate that parasitizes the human oral cavity, intestine, or vagina. However, respiratory infection is rare. We report a patient with pyothorax related to Tetratrichomonas species, which is the first reported case in Japan. The patient was a 66-year-old female. She consulted the Emergency Outpatient Unit of our hospital with fever, dyspnea, and the retention of pleural effusion. The appearance of the pleural effusion collected by thoracic drainage was brown, fetid pus. On microscopy, Trichomonad was detected in the pleural effusion. On a gene test, Tetratrichomonas sp. was identified. Based on this experience, we propose that non-stained specimens should be examined to detect Trichomonad on a puncture fluid test. (Case report).

Particularities regarding the etiology of sepsis in forensic services

If in clinical practice definitive diagnostic criteria had been established, after death sepsis is often difficult to diagnose, especially if a site of origin is not found or if no clinical data are available. This article will analyze the etiology of sepsis in a medical-legal service with emphasis on the differences in diagnosing it in clinical and forensic environments. A total of 78 cases of sepsis cases diagnosed or confirmed at the autopsy were selected. The etiological agent was determined either during the hospitalization or by postmortem bacteriology. A high prevalence of Gram-negative sepsis was found, especially multidrug-resistant micro-organisms. Most frequent etiological agents were Acinetobacter baumannii, Escherichia coli, Enterobacter, Enterococcus, Pseudomonas, and Klebsiella. Polymicrobial sepsis is much more frequent than in nonforensic cases. In legal medicine, the prevalence of Gram-negative sepsis is much higher than in nonforensic autopsies, and the point of origin is shifted toward the skin and the gastrointestinal system.

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.

Soluble triggering receptor expressed on myeloid cells-1 for diagnosing empyema

BACKGROUND

Studies have shown that soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) is upregulated by microbial products in the bronchoalveolar lavage fluid, and cerebrospinal fluid of patients with pneumonia and bacterial meningitis, respectively. Our goal was to evaluate whether sTREM-1 in pleural fluid can distinguish pleural empyema from postthoracotomy-related pleural effusion and effusions of other etiologies.

METHODS

Patients who presented with pleural effusion were identified through laboratory records. In addition to routine biochemical markers, differential white blood cells, cytology, Gram stain, and pleural fluid culture, pleural fluid sTREM-1 was measured by enzyme-linked immunosorbent assay using a commercial kit (R&D Systems, Minneapolis, MN).

RESULTS

Eighty-nine patients were included in the study: 17 with empyema, 7 simple parapneumonic effusion, 18 transudate, 12 postthoracotomy pleural effusion, 22 malignancy, 1 connective tissue disease, and 12 with undetermined effusion. Mean levels of sTREM-1 were significantly higher in empyema than in postthoracotomy pleural effusion (687 +/- 479 pg/mL vs 34 +/- 81 pg/mL, p < 0.0001, respectively) and in effusions of other etiologies (15 +/- 54 pg/mL, p < 0.0001). A cutoff value of 114 pg/mL for pleural sTREM-1 achieved a sensitivity of 94% and a specificity of 93% in differentiating empyema from pleural effusions of other etiologies. The area under the receiver operating characteristic curve for pleural effusion sTREM-1 as a predictor for empyema was 0.966.

CONCLUSIONS

Our findings suggest that sTREM-1 in the pleural fluid can potentially assist clinicians in the differentiation of bacterial from nonbacterial pleural effusion, particularly in postthoracotomy pleural effusion.

Intrapleural heparin or heparin combined with human recombinant DNase is not effective in the treatment of empyema in a rabbit model

OBJECTIVE AND BACKGROUND

The aim of this study was to investigate the effectiveness of intrapleural heparin or heparin combined with human recombinant DNase in the treatment of empyema.

METHODS

Empyema was induced in rabbits with an intrapleural injection of 10(9)Pasteurella multicoda organisms in infusion agar via a surgically placed chest tube. Once empyema was verified, a blinded investigator administered drugs via the chest tube. There were three treatment groups each with six rabbits. One group was given 1000 IU heparin, a second group was given 1000 IU heparin plus 1 mg of human recombinant DNase via chest tube and the control group received saline. The rabbits received treatment every 12 h for a total of six treatments and the volume of each treatment was 3 mL. The animals were sacrificed at day 10 and the amount of empyema and pleural thickening was scored macroscopically on a scale of 0-6.

RESULTS

The total volume of pleural effusion aspirated was significantly higher in the heparin group (25.8+/-10.7 mL) compared with either saline (8+/-8.9) or heparin plus human recombinant DNase (6.8+/-6.1) groups (P=0.003). The mean empyema and pleural thickening scores did not differ significantly between the groups (P=0.8, P=0.5 respectively). A weak correlation was found between total volume of aspirated pleural fluid and pleural parameters of white blood cell counts and LDH levels (r=0.546 and P=0.02, r=0.631 and P=0.02 respectively).

CONCLUSION

The intrapleural administration of 1000 IU heparin alone or in combination with 1 mg of human recombinant DNase is no more effective than saline in the treatment of empyema in rabbits. Intrapleural heparin significantly increased the drainage of pleural fluid compared with the combination and saline group.

Video-assisted thoracoscopic surgery under local anesthesia for right empyema secondary to aspiration pneumonia caused by esophageal achalasia: case report

A 55-year-old man was admitted to the Department of Internal Medicine of our hospital with chief complaints of fever, cough, and right-sided chest pain. Plain radiography of the chest revealed widening of the mediastinum (attributed to esophageal achalasia), pneumonia, and right pleural effusion. According to the properties of the pleural fluid, empyema was diagnosed. Because the empyema was resistant to antibiotic treatment and was in the fibrinopurulent stage, it could not be drained effectively. Therefore, after treatment of the esophageal achalasia by balloon dilatation of the lower esophagus, the empyema was treated by video-assisted thoracoscopic surgery, i.e., by video-assisted thoracoscopic drainage and curettage of the empyema cavity, under local anesthesia.

Neuroimaging of infections

Neuroimaging plays a crucial role in the diagnosis and therapeutic decision making in infectious diseases of the nervous system. The review summarizes imaging findings and recent advances in the diagnosis of pyogenic brain abscess, ventriculitis, viral disease including exotic and emergent viruses, and opportunistic disease. For each condition, the ensuing therapeutic steps are presented. In cases of uncomplicated meningitis, cranial computed tomography (CT) appears to be sufficient for clinical management to exclude acute brain edema, hydrocephalus, and pathology of the base of skull. Magnetic resonance imaging (MRI) is superior in depicting complications like sub-/epidural empyema and vasculitic complications notably on FLAIR (fluid-attenuated inversion recovery)-weighted images. The newer technique of diffusion-weighted imaging (DWI) shows early parenchymal complications of meningitis earlier and with more clarity and is of help in differentiation of pyogenic abscess (PA) from ring enhancing lesions of other etiology. Proton magnetic resonance spectroscopy (PMRS) seems to produce specific peak patterns in cases of abscess. The presence of lactate cytosolic amino acids and absence of choline seems to indicate PA. Also in cases of suspected opportunistic infection due to toxoplasma DWI may be of help in the differentiation from lymphoma, showing no restriction of water diffusion. In patients with herpes simplex and more exotic viruses like West Nile and Murray Valley virus DWI allows earlier lesion detection and therapeutic intervention with virustatic drugs.

Diagnosis of bacterial cerebellitis: diffusion imaging and proton magnetic resonance spectroscopy

Diffusion-weighted imaging and in vivo proton magnetic resonance spectroscopy ((1)H magnetic resonance spectroscopy) have demonstrated great potential in differentiating intracranial lesions of various pathologies. This report describes a case of a 12-year-old child with cerebellitis and subdural empyema that manifested presence of succinate, acetate, lactate, and amino acids on in vivo (1)H magnetic resonance spectroscopy from a large area of restricted diffusion in the vermis on diffusion-weighted imaging, a finding specific for bacteria-induced infection. The child made a complete clinical and imaging recovery on conservative management.

Intrapleural fibrinolytic treatment of multiloculated pediatric empyemas

AIM

The aim of this paper was to compare the efficacy of adjunctive intrapleural fibrinolygic agents (streptokinase, urokinase) on fibrinopurulent stage empyema and chronic stage empyema.

METHODS

In our clinic, we used intrapleural fibrinolytic agents in 78 pediatric patients (36 fibrinopurument stage empyemas, 42 chronic stage empyemas) between December 1994 and September 2002. Pleural biopsy was done for staging. Streptokinase 250,000 units in 100 ml 0.9% saline solution (62 patients) and 125000 units in 100 ml 0.9% saline solution (16 patients) was instilled daily to the chest tube, and the tube was clamped for 4 h followed by suction. This treatment was continued daily for 2 to 8 days until resolution was demonstrated by chest radiograms and/or computed chest tomography.

RESULTS

The treatment was discontinued due to allergic reaction and pleural hemorrhage in 1 patient with fibrinopurulent empyema. This patient died 1 day later in a septic condition. The regimen was completely successful in 24/36 (66.6%) fibrinopurulent empyemas, and partially successful in other 11/36 (30.55%). Treatment was ineffective in 38 of 42 patients with chronic empyemas (90.6%). Two cases in chronic phase empyema completely recovered and 2 other patients had a partial response. Success of the treatment was 91.66% (35/36) (complete response: 24/36' partial response 11/36) in the fibropurulent stage and 9.4% (2/42 complete response, 2/42 partial response in chronic cases.

CONCLUSIONS

Our study suggests that intrapleural fibrinolytic treatment is an effective and safe therapy in children with fibrinopurulent phase thoracic empyema.

Pleural fluid transforming growth factor-beta1 correlates with pleural fibrosis in experimental empyema

Transforming growth factor-beta1 (TGF-beta1) is a growth factor that is implicated in fibrosis of many organs. The purpose of this study was to determine the sequential levels of TGF-beta1 in the pleural fluid of rabbits that had undergone empyema induction, as fibrosis of the pleural space develops. Thirty-seven rabbits underwent empyema induction. Rabbits were sacrificed on Days 1, 2, 3, 4, 5, 6, and 8. Pleural fluid and viscera pleura specimens were collected at autopsy. TGF-beta1 levels were measured in pleural fluid using a commercially available ELISA kit, and pathologic specimens were scored for evidence of fibrosis (pleural thickness and number of fibroblasts). The median levels of pleural fluid TGF-beta1 increased from 8,100 pg/ml (Days 1 and 2) to 39,600 pg/ml (Day 8). Pleural fluid TGF-beta1 levels closely correlated with microscopic pleural thickness (r = 0.7, p < 0.001) and number of fibroblasts present in the visceral pleura (r = 0.68, p < 0.001). The first increase in pleural fluid levels of TGF-beta1 (Day 3) occurred before the increase in pleural thickness (Day 4) and before the increase in number of fibroblasts (Day 4). In conclusion, pleural fluid levels of TGF-beta1 rise in experimental empyema as pleural fibrosis develops. The rise in empyemic pleural fluid TGF-beta1 levels correlates with markers of pleural space fibrosis.

Diffusion-weighted imaging in acute bacterial meningitis in infancy

Bacterial meningitis is frequently fatal or leads to severe neurological impairment. Complications such as vasculitis, resulting in infarcts, should be anticipated and dealt with promptly. Our aim was to demonstrate the complications of meningitis by diffusion weighted imaging (DWI) in patients who deteriorated despite therapy. We studied 13 infants between the ages of 1 day and 32 months who presented with symptoms ranging from fever and vomiting to seizures, encephalopathy and coma due to bacterial meningitis, performing MRI, including DWI, 2-5 days after presentation. Multiple infarcts were found on DWI in 12 of the 13, most commonly in the frontal lobes (in 10). Global involvement was seen in four children, three of whom died; the fourth had a very poor outcome. In one case abnormalities on DWI were due to subdural empyemas. We diagnosed vasculitis in three of five patients studied with MRA. We think DWI an important part of an MRI study in infants with meningitis. Small cortical or deep white-matter infarcts due to septic vasculitis can lead to tissue damage not easily recognized on routine imaging and DWI can be used to confirm that extra-axial collections represent empyemas.

Diffusion-weighted MRI of subdural and epidural empyemas

We reviewed diffusion-weighted images (DWI) from eight patients with subdural and four with epidural empyemas to assess the possibility of differentiating between these lesions by DWI. The signal intensities of the empyemas on DWI, and maps of the apparent diffusion coefficient (ADC) were analysed in seven patients. In seven of the eight patients with subdural empyema, the lesions appeared as areas of high signal. The ADC maps confirmed that these areas were the result of restricted diffusion. (In the remaining patient, the lesion showed a mixture of high and low signal.) The epidural empyemas contained areas of low signal in all four patients; part of the empyema was isointense or gave high signal in two. DWI may be an adjunct to conventional sequences for differentiating between subdural and epidural empyemas.

Changing patterns of disease in Papua New Guinea over a period of 40 years from 1962. Pathology encountered in a stoneage culture by the first western-trained doctors who entered the country

The diseases observed in Papua New Guinea coastal and highland people were described: segmental enteritis necroticans caused by the ingestion of pig meat contaminated with Clostridium welchii type C; chest empyemas caused by thoracostomies performed by village doctors because of ancient superstition; traumatic injuries; primary and secondary (lepromatous leprosy or tuberculosis) amylosis; slow prominent atherosclerosis and myocardial infarction.

Microradiographic and histopathologic findings in a human cage explant after two-level corpectomy: a case report

STUDY DESIGN

A case involving microradiographic and histopathologic analysis of an explanted human corpectomy mesh cage is reported.

OBJECTIVE

To describe the clinical circumstance, the radiographic appearance, and the histopathologic assessment of a titanium mesh device explanted from a two-level corpectomy.

SUMMARY OF BACKGROUND DATA

To the authors' knowledge, no published microradiographic or histopathologic reports have described a retrieved human corpectomy cage.

METHODS

The explanted device was stained using Osteochrome Villanueva bone stain and underwent routine decalcified histologic processing and embedding in polymethylmethacrylate. Midsagittal sections were prepared and polished to 100 microm for histologic and microradiographic analysis.

RESULTS

Microscopic analysis demonstrated normal-appearing lamellar and woven trabecular bone in close contact with the titanium implant interface. Further analysis of serial sections indicated that, on the average, 35% (range, 30-40%) of the inner device region contained trabecular bone.

CONCLUSION

Osteosynthesis and bone remodeling can occur within titanium corpectomy cages.

METHODS

This study involved one titanium mesh device (Harms cage), 20 mm in diameter and 45 mm long, explanted from a two-level corpectomy clinical case. This device was retrieved, processed, and analyzed after informed patient consent and approval from the authors' institutional review board.

Empyema of the guttural pouch (auditory tube diverticulum) in horses: 91 cases (1977-1997)

OBJECTIVE

To identify features of guttural pouch (auditory tube diverticulum) empyema in horses and compare findings of uncomplicated guttural pouch empyema with guttural pouch empyema complicated by chondroids.

DESIGN

Retrospective study.

ANIMALS

91 horses with guttural pouch empyema.

PROCEDURE

Medical records of horses with guttural pouch empyema were reviewed.

RESULTS

The most common owner complaint and abnormal finding was persistent nasal discharge. Chondroids were detected in 21% (19/91) of affected horses. Streptococcus equi was isolated from the guttural pouch in 14 of 44 horses; for Streptococcus spp, in vitro resistance to sulfadimethoxine and trimethoprim-sulfamethoxazole was detected. Retropharyngeal swelling and pharyngeal narrowing were significantly more prevalent in horses with chondroids, compared with horses with uncomplicated empyema. Ninety-three percent of affected horses were discharged from the hospital; at time of discharge, 66% had complete resolution of disease, 19% had improvement without resolution, and 15% did not have improvement.

CONCLUSIONS AND CLINICAL RELEVANCE

Horses with persistent nasal discharge should be examined endoscopically for guttural pouch empyema. Treatment with lavage offers a good prognosis for resolution of uncomplicated guttural pouch empyema. Aggressive treatment with lavage and endoscopic snare removal of chondroids offers a good prognosis and may make surgical intervention unnecessary.

Primary distension of the guttural pouch lateral compartment secondary to empyema

A 6-year-old, 420-kg quarter horse gelding was presented with a 2-month history of difficulty swallowing and dyspnea. The horse was diagnosed with a right guttural pouch empyema with many large chondroids. Two surgeries were required to completely remove all the chondroids from what proved to be a primary distension of the guttural pouch lateral compartment.

[Therapeutic thoracoscopy for empyema thoracis]

In empyema thoracis, it is important to reduce the duration of treatment and to expand the collapsed lung as fully as possible while managing intrathoracic infection. We used thoracoscopy to treat 10 cases of empyema that were not completely cured by antibiotics or thoracic drainage. The 8 men and 2 women were 43-73 years of age. Thoracoscopy was done under general anesthesia except for 2 pneumonia patients. After inserting two trocars into the thoracic cavity, we removed pus, the purulent coat, and fibrinous membrane. Into one unilocular cavity, two intrathoracic tubes were inserted via trocarholes. Postoperative irrigation of the thoracic cavity was conducted daily through the two tubes. We subclassified the fibropurulent stage into three phases, namely, the purulent, fibrous, and purulent-capsular. One case required redrainage, but no cases were accompanied by severe complications or postoperative death. Patients were discharged on post-operative day 33, on average. We found no recurrence or cases of recollapsed lung during the study, from 8 months to 4 years and 11 months postoperatively.

[A 56-year-old man with fever, backache and tetraparesis]

We report a 56-year-old man who developed progressive paraparesis. He was apparently well, except for left Bell's palsy which developed on May 9 of 1994, for which he received stellate ganglion block on the left side more than ten times until July 2nd of 1994, when he noted pain in his left shoulder and in his lumbar region. On July 5th, he noted some difficulty in urination. On July 6th, he noted tingling sensation in his four extremities and difficulty in gait. He was admitted to another hospital where he was treated with intravenous infusion of glycerol. After this treatment, his gait and sensory disturbance showed some improvement, however, on July 7th, his shoulder and lumbar pain worsened, and he became unable to stand. His temperature went up to 39 degrees C on the next day. Lumbar CSF on that day contained 119 cells/microliters, 112 mg/dl of protein, and 53 mg/dl of sugar. He was transferred to our hospital on July 14th. His past medical history revealed that he had suffered from frequent bouts of osteomyelitis since the age of 13 years. He was operated on several times on osteomyelitis. He had been treated on his tooth ache until shortly before the onset of the present illness. He also received steroid hormone for his Bell's palsy. On admission, his consciousness varied from alert to stupor. His BP was 150/100 mmHg, HR 98/min and regular, BT 39.4 degrees C. The bulbar conjunctiva appeared somewhat icteric. Otherwise, general physical examination was unremarkable. On neurologic examination, there was no apparent dementia. Higher cerebral functions appeared intact. The optic discs were flat. Pupils were round and isocoric reacting to light and accommodation promptly. Ocular movements were full without nystagmus. Some exophthalmos was noted bilaterally. The sensation of the face and facial muscles were intact. The remaining cranial nerves also appeared intact. Nuchal rigidity was present. He was unable to stand or walk. Muscle strength was markedly diminished in all four limbs; manual muscle testing revealed 1 to 2/5 weakness in both upper and lower extremities bilaterally. Muscle stretch reflexes were decreased or lost in both upper and lower limbs, but the plantar response was extensor on the right. Sensation appeared to be diminished in legs, but detail was not clear because of disturbance of consciousness. Pertinent laboratory findings were as follows: WBC 12,800/microliter, GPT 58 IU/l, total bilirubin 2.65 mg/dl, and CRP 16.8 mg/dl. Cerebrospinal fluid contained 34 cells/microliter (approximately two thirds were neutrophils), RBC 1,110/microliter, 2,949 mg/dl of protein, and 119 mg/dl of glucose; stapylococcus aureus was cultured from the CSF. Myelogram showed a filling defect in the anterior epidural space between the low thoracic and the upper lumbar region. The patient was treated with cephotaxim, aminobenzyl penicillin, and chloramphenicol. On the second hospital day, his BT was still 39 degrees C and he was agitated His weakness was worse than the previous day. Spinal MRI was attempted; as he was agitated 5 mg of diazepam was given intravenously at 4 PM. His respiration was rapid and somewhat shallow. At 6 PM, gadolinium DTPA was injected intravenously; at that time, he was breathing and pupils were 3 mm on both sides. At 6:35 PM, an examiner noted that he stopped breathing; the left pupil was dilated to 5 mm. Cardiopulmonary resuscitation was initiated immediately, and intubation was performed. He was placed on a respirator. His blood pressure did not reach 100 mmHg; he was in deep coma. Cardiac arrest occurred at 8:53 AM on the next morning. The patient was discussed in a neurological CPC. Most of the participants thought that the patient had either spinal epidural empyema or spinal subdural abscess. The question was what might be the original focus of infection. Three possibilities were considered, i.e., stellate ganglion block, teeth infection, and osteomyelitis...

Endoscopic endonasal dacryocystorhinostomy: results in 56 patients

Fifty-six patients with a complete stenosis of the nasolacrimal duct were treated by endoscopically controlled intranasal dacryocystorhinostomy according to West. Forty-four patients had idiopathic stenosis and 12 had posttraumatic scarring. Revision surgery was done in 11 of these 56 cases (8 patients with a previous external Toti procedure, and 3 patients with previous endonasal surgery). Altogether, 95% of the patients were symptom-free (86%) or felt improved (9%) postoperatively. Surgical revision was successful in 82%. Of patients with an "idiopathic" stenosis, 84% were healed and an additional 11% were improved. The success rate in the 12 patients with posttraumatic stenosis was 92%. Endoscopic duct surgery is a highly successful procedure with a low complication rate, the worst complication being persistence of symptoms.

Recruitment of inflammatory cells to the pleural space. Chemotactic cytokines, IL-8, and monocyte chemotactic peptide-1 in human pleural fluids

Pleural effusions secondary to various diseases are associated with the presence of different inflammatory cells. The role of selective chemotactic cytokines in the recruitment of phagocytes to the pleural space is unclear. IL-8 and monocyte chemotactic peptide-1 (MCP-1) are recently described cytokines that are chemotactic for neutrophils and monocytes, respectively. We prospectively studied 63 patients, using strictly defined criteria for their selection. IL-8 concentrations were elevated in both empyema fluid (9.15 +/- 0.89 ng/ml) and parapneumonic effusions (4.7 +/- 0.697 ng/ml) when compared with pleural effusions secondary to other diseases. IL-8 levels were higher in empyema fluid than in parapneumonic effusions (p = 0.01). There was a significant correlation between IL-8 levels and the total numbers of neutrophils in empyema fluids (r = 0.80). Chemotactic activity for neutrophils was elevated in empyema fluid and the addition of IL-8 neutralizing serum decreased bioactivity by 32.22%. Malignant pleural effusions had the highest levels of MCP-1 (12.0 +/- 3.7 ng/ml) when compared with others. Cytology-positive pleural fluids (n = 10) had a higher level of MCP-1 than cytology-negative effusions (p = < 0.05). Malignant pleural fluid MCP-1 levels correlated (r = 0.70) with the absolute number of monocytes in the pleural fluid. Neutralization of monocyte chemotactic activity of malignant pleural fluid by specific neutralizing serum caused a 70.3% inhibition of bioactivity. Immunohistochemical staining of malignant pleural fluid localized antigenic MCP-1 to malignant cells. We conclude that both IL-8 and MCP-1 play major but not exclusive roles in the recruitment of neutrophils and monocytes from the vascular compartment to the pleural space.

Pleural infections: a clinical-radiologic review

Pleural space infection is a common disorder that may result from a wide variety of causes and is associated with a wide range of etiologic agents. The authors reviewed retrospectively records of 102 patients with discharge diagnoses of empyema and/or bronchopleural fistula. Chest radiographs and computed tomography closest to the time of initial diagnosis were evaluated separately. In 78 cases of empyema, the etiologies included primary pulmonary infections (49%), postsurgical (23%), traumatic (11.5%), intraabdominal pathology (5%), and unknown (11.5%). In 24 cases of bronchopleural fistulas, the etiologies were previous surgical procedures (37.5%), pulmonary infections (37.5%), traumatic (4%), and unknown (21%).

Empyema after pneumonectomy--empyema window or thoracoplasty?

369 pneumonectomies carried out within the years 1981 to 1988 and their empyema complications form the basis for a retrospective analysis to assess the outcome of treating pneumonectomy cavity empyema by window healing. During the same period 31 empyema after 322 pneumonectomies to treat bronchial carcinoma are investigated in more detail as far as their therapeutic modalities are concerned. 20 patients received a thoracic window. 18 of 31 patients (58%) could be cured, and 9 of these were in the thoracic window group. The hospital mortality of empyema patients after pneumonectomy amounted to 42%. In an historical comparison no progress could be recognized in the treatment of this septic complication.

Curschmann's spirals in pleural and peritoneal effusions

Curschmann's spirals were found in smears and cell block preparations of five spontaneously occurring pleural and peritoneal fluids. The spirals were similar to those seen in the respiratory tract, although generally much smaller. In three of the five cases, the fluids also contained mucus-secreting adenocarcinoma cells; it is postulated that the spirals formed from mucus secreted by these cells. In the other two cases, there was evidence of serosal inflammation; it is suggested that the spirals in these cases developed from submesothelial connective tissue mucosubstances that entered the serosal cavity through a mesothelium of increased permeability due to the inflammation. No simple explanation can be accepted as to the exact mode of spiral formation, which is presumed to be a complex physical and biochemical phenomenon.

Role of lung decortication in symptomatic empyemas in children

Despite appropriate antibiotics and pleural drainage, the condition of some children with empyema fails to improve. In a 5-year period, 10 children ranging in age from 2 to 16 years underwent lung decortication for a refractory, symptomatic empyema, which had developed 3 to 5 weeks after an initial pneumonic infiltrate. Responsible organisms included beta-hemolytic streptococci, Haemophilus influenzae, or Streptococcus pneumoniae in 6 children. Negative cultures were found in 4 children. The initial computed tomographic scan of the chest in 4 of 8 patients showed more than 75% limitation of lung expansion by the contents of the empyema cavity. In 4 other patients, an extensive pleural peel was seen on initial computed tomographic scan of the chest. Several studies also showed cystic lesions in the collapsed lung. Multiple computed tomographic scans in 3 patients confirmed the lack of clinical and chest roentgenographic improvement with conservative therapy. At decortication in each, the visceral and parietal pleural peel was completely removed, freeing the trapped lung. Two patients also had a concomitant lobectomy for a necrotic right upper lobe (1 patient) and left lower lobe (1). Clinical improvement was marked, with return of temperature, white blood cell count, and appetite to normal. Postoperative morbidity was minimal. Analysis of these patients in whom traditional conservative therapy failed suggested that the initial management during the early exudative phase was often delayed and was not aggressive enough from the standpoint of pleural drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

[Three cases of malignant lymphoma developing from chronic empyema wall]

Three patients with non-Hodgkin's lymphoma (NHL) involving the lung or chest wall are reported. All patients had tuberculous pleuritis or received artificial pneumothorax for pulmonary tuberculosis 30 years or more previously. The NHL of these patients developed in or close to the thickened pleura. Histologic examination showed diffuse large cell type (LSG classification) in all cases. Lymphomas of all cases were considered to have originated from B-cell lineage because their neoplastic cells expressed B1 (CD20) antigens. In no case the tumors were resectable, and chemotherapy or radiotherapy were performed. Two died of local NHL at 5 and 6 months respectively after diagnosis. One patient is still alive at 8 months after the first treatment for NHL. Early diagnosis is essential to improve the prognosis of these NHLs although it is difficult because of the co-existent pyothorax. Following features seemed to be useful for diagnosis: 1) chest pain or shoulder pain, 2) elevation of LDH level, 3) mass shadow in computed tomography, and 4) abnormal uptake of gallium 67. As precise assessment of tumor size is difficult because of the co-existent pyothorax and necrosis, follow-up studies by gallium scan or magnetic resonance imaging might be useful for proper treatment.

Parietal pleural changes in empyema: appearances at CT

The parietal pleura bordering pleural space collections was analyzed with computed tomography (CT) in 35 patients with thoracic empyema, 30 patients with malignant effusion, and 20 patients with transudatory effusion. Enhancement of the parietal pleura was present in 96% of the 25 patients with empyema who underwent contrast material-enhanced examinations. Of the 35 patients with empyema, 86% showed thickening of the parietal pleura, 60% showed thickening of the extrapleural subcostal tissues, and 35% showed increased attenuation of the extrapleural fat. None of the 20 patients with transudatory effusion showed these findings. Of the 30 patients with malignant effusion, eight patients (27%) showed chest wall changes similar to those of the patients with empyema. However, two-thirds of these patients had a recognized superimposed complication (ie, sclerotherapy). Contrast-enhanced CT appears to be sensitive to chest wall changes in patients with empyema. CT study of the parietal pleura may help suggest occult pleural space infections and may influence therapeutic decisions that vary with the stage of empyema.

Necrotising pneumonia and empyema due to Clostridium perfringens complicating pulmonary embolus

A fatal case of necrotising pneumonia due to Clostridium perfringens developing as a complication of pulmonary infarction is reported.

The histology of experimental pleural injury with tetracycline, empyema, and carrageenan

Models of pleural injury were established with intrapleural tetracycline, intrapleural carrageenan, and empyema in New Zealand White rabbits to evaluate histologically the pleural inflammatory response from 3 to 90 days. Both tetracycline and empyema models produced increases in the pleural connective tissue layers both above and below the fibroelastic membrane associated with angiogenesis and lymphangiogenesis. The influx of fibroblasts from the pleural surface into acellular fibrin strands formed adhesions between the visceral and the parietal pleurae. Injury to the mesothelial cell ranged from a cuboidal transition to total desquamation with the degree of mesothelial injury associated with the amount of fibrin adherence and the propensity toward fibrosis at 90 days. Intervention to promote the resolution of pleural inflammation without fibrosis should be directed toward preservation of the mesothelial surface, removal of pleural fibrin, and inhibition of fibroblast growth and chemotaxis.

Empyema necessitatis

Empyema necessitatis is the accumulation of pus in a small space in the pleural cavity, with subsequent rupture of the purulent material into the surrounding soft tissue. Drainage may occur into the breast, bronchus, mediastinum, esophagus, diaphragm, pericardium or retroperitoneum. Pus may even reach the flank, groin or thigh. Before antibiotics became available, empyema necessitatis was a complication of tuberculosis, fungal infections and various forms of pneumonia. Silent infections due to tuberculosis or fungus can still present as empyema necessitatis, even in healthy young adults.

[An unusual course of thoracic actinomycosis]

A 56-year-old farmer who had been suffering from exogenous allergic alveolitis developed, after a long prodromal period of illness, a granulocyte-rich pericardial effusion and bilateral pleural effusions in which Actinomyces aggregates were identified. Despite intensive treatment with clindamycin, erythromycin and tetracycline (he was allergic to penicillin) he died in septic shock.

Contained thoracic empyema presenting as an anterior chest wall abscess: empyema necessitatis revisited

Protean manifestation of pulmonary and pleural space infections can be expected in drug addicts. Because of the need to establish strict environmental protection for staff and patients, even simple drainage procedures should be performed in the operating room. Without testing, these patients should be considered as potential carriers of the AIDS virus. If a subcutaneous abscess is found to extend into the pleural space, drainage and full lung expansion are attempted through a limited rib resection. If this is unsuccessful, a full thoracotomy should be done to meet these surgical objectives.

Pleural exudate in a tropical hospital

In one hundred consecutive patients with non-purulent pleural exudates without apparent cause, the final diagnosis was tuberculosis in 58, malignancy in 20, pyogenic infection in four, cardiomyopathy in two, pulmonary infarction in one. The aetiology remained unknown in 15. The technique of "semi-open" pleural biopsy was performed under local anaesthesia. It accurately detected 70% of cancer and 69% of tuberculosis cases with a 9% complication rate and no mortality. Tuberculosis was seen at all ages but mainly between 20 and 39 yrs, where it represented 75% of cases. In this age group, malignancy was relatively rare: 10% of cases. In our environment of limited facilities, early chemotherapy trial for tuberculosis is justified for unknown pleural exudates in patients below the age of 40 yrs.

Pathology of pleural infections

The pleura is protected by several tissue boundaries of differing degrees of strength. Penetration of the pleural space by mediastinal infection occurs more easily than from the lung, which in turn occurs more easily than through the diaphragm or chest wall. Infectious organisms of all classes, including bacteria, viruses, fungi, and protozoa are capable of causing pleural infection. The basic tissue response in the pleura is similar to that seen in other tissues but is modified by the peculiar anatomy of the pleura, flat serosal surfaces in constant motion against each other. Most pleural infections are initiated in the lung. Some of the most spectacular pathologic lesions are caused by aspergillus where vasculoinvasive fungi cause infected infarcts that result in round visceral pleural lesions. These in turn result in "kissing lesions" of the parietal diaphragmatic surfaces which are of the same size and shape as the visceral pleural lesions, indicating attachment and splinting of the pleural surfaces in these loci. Studies in rabbit demonstrate rapid resolution of experimental empyema with a standardized series of pathologic responses. In uncomplicated empyema, the end result is an extremely thin, almost undetectable scar. Thick fibrotic pleural lesions suggest a complicated course with continuing infection.

Postmortem microbiological findings of two total artificial heart recipients

This report describes the postmortem microbiological findings and related gross pathology from two patients who had the longest survival after implantation of the Jarvik-7-100 total artificial heart. We documented extensive polymicrobial colonization at the site of the device and adjacent structures; however, the internal drive lines were remarkably free of bacterial colonization despite evidence of infection at the skin junction and in close proximity to the artificial heart. The polyurethane polymer (Biomer) on the external surface of the device was discolored and pitted in appearance and the Velcro material that attaches the two ventricles together was eroded. A nonspecific mass of tissue that was adherent to the device and to portions of the drive lines contained inflammatory cells, fibrinous debris, and colonies of microorganisms.

Sonographic guidance in diagnostic and therapeutic interventions in the pleural space

One hundred eighty-seven diagnostic and therapeutic interventional procedures in the pleural space were performed by using sonographic guidance. These consisted of diagnostic aspiration (118), drainage of malignant and nonmalignant effusions (41), empyema drainage (17), pleural sclerotherapy with tetracycline or bleomycin (7), and pleural biopsy (4). Diagnostic aspiration was performed with 20-gauge needles, and therapeutic and empyema drainages were performed by trocar technique with either a 7-French Sacks catheter or a specially designed empyema drainage catheter. Pneumothoraces were seen in 3% of the patients, and most of these were treated by the radiologist with placement of a Heimlich valve. We conclude that the use of sonography allows rapid localization of pleural fluid collections and instant monitoring of drainage of noninfected fluid collections and empyemas.

[Empyema of cavum septi pellucidi and cavum vergae--case report]

A case of an empyema of cavum septi pellucidi and cavum Vergae is reported. A 60-year-old male was admitted because of fever, chill shivering, and slight conscious disturbance four days after head trauma. CT scan on admission showed cavum septi pellucidi and cavum Vergae. Lumbar puncture revealed whitish cloudy CSF containing 12256/3 WBC. So he was treated with antibiotics under the diagnosis of suppurative meningitis. Five days after administration of antibiotics high fever went down and consciousness was cleared. But about 10 days later his conscious level was lowered again. The follow up CT demonstrated remarkable expansion of cavum septi pellucidi and cavum Vergae with enhanced cavity wall. Empyema of the cavums was suspected and stereotaxic operation was performed. 10 ml of yellowish pus was aspirated. Post operative course was uneventful. CT scan of 15 days after operation revealed a marked decrease in size of the cavums, which almost completely disappeared three months later. Case similar to this was not found to be reported. The mechanism of formation of empyema of cavum septi pellucidi and cavum Vergae after meningitis in this case is discussed.

Thoracic surgical problems in infancy and childhood

Thoracic surgical problems in infants and children range from congenital anomalies to acquired inflammatory problems. This article reviews the most common parenchymal, pleural, and mediastinal problems encountered in infants and children and presents recommendations for prompt and accurate diagnosis and therapy.