Advantages and disadvantages of Seldniger transthoracic drainage in purulent-destructive diseases of the lung and pleura in childhood

BACKGROUND

Suppurative-destructive diseases of the lung and pleura are prevalent kind of diseases occurring in children. They represent 9.1% of thoracic surgical diseases in this age. In such diseases, the pleural drainage is the most commonly used at present time. One of the methods is the transthoracic drainage by Seldinger.

MATERIAL AND METHODS

Over the period of 13 years (2000-2012), 101 children with different forms of acute purulent destructive processes of the lung and pleura were treated in the Department of Pediatric Surgery of the University Hospital "St. George "- Plovdiv. We used percutaneous (transthoracic) drainage (Seldinger method) in the case of three children with lung abscess complicated pleuropneumonia with empyema.

RESULTS

We achieved positive effect in treatment with all three children, without introducing additional operating procedures.

CONCLUSION

There is still no consensus regarding the surgical treatment of various forms of acute suppurative-destructive diseases of the lungs and pleura (ASDDLP). Some authors attach great importance to the puncture method of treating ASDDLP, whilst they recommend the application of another treatment in case of failure.

A renal transplant patient with intractable hiccups and review of the literature

Intractable hiccups in transplanted patients may be caused by various medical conditions including infections. We report a case of a 44-year-old man who suffered from intractable hiccups after cadaveric kidney transplantation. We identified 3 different hiccup periods with different causes: 1) steroid and anesthetics use, 2) severe ulcerose herpetic and mycotic esophagitis, and 3) pleuropneumonia caused by nosocomial methicillin-resistant Staphylococcus epidermidis and pulmonary abscess requiring thoracic surgery.

Destructive staphylococcal pleuropneumonia in a two-year-old boy with hyperimmunoglobulin-E syndrome

Hyperimmunoglobulin-E syndrome (HIES) is a rare immunodeficiency disorder that is characterized by elevated serum concentration of IgE, eosinophilia and severe, recurrent bacterial and fungal infections. Poor regulation of immune system is evident, with decreased production of cytokines, especially interferon. Production of specific antibodies to capsular polysaccharide antigens is decreased Skeletal malformations have been reported in these patients. They can be caused by excessive production of interleukin-4, which may lead to pathologic bony tissue resorption. Due to immune system deficiency and malformations of skeletal and connective tissue, HIES is a multisystem disorder. We present a patient with recurrent bacterial infections since the early age. At the age of two years he presented with severe destructive staphylococcal pneumonia with pleural effusion, pneumatocela formation and pneumothorax. The patient also had a dysmorphic face and skeletal malformations that were most evident at the head. The diagnosis of HIES was made on the basis of elevated serum concentrations of IgE, hypereosinophily, and decreased leukocyte function in vivo and in vitro. Family history of our patient showed an autosomal-dominant inheritance pattern of HIES.

[Differential diagnostics in thoracoabdominal syndrome]

The article discusses diagnostic difficulties in patients with acute abdominal pain. The author adduces data on the frequency of late diagnostics of pleuropneumonia and diaphragmatic pleuritis in patients with abdominal syndrome before admission, and in the admission department of an urgent aid hospital. The analysis of the causes of delayed diagnosis of lung and pleura diseases is exemplified with 2 clinical observations. The article also covers ways of prevention of diagnostic errors in patients with abdominal pain.

A hematogenic pleuropneumonia caused by postoperative septic thrombophlebitis in a Thoroughbred gelding

A 7-year-old Thoroughbred gelding was admitted to Equine Hospital, Korea Racing Association for evaluation and treatment of colic. Based on the size and duration of the large colonic and cecal impaction, a routine ventral midline celiotomy and large colon enterotomy were performed to relieve the impaction. Six days following surgery the gelding exhibited signs of lethargy, fever, inappetence and diarrhea. Eleven days following surgery, the jugular veins showed a marked thrombophlebitis. On the sixteenth day of hospitalization the gelding died suddenly. Upon physical examination, the horse was febrile, tachycardic and tachypnoeic. Thoracic excursion appeared to be increased; however, no abnormal lung sounds were detected. No cough or nasal discharge was present. Hematology revealed neutrophilic leukocytosis. Serum biochemistry was normal but plasma fibrinogen increased. In necropsy, fibrinopurulent fluid was present in the thoracic cavity. There were firm adhesions between visceral pleura and thoracic wall. White, mixed and red thrombi were formed in both jugular veins from the insertion point of IV catheter. Histopathological examination showed fibrinopurulent inflammation and vascular thrombosis in the lung. The pleura showed edematous thickening and severe congestion. The clinicopathological and pathological findings suggest that septic thrombi associated with septic thrombophlebitis metastasized into the pulmonary circulation and were entrapped in the pulmonary parenchyma and provoked pleuropneumonia.

[Hepatotoxic effect of etacizin in acute pneumonia]

The paper describes one acute toxic hepatitis event in a woman of 60 with pleuropneumonia and exudative pleurisy. She had been treated with ethacizinum in small dose. To solve the problem, antioxidant and drug with hepato protective action should be prescribed along with ethacizinum.

[Lemierre's syndrome: a case report]

We report a case of Lemierre's syndrome with a pleuropulmonary complication. Lemierre's syndrome is a rare etiology of lung abscess. The diagnosis is clinical and microbiological (anaerobic organisms). This syndrome associates an acute oropharyngeal infection with septic thrombophlebitis of the internal jugular vein (sometimes many days before the lung lesion) and pulmonary abscess formation. Clinicians should be aware of this syndrome that is fatal in 10% of patients, usually after delayed or missed diagnosis. The frequency of Lemierre's syndrome would be higher if antibiotics were given only to pharyngitis patients positive for streptococcus.

Pneumothorax in horses: 40 cases (1980-1997)

OBJECTIVE

To characterize pneumothorax in horses and to describe clinical signs, diagnostic testing, and clinical outcome of horses with pneumothorax.

DESIGN

Retrospective study.

ANIMALS

40 horses.

PROCEDURE

Medical records of horses with pneumothorax were reviewed to obtain information on signalment, history, clinical signs, diagnostic testing, treatment, and clinical outcome.

RESULTS

Horses developed pneumothorax secondary to pleuropneumonia (17 horses), open wounds of the thorax (9), closed trauma to the thorax (7), surgery on the upper portion of the respiratory tract (3), and surgery involving the thoracic cavity (1); 3 horses had pneumothorax of unknown cause. Clinical signs included tachypnea, dyspnea, cyanosis, lack of lung sounds on auscultation of the dorsal aspect of the thorax, fever, tachycardia, signs of depression or anxiousness, and cough. Radiography and ultrasonography were useful to definitively diagnose pneumothorax. Pneumothorax was bilateral in 47.5% (19/40) and unilateral in 42.5% (17/40) of horses; designation of unilateral versus bilateral was not recorded in the remaining 4 horses. Horses with pneumothorax secondary to pleuropneumonia more commonly had unilateral pneumothorax (64.7% for unilateral vs 29.4% for bilateral; not specified for 1 horse). Horses with pneumothorax secondary to pleuropneumonia were less likely to survive than horses with pneumothorax secondary to other causes (35.3 vs 69.6% survived, respectively).

CONCLUSIONS AND CLINICAL RELEVANCE

Pleuropneumonia is an important cause of pneumothorax in horses. Classic clinical signs of pneumothorax may not be evident. Radiography, ultrasonography, or both may be required for diagnosis. Prognosis for survival is better for horses with pneumothorax not associated with pleuropneumonia.

[Acute abdomen: consider also the thorax]

Three patients, 2 men aged 22 and 62 years en 1 woman aged 49, presented with symptoms of an acute abdomen. While infiltrative signs were described on radiodiagnostic images two patients underwent laparotomies. In all three subsequently the diagnosis of pneumonia was established and the patients made full recovery after antibiotic therapy. When a patient presents with symptoms of an acute abdomen, the possibility of an existing pneumonia should always be borne in mind. It is therefore recommended to make a chest radiograph with frontal and lateral view. In the presence of infiltrative signs the existence of pneumonia as the cause of abdominal symptoms should be considered in order to avoid unnecessary laparotomy.

Hemothorax under thrombolytic therapy with recombinant tissue: plasminogen activator (rt-PA) in a 16-year-old girl

We present the case of a 16-year-old girl with an extended thrombosis of the femoral and iliac vein and the inferior vena cava during pleuropneumonia; predisposing risk factors for thrombophilia were: use of contraceptives, nicotine abuse and congenital deficiency of antithrombin III (not previously diagnosed). Thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA; initial dose: 0.08 mg/kg/h) was started. 2 days later--after diagnosis of an extended hemothorax: 1500 ml blood were obtained after thoracocentesis, transfusion of packed red blood cells was necessary--rt-PA was stopped, with only heparin (400 U/kg/d) being administered. 36 h later--the thrombosis had not yet changed--the thrombolytic therapy with rt-PA was continued in a markedly reduced dose (0.015 mg/kg/d) with no further bleeding complications. 8 days later--after successful thrombolysis--t-PA was stopped, heparin was given for another 10 days, then cumarin was administered orally.

[Differential diagnosis of pleural effusion]

The results of following up 598 patients diagnosed as having pleural exudate were used to analyze the potentialities of complex radiation and clinical differential diagnoses of this abnormality. The authors identified 4 most common nosological entities (tuberculosis, pleuropneumonia, cancer, mesothelioma) among patients of diagnostic hospitals. The diagnostic algorithm should be derived by taking into account the current techniques applicable to each disease form. With this, valid diagnosis may be made in 98.5% of cases.

[A case of total complicated pleuropneumonia in someone who worked in the cleanup of the aftermath of the Chernobyl catastrophe]

A case is described that is not typical one, of total complicated pleuropneumonia in the liquidator K. of 1986 Chernobyl disaster aftermath. The dose of radiation he had been exposed to amounted to 25.75 rads. In 1989 he had acute right-sided pneumonia, in 1996-acute right-sided pleuropneumonia that got complicated by purulent meningoencephalitis. Examination of the patient revealed secondary T-cellular dysbalance.

Detection of parvovirus B19 in skin biopsy, serum, and bone marrow of a patient with fever, rash, and polyarthritis followed by pneumonia, pericardial effusion, and hepatitis

A previously healthy 33-year-old male patient presented with fever, rash and polyarthritis. Subsequently, he developed pleuropneumonitis, pericardial effusion and hepatitis. The diagnosis of parvovirus B19 infection was based on the detection of parvovirus DNA by PCR in a skin biopsy, bone marrow cells and serum. The patient had high parvovirus IgG antibody titres but remained negative for IgM at a three month follow-up, suggesting persistence of the virus or reinfection. It is concluded that detection of viral DNA is needed to verify a parvovirus B19 infection even in an immunologically healthy host.

Pleural effusion associated with acute and chronic pleuropneumonia and pleuritis secondary to thoracic wounds in horses: 43 cases (1982-1992)

Case records of 43 horses with pleural effusion associated with acute pleuropneumonia, chronic pleuropneumonia, or pleuritis secondary to a penetrating thoracic wound were reviewed to determine the predisposing factors, diagnosis, and treatment of this condition. Acute pleuropneumonia was diagnosed in 36 horses, the majority of which were Thoroughbreds (89%). Of 22 (61%) horses that were in race training at the onset of illness, 11 (31%) had been recently transported a long distance and 4 (11%) had evidence of exercise-induced pulmonary hemorrhage. Physical examination findings and hematologic data were nonspecific. The most consistent abnormality was hyperfibrino-genemia. Affected horses were treated with antibiotics, thoracic drainage, nonsteroidal anti-inflammatory drugs, and supportive care. Twenty-two (61%) horses were discharged from the hospital, with the mean duration of hospitalization for those discharged being 23 days. Nine (25%) horses were euthanatized and 5 (14%) died. Bacterial culturing of thoracic fluid resulted in growth in 30 of the 36 (83%) horses. The finding of anaerobic bacteria in thoracic fluid was not associated with a lower survival rate (62%) than the overall survival rate (61%). Four horses with chronic pleuropneumonia had a history of lethargy and inappetence for > 2 weeks. Actinobacillus equuli was isolated, either alone or in combination with other bacteria, from thoracic fluid of these 4 horses. Each horse was treated with broad spectrum antibiotics and made a rapid recovery. Three horses with acute pleuritis secondary to penetrating thoracic wounds also had nonspecific clinical signs, apart from the wound and a large volume of pleural effusion. Bacteriologic isolates from these horses differed slightly from those of horses with acute pleuropneumonia.

[Dissecting aortic aneurysm as a cause of fever of unknown origin]

Dissecting aortic aneurysm is a clinical syndrome commonly with a dramatic course and a fatal prognosis. The disease often has a fatal ending at the very beginning, a few hours after the onset. High temperature happens sometimes, but is rarely a dominant symptom. We presented a case of a patient with a long term febrile state caused by dissecting aortic aneurysm, where pleuropneumenia covered the real nature of the disease. It has been pointed out that dissecting of aorta should be thought of in patients with unclear febrile states, especially if they have difficulties in the area of thorax.

[Treatment of parapneumonic empyema in children]

A 31 case series of pleuropneumonia is presented, in a 7 year period. All patients were treated following same standards consisting of a pleural catheter insertion. Results support conservative treatment: short hospitalization and absence of psychological or physical traumas was achieved. Follow up is very good for all patients and none had invalidating consequences.

Pneumocystis carinii pleuropneumonia after aerosolized pentamidine prophylaxis

We observed an atypical Pneumocystis infection with spontaneous pneumothorax, bronchopleural fistulae, an apical cyst and Pneumocystis pleuritis after aerosolized pentamidine prophylaxis in an AIDS patient. These findings suggest a failure of pentamidine aerosol in controlling active Pneumocystis infection in peripheral pulmonary areas. A relapse of Pneumocystis carinii pneumonia (PCP) must be suspected when pneumothorax occurs during secondary prophylaxis with aerosolized pentamidine. It should always be confirmed by bronchoalveolar lavage or transbronchial or open biopsy. Cases presenting as atypical Pneumocystis pneumonia may additionally reveal extrapulmonary dissemination of Pneumocystis infection.

Pleuropneumonia

The historical, clinical, diagnostic, and therapeutic aspects of pleuropneumonia are reviewed with emphasis placed on aggressive treatment and ultrasound diagnosis. The common sequelae are described, and appropriate treatment recommendations are included. A favorable prognosis may be expected for horses receiving long-term treatment.

Cranial thoracic masses in the horse: a sequel to pleuropneumonia

The formation of cranial thoracic masses (CTM) as a sequel to infectious pleuropneumonia is described. Using ultrasound, masses were diagnosed subjectively as abscesses or loculations. Eight of 99 cases with pleuropneumonia had CTM. Clinical signs associated with the presence of a CTM included increased heart rate, jugular distention, forelimb 'pointing' and caudal displacement of the heart. Techniques used for diagnostic ultrasonographic examination of the cranial thorax are described. Five of the eight horses with CTM responded to conservative medical management; the other three required percutaneous drainage of the mass to relieve worsening signs of cardiac decompensation. Improvements in cardiovascular parameters were evident within 12 h of drainage. The indications for and limitations of invasive drainage of cranial thoracic masses are discussed.

[Floating right atrial thrombus as the cause of recurring pulmonary embolisms]

After an attack of pleuropneumonia a 25-year-old woman developed persistent dyspnoea due to pulmonary emboli, as demonstrated by scintigraphy. There was no clinical or phlebographic evidence of the peripheral venous system as the source. Two-dimensional echocardiography demonstrated a floating spherical tumour in the right atrium, attached to the interatrial septum and prolapsing into the right ventricle during ventricular diastole. Because of the risk of further thromboembolic episodes the tumour was removed operatively without any complication. It proved to be myxoma-like, 3 x 3 cm in diameter. Histologically it was a thrombus without evidence of myxoma. No further thromboemboli occurred under phenprocoumon anticoagulation.

Echocardiographic detection of an intact aneurysm in a horse

Two-dimensional real-time echocardiographic examination of a 3-year-old Thoroughbred gelding with pleuropneumonia revealed an intact aneurysm of the right sinus of Valsalva, which was confirmed at postmortem examination. The horse had no clinical signs associated with the aneurysm.

Cholesterol in pleural effusions. A diagnostic aid

In this prospective study of 70 patients with pleural effusion, the underlying disease could be identified in 62 cases. By predefined criteria, 31 of these effusions were classified as transudates and 31 as exudates. Pleural fluid protein content, LDH activity and cholesterol level were measured to investigate their utility in differentiating the exudates from the transudates. Protein and LDH levels, and their pleural fluid-to-serum ratios, resulted in erroneous classification of 11 to 15 percent of the effusions. Mean cholesterol level in malignant effusions was 94 mg/dl, 76 mg/dl in inflammatory effusions and 30 mg/dl in the transudates. Using a dividing line of 60 mg/dl to separate the exudates from the transudates, only 5 percent were incorrectly classified. Elevated cholesterol levels in exudates seem to be independent of the serum levels. Our findings indicate that the pleural fluid cholesterol level is a simple and cost-effective aid in differentiating exudative from transudative pleural effusions.

[Inappropriate antidiuretic hormone secretion syndrome associated with a pleuropulmonary infection]

A case of pleuropulmonary infection without a demonstrable causal agent associated to inappropriate secretion of antidiuretic hormone is reported. Although antidiuretic hormone levels were not measured, unequivocal indirect proof of elevated levels was present as evidenced by characteristic serum and urinary electrolyte abnormalities, other possible causes having been carefully ruled out. The hyposmolar clinical picture was refractory to conservative measures, and it was corrected only when a loculated empyema was surgically drained by way of thoracotomy. The literature on inappropriate secretion of antidiuretic hormone related to pleuropulmonary pathology is briefly reviewed. Particular emphasis is made on the pleural encapsulation in the present case as the factor responsible for perpetuation of pulmonary infection and origin of the hormonal disturbance.

Strain of mycoplasma associated with human reproductive failure

A strain of mycoplasma not previously described has been isolated from the chorion, decidua, and amnion of a patient who sustained a spontaneous abortion during the middle trimester. The fetal membranes exhibited an inflammatory reaction, but no evidence of other infectious agents, bacterial or viral, was noted. The T strain identified is not a classical mycoplasma; it differs in growth and nutritional requirements from the T strains previously characterized.