Empyema Necessitans Caused by M. kansasii

Abstract

SESSION TITLE: Fellow Case Report Poster - Disorders of the Pleura SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Empyema necessitans is a rare complication of untreated empyema thoracis. Reported cases due to nontuberculous mycobacteria (NTM) are exceedingly rare. There have been no previous cases of M. kansasii causing empyema necessitans reported in the literature. CASE PRESENTATION: This is a 59 year old man with a history of illicit drug use presenting with a fluctuant nodule on his left anterolateral chest (Fig 1). 2 years prior to this presentation, he was diagnosed with pulmonary M. kansasii infection, but was lost to follow up. 3 months prior, he was evaluated for cough associated with hemoptysis and dyspnea and sputum smears for AFB again grew M. kansasii. After questionable compliance with a regimen that included rifampin, isoniazid and ethambutol, our patient noted the aforementioned chest wall nodule. Fluid from the nodule stained positively for AFBs which were demonstrated to be M. kansasii. CT of the chest revealed a broncho-pleuro-cutaneous fistula (Fig 2). Given his clinical stability and improved symptoms with medical management alone, surgical intervention was avoided. DISCUSSION: Empyema necessitans is characterized by dissection of pus through the parietal pleura, chest wall and surrounding tissues. M. kansasii rarely causes empyema and has never been associated with empyema necessitans. Pleurocutaneous fistulas are much more commonly associated with MTB and Actinomyces spp, but have only rarely been reported in association with other NTM.1 Patients infected with M. kansasii typically have a good prognosis and are responsive to antimycobacterial drugs. Therefore, late complications such as empyema necessitans rarely occur.2 As with our patient, empyema necessitans does not necessitate surgical intervention and often responds to drainage and antibiotic therapy.3 CONCLUSIONS: This case demonstrates that less aggressive nontuberculous mycobacteria such as M. kansasii are capable of causing empyema necessitans if not effectively treated. Physicians should be aware of this rare complication of mycobacterial infection, especially in difficult to treat patient populations. Reference #1: Jo KW, Kim JW, et al. A case of empyema necessitatis caused by Mycobacterium abscessus. Respir Med Case Rep. 2012; 6:1-4. Reference #2: Maliwan N, Zvetina JR. Clinical features and follow up of 302 patients with Mycobacterium kansasii pulmonary infection: a 50 year experience. Postgrad Med J. 2005; 81: 530-3. Reference #3: Gomes MM, Alves M, et al. Empyema necessitans: very late complication of pulmonary tuberculosis. BMJ Case Rep. 2013 Dec 10; 2013. DISCLOSURE: The following authors have nothing to disclose: Nathaniel Soriano, Charles Lanks, Jeffrey Phillips No Product/Research Disclosure Information