Case Of Empyema Research Articles

Subdural Empyema in a 13-Year-Old Male With History of Head Trauma: A Case Report.

Subdural empyema is rare but serious intracranial infection characterized by accumulation of pus between dura mater and arachnoid layer. The spread of infection is typically originating from sinusitis, otitis media, or osteomyelitis. Early diagnosis by radiological imaging and prompt treatment, either by surgical intervention or by broad spectrum antibiotics are crucial to prevent life threatening complications. Here, we present a case of subdural empyema in a 13-year-old male managed by surgical drainage and intravenous antibiotics.

Clinical characteristics and decortication outcomes of bacterial, tuberculous and fungal pleural infection.

<sec><title>BACKGROUND</title>Pleural infection leading to empyema is a severe condition marked by accumulated infected fluid in the pleural space. Pneumonia with parapneumonic effusion is its most common precursor. The global incidence of pleural infections has increased significantly, with existing literature mainly focusing on bacterial empyema, leaving a gap in comparative analyses.</sec><sec><title>METHOD</title>A retrospective review was conducted on 561 cases of bacterial, tuberculous, and fungal empyema over a 10-year period. The study compared and analysed overall survival rates, 30-day mortality rates after surgery, and clinical characteristics.</sec><sec><title>RESULTS</title>The three empyema groups displayed distinct clinical characteristics. Fungal empyema had the worst overall survival compared to bacterial and tuberculous empyema, which had similar survival rates based on 30-day and 2-year mortality. Fungal empyema, advanced age, and high Charlson Comorbidity Index (CCI) score were independent predictors of poor prognosis.</sec><sec><title>CONCLUSION</title>Fungal empyema has the highest mortality rate post-decortication surgery. Advanced age and high CCI score are independent predictors of poor prognosis.</sec>.

A Global Bibliometric Analysis of the Top 100 Most Cited Articles on Early Thoracotomy and Decortication in Pleural Empyema.

Most pleural empyema cases are linked to pneumonia, a substantial fraction of patients present with empyema without any association to pneumonia. The occurrence of empyema caused by tuberculosis (TB) is increasing in regions where TB is prevalent. In May 2024, a bibliometric analysis was conducted involving the screening of 7,620 articles sourced from Google Scholar. Google Scholar was selected for its comprehensive nature, encompassing articles indexed in prominent databases like Web of Science, Scopus, and PubMed. This allowed access to significant studies that might be overlooked if they were not indexed by these databases. Articles were selected based on their citation count and specific inclusion criteria, focusing on early thoracotomy and decortication in pleural empyema. Two authors (VB and MK) independently conducted a thorough screening and data collection. The hundred top articles published from 1945 to 2015, garnered a total of 16,928 citations. These articles were written by 93 distinct first authors from 22 countries and 83 institutions, and were featured in 35 journals. The primary categories of literature included those describing the disease characteristics, features, causes, and types of pleural empyema, as well as various treatment modalities and management strategies, each constituting 37% of the literature. Additionally, pediatric empyema was a focus in 11% of the articles. The present analysis highlights publication trends, identifies gaps in the literature, and suggests areas for future research, serving as a valuable resource for guiding upcoming studies on early thoracotomy and decortication in pleural empyema.

Rare Case of Fusobacterium necrophorum Bacteremia and Pleural Empyema Originating from a Burn Ulcer in a 16-Year-Old Female Patient

Rare Case of Fusobacterium necrophorum Bacteremia and Pleural Empyema Originating from a Burn Ulcer in a 16-Year-Old Female Patient

Severe Invasive Pneumococcal Disease Caused by Serotype 19A in Children Under Five Years in Tāmaki Makaurau Auckland, Aotearoa New Zealand.

Increases in childhood invasive pneumococcal disease (IPD) have been reported in several countries following the easing of COVID-19 pandemic mitigations. In Aotearoa New Zealand (AoNZ), a surge in IPD is occurring in young children concurrent with changes in pneumococcal vaccines and declining immunization coverage. We sought to examine epidemiologic and clinical features of IPD among children under 5 years in a large urban region of AoNZ in the 3 years post-COVID-19. Demographic, clinical and laboratory data were collated from children under 5 years with Streptococcus pneumoniae identified from normally sterile sites between January 1, 2021, and December 31, 2023, in Tāmaki Makaurau Auckland, AoNZ. We identified 93 episodes of IPD (annual incidence of 18-40 cases per 100,000 population per year). Serotype was identified in 68 episodes and 46 (68%) were serotype 19A. Incidence was higher in Pacific children compared with non-Māori, non-Pacific children (incidence rate ratio: 2.3; 95% confidence interval: 1.4-3.7). Bacteremia occurred in 65 (70%) episodes, empyema in 47 (51%), meningitis in 11 (12%) and hemolytic uremic syndrome in 7 (7.5%). All cases of hemolytic uremic syndrome and empyema were only among children with serotype 19A. Two children died, both had serotype 19A, and 13/91 survivors (14%) experienced serious sequelae. The use of the pneumococcal conjugate vaccine with lower valency and easing of COVID-19 containment measures each may have contributed to an increase in IPD in AoNZ. Serotype 19A is associated with empyema and causes severe disease in young children. Urgent efforts are required to improve PCV13 coverage in AoNZ.

An Australian Single-Center Cohort of Pediatric Empyema: Incidence, Pathogens and Disease Severity, and the Interaction of the COVID-19 Pandemic.

Empyema is the most common complication of pediatric community-acquired pneumonia, posing a significant morbidity to children. Clinicians have observed an increase in empyema rates and acuity in the years following the COVID-19 pandemic. This retrospective analysis of children managed for empyema in a tertiary pediatric hospital, aimed to compare the incidence and describe the clinical characteristics prepandemic and postpandemic (2017-2023). There were 222 empyema cases, with a median age of 3 years (0.3-15 years). The majority (87.8%) of cases were managed with a chest drain and fibrinolytics. The remaining underwent minimally invasive video-assisted thoracoscopic surgery. Admissions postpandemic were associated with significantly longer lengths of stays (14 vs 12 days, P ≤ 0.001), higher rates of pediatric intensive care unit admissions (32% vs 26%, P = 0.045), and they required higher level of care (inotropes, noninvasive and invasive ventilation). There were also significantly higher rates of Streptococcus pyogenes (28% vs 7%, P ≤ 0.001), while rates of other organisms were not significantly different. We also noted a significant reduction in immunization rates post-pandemic (95.8% vs 83.1%, P < 0.01); however, there was no significant difference in S. pneumoniae serotypes between epochs. This study demonstrates an increased rate and severity of pediatric empyemas in the post-pandemic period. We propose that the increase was secondary to the increased rates of S. pyogenes seen in the postpandemic period. This rise in infection rates may be alleviated with nonpharmacologic measures aimed at reducing transmission; however, such measures are not sustainable and should be avoided.

Subdural empyema—a rare complication of chronic otitis media: a case report

BackgroundSubdural empyema is an extremely rare and fatal intracranial complication of chronic otitis media. Due to its rarity and vague symptoms, it is often diagnosed late if not completely missed; specially in developing countries where the diagnostic modalities are hardly available or accessible. To the best knowledge of the authors, this is a preliminary reported case of subdural empyema as a complication of chronic otitis media in Eritrea. It aims to provide vital information on the clinical presentation, preferred diagnostic modalities, and the proper management of such cases.Case reportAn 8 years old female patient from the Rashaida ethnic group presented with fever, right ear purulent discharge, right post-auricular swelling, and altered mental status. Prior to her admission, she had history of recurrent purulent discharge from her right ear for almost 2 years, and had been diagnosed with chronic otitis media. Upon admission her GCS was 13/15 which later on deteriorated to be 3/15 on day 3. MRI was done and showed a right fronto-tempo-parietal subdural empyema with mass effect, shifting the midline to the left. She was immediately started on empirical broad-spectrum antibiotics. After the diagnosis was made, craniotomy was done, and 30 ml of pus was removed from the subdural space. Culture and sensitivity of the pus obtained intraoperatively was done but produced no yield. Hence, she was continued on the empirically started antibiotics. The patient’s condition was well improved by post-operative day 4.ConclusionIt is important to have a high index of suspicion of intracranial complications in patients with history of chronic otitis media or other otologic complaints, who present with neurologic manifestations. Subdural empyema still being uncommon even among the intracranial complications of COM, it is often missed. Hence, timely diagnosis with MRI, immediate surgical evacuation of the empyema along with the prolonged administration of broad-spectrum antibiotics is highly recommended.

A case report of empyema caused by Enterococcus gallinarum

BackgroundEnterococcus gallinarum is an infrequently intestinal symbiotic pathogen associated with nosocomial infection in immunocompromised individuals. To date, rare cases of pulmonary infection attributable to Enterococcus gallinarum were reported. Herein, we presented the first case of empyema resulting from Enterococcus gallinarum infection.Case presentationAn 81-year-old male presented with fever and dyspnea upon admission. Chest CT scan and thoracic ultrasonography confirmed the presence of right pleural effusion. Thoracoscopy revealed extensive adhesion, purulent fluid, and necrotic materials within the thoracic cavity. Enterococcus gallinarum was identified through pleural effusion culture. The patient underwent an intrathoracic injection of urokinase along with thoracic drainage. Following surgery, He took oral linezolid for over one month. Undergoing comprehensive treatment, the patient exhibited favorable recovery.ConclusionsWe reported the first case of empyema due to Enterococcus gallinarum infection. It should be suspected in patients with impaired immune function and invasive therapies, without responding to conventional anti-infectious treatment.

Management of patient with Fusobacterim nucletum related pleural empyema: intrapleural antibiotic therapy can be considered for salvage therapy

Pleural empyema can lead to significant morbidity and mortality despite chest drainage and antibiotic treatment, necessitating novel and minimally invasive interventions. Fusobacterium nucleatum is an obligate anaerobe found in the human oral and gut microbiota. Advances in sequencing and puncture techniques have made it common to detect anaerobic bacteria in empyema cases. In this report, we describe the case of a 65-year-old man with hypertension who presented with a left-sided encapsulated pleural effusion. Initial fluid analysis using metagenomic next-generation sequencing (mNGS) revealed the presence of Fusobacterium nucleatum and Aspergillus chevalieri. Unfortunately, the patient experienced worsening pleural effusion despite drainage and antimicrobial therapy. Ultimately, successful treatment was achieved through intrapleural metronidazole therapy in conjunction with systemic antibiotics. The present case showed that intrapleural antibiotic therapy is a promising measure for pleural empyema.

Large-bore Chest Tube Insertion: Seldinger Technique over Two Guidewires.

Large-bore chest tube insertion is commonly performed using the trocar technique and blunt dissection; however, large-bore chest tube can cause severe visceral injury due to penetration, which is a life-threatening complication. Conversely, small-bore chest tubes can be safely inserted using the Seldinger technique; however, small-bore chest tubes are prone to blockage, especially in empyema cases. Therefore, this study aimed to demonstrate large-bore chest tube insertion using the Seldinger technique over two guidewires following image-guided puncture. We started performing large-bore chest tube insertion using the Seldinger technique over two guidewires following image-guided puncture in February 2022. Demographic data and procedural details, such as chest tube size, dilator size, procedure time, and type of image-guided puncture, of patients who underwent this procedure between February 2022 and March 2023 were retrospectively reviewed. Technical success was defined as the successful drainage of the pleural cavity. This method was used for performing ten procedures in nine patients who presented with empyema, pneumothorax, and pulmonary fistula. The insertion of a large-bore chest tube with a size ranging from 18- to 24-French was successfully performed in all cases without any complications. The median procedure time was 17.5 (first quartile-third quartile, 13.5-28.0) min. Large-bore chest tube insertion using the Seldinger technique over two guidewires may be used as an alternative to conventional methods.

Eikenella corrodens isolated from pleural effusion: A case report

BACKGROUND The bacterium Eikenella , classified as a gram-negative member of the phylum Proteobacteria, is distinguished by its rarity, corrosive nature, facultative anaerobic properties, and conditional pathogenicity. It represents the sole species within its genus-Eikenella corrodens (E. corrodens )-and can be found colonizing both human and animal oral and nasopharyngeal regions. Additionally, it occasionally inhabits the gastrointestinal or urogenital tracts. However, its slow growth rate can be attributed to its high nutritional requirements. However, there is an uneven distribution of construction and diagnostic capacity in China which poses undeniable challenges for the clinical examination and analysis of this case, especially in the basic hospitals. CASE SUMMARY Here we presented a case of empyema associated with E. corrodens infection in a 67-year-old male patient without any previous history of infectious diseases in our primary hospital in Dongguan district of China. The patient was admitted due to recurrent worsening cough, sputum production, and dyspnea for 3 d, which had persisted for over 20 years. Moreover, the patient experienced a one-hour episode of unconsciousness. Upon admission, immediate comprehensive examinations were conducted on the patient which subsequently led to his admission to the intensive care unit. Meanwhile, the patient presented with drowsiness and profuse sweating along with bilateral conjunctival edema observed during initiation of non-invasive ventilation, suggesting empyema. A significant amount of coffee-colored malodorous pleural fluid was drained during the procedure above and sent to the laboratory department for inspection. Finally, laboratory culture results confirmed the presence of E. corrodens infection in the pleural fluid sample. The patient received antimicrobial therapy until died on day 22 in the hospital. CONCLUSION In this report, we presented a case of empyema associated with E. corrodens infection. Multiple courses of morphological examination, viable culture analysis, and biochemical identification revealed its difficulties in detecting distinctive characteristics, as well as a detection model worth promoting. It’s just that there were still certain deficiencies in terms of morphological assessment, biochemical identification, and drug susceptibility testing.

Presumed intracranial and spinal subdural empyema secondary to periorbital abscesses in a golden retriever

AbstractIntracranial and spinal subdural empyema was presumptively diagnosed in a 2‐year‐old golden retriever secondary to periorbital abscesses. The patient initially presented to the referring veterinarian for right eye conjunctivitis, intermittent left head turn and reluctance to eat on the left side. The patient then suffered neck trauma from a rope, developing neck pain, left‐sided conscious proprioceptive deficits and right‐sided Horner's syndrome. Most signs resolved with medical management at the referring veterinarian, but neck pain persisted. Severe acute neurological deterioration occurred before presentation at our hospital, culminating in decerebrate rigidity and opisthotonos. Neurological exam revealed multifocal intracranial disease. Magnetic resonance imaging showed periorbital abscesses and extensive intracranial and cervical spinal subdural empyema. The owners elected for euthanasia and declined postmortem examination. Cerebrospinal fluid sampled immediately postmortem confirmed empyema. This is the first report of a presumed case of intracranial and cervical spine subdural empyema caused by periorbital abscesses in a dog.

Successful treatment with fenestration followed by daily decortication and negative-pressure wound therapy for acute exacerbation of chronic empyema: a case report.

Most cases of chronic empyema are caused by acute thoracic empyema or tuberculous pleuritis. Open thoracotomy and decortication are traditional treatments for chronic empyema. However, some cases, such as those with thick calcifications around a large cavity, may be difficult to decorticate in a single surgery. We successfully treated a case of chronic empyema with a large cavity surrounded by a thick calcified membrane that was peeled off gradually each day through fenestration of the thoracic cavity with negative-pressure wound therapy (NPWT). The patient was a 47-year-old man who had undergone thoracic drainage for left post-pneumonia empyema at another hospital 10years previously. He presented to our hospital with a fever of 39°C, bloody sputum, and severe fatigue for 3days. Computed tomography showed a 9-cm mass shadow in the left intralobar space and an adjacent 21 × 15 × 9-cm fluid-filled calcified unilocular cavity up to 5mm in thickness. He underwent thoracic drainage for fluid, and empyema was suspected; the fluid was foul-smelling and purulent. The patient did not improve with antibiotics and intrathoracic lavage; therefore, thoracoscopic decortication was performed. The thoracic cavity had a thick calcified membrane filled with dark-red slurry resembling old blood. We attempted decortication; however, the calcified membrane was difficult to remove. Two drains were used for the pleural lavage. However, no improvement was observed with intrathoracic lavage and drainage; therefore, a fenestration was performed. The calcified membrane was peeled off each day for 3months. Gradually, granulation increased and the inflammatory reaction improved. After NPWT, the empyema cavity gradually shrank to 8cm × 6cm × 2cm. A latissimus dorsi flap closure was performed, and the patient was discharged. This is an informative report on the daily decortication of a highly calcified purulent membrane using NPWT in a patient with chronic empyema. The description of this method will aid in the management of patients with chronic empyema and thick calcified membranes.

Actinomyces turicensis: a peculiar case of empyema after COVID-19 in a patient with ulcerative colitis

Actinomyces species are recognized as common mucosal bacteria in humans and as a newly discovered source of infection. Since its discovery in 1995, the subspecies Actinomyces turicensis has been reported as the causative pathogen of numerous infections. Only two instances of A. turicensis-related empyema, however, have been documented in the literature as of late. We report a unique case of polymicrobial empyema caused by A. turicensis shortly after a COVID-19 without any clear risk factors for anaerobic aspiration, along with a brief review of the literature. Tetracycline was successfully used for the first time to treat A. Turicensis empyema, following chest drainage.

Prognostic Markers of Acute Suppurative Lung Disease

The mortality rate among patients with acute suppurative lung diseases (ASLD) in the ICU reaches 30%. Early, pathogenetically relevant biomarkers are needed to ensure personification and better efficacy of ASLD treatment. Numeric variations in the counts of immune system cells in patient’s blood can be viewed as such candidate biomarkers.The aim of the study. Identification of potential markers predicting ASLD outcome after community-acquired pneumonia and COVID-19.Materials and methods. The study included 216 in-hospital patients aged 18-87 with ASLD after community-acquired pneumonia with (N=81) and without (N=135) COVID-19 history.Results. Patients survival after COVID-19 was linked to lymphocyte count on Day 1 of hospital stay (hazard ratio, HR=5.9 95%CI 0.9–37.4; P=0.0188, log-rank test). In patients who had not have COVID-19, a difference in survival was associated with lymphocyte (HR=2.9 95%CI 1.0–8.4; P=0.0184, log-rank test; N=135), and monocyte counts (HR=2.7 95% CI 0.8–9.5; P=0.0196, log-rank test) on Day 1 of hospital stay. Patients’ survival after COVID-19 infection depended on SII (systemic immune-inflammation index. HR=9.3 95%CI 1.7–49.8; P=0.0124, log-rank test; N=81, SIRI (systemic inflammatory response index, HR=7.2 95%CI 1.4–36.6; P=0.0339, log-rank test; N=81) and NLR (neutrophil-to-lymphocyte ratio, HR=9.6 95%CI 1.8–52.0; P=0.0108; log-rank test; N=81) values on Day 1 of hospital stay. In patients who did not have COVID-19 SII values had no influence on survival.Conclusion. The lymphocyte count makes it possible to predict outcomes of pleural empyema, regardless of patient’s history of COVID-19, i. e. a decrease in the lymphocyte count below 1.2×10⁹ in 1 L is associated with fatal outcome. Monocyte count carries prognostic information for cases of pleural empyema without previous COVID-19 infection. As for the relative indicators, SIRI, SII and NLR values measured on Day 1 in the hospital were predictors of ASLD outcome only in patients after COVID-19 infection, i. e., higher values were associated with increased risk of death, with NLR index being the most informative. Overall severity of illness above 10 scores by CIRS was associated with an unfavorable ASLD outcome, regardless of patient’s history of COVID-19.

186 Outbreak of Bacterial Subdural Empyema in Pediatric Patients After Relaxation of COVID-19 Non-pharmaceutical Interventions (NPIs)

INTRODUCTION: Non-pharmaceutical interventions (NPIs), in response to the COVID-19 viral pandemic altered viral transmission. In addition, endemic viral strains (influenza, RSV, etc) also experienced unprecedentedly low infection rates. Endemic viral infections typically followed seasonal outbreak spikes, but these spikes were noticeably absent in the COVID-19 control period. After many COVID-19 restrictions were ceased, there was an unusually high spike in endemic viral infections. Many COVID-19 measures were relaxed in the early/middle part of 2021, and we noted a sharp increase in post-viral, complicated sinusitis/subdural empyema cases. METHODS: Data collection was via retrospective chart review of subdural empyema cases at our institution. “Post-viral” was defined as positive viral test or VURI symptoms within 30 days. RESULTS: Our group previously published our case series on the management of subdural empyema. That served as an historical cohort of 16 patients and 23 procedures over an 8 year period (July 2013-June 2021). During the previous academic year, July 2021 to June 2022, there were a total of 14 patients and 19 surgeries, which nearly doubles the previous 8 years combined. The current academic year (to date) has had 9 empyema patients and 12 surgical cases. 100% of patients in the previous 2 years has had historical symptoms of viral URI symptoms or positive viral URI testing within 30 days. None were documented positive for COVID-19. In less than 2 years since many NPIs were lifted, post-viral, bacterial empyema cases have increased dramatically by a fold of 2.56. CONCLUSIONS: NPIs may have created an endemic viral “immunity gap” and an immunologically susceptible population, and thereby could have contributed to a sharp increase in bacterial subdural empyema.

Costal cartilage as a promising technique for large bronchial fistula closure in fistulous empyema: a case report

BackgroundThere is no high level of evidence for the treatment of fistulous empyema. We report here a promising technique for closure of a bronchopleural fistula using costal cartilage as a bronchial embolus.Case presentationThe patient is a 79-year-old man. A computed tomography scan diagnosed a fistulous empyema associated with perforation of lung abscess of right middle lobe. After thoracoscopic curettage of the right empyema cavity, right middle lung resection and intercostal muscle flap coverage over the bronchial stump were performed. Seven months after the surgery, a bronchopleural fistula developed. Bronchoscopy revealed fistulas in the middle lobe bronchus and B3b. After the open window thoracostomy, the empyema cavity was cleaned up. The empyema cavity remained from the anterior to the lateral thoracic region of the second to fourth ribs. A part of the second through fourth ribs that formed the ceiling of the pleural empyema cavity was removed to create space for skin and thickened parietal pleura to fill the cavity. The costal cartilage obtained from the rib resection was trimmed and harvested to fit into the diameter of the bronchopleural fistula. The free costal cartilage was sutured and fixed with five stitches with 3-0 PDS. The visceral pleura was covered with the thickened parietal pleura and skin and fixed airtight. To maintain a tight seal, a Blake® silicone drain was inserted between the visceral pleura and the thickened parietal pleura, and a suction reservoir was utilized to sustain negative pressure. The drain was removed on the 21st day. As of 21 months postoperatively, the skin and thickened parietal pleura flap has maintained its integrity, and there has been no evidence of pus or recurrence of air leaks.ConclusionIn the case of a fistulous empyema extending anteriorly, costal cartilage can be easily harvested, making it a promising option as a lid for fistula closure.

Empyema necessitans caused by methicillin-resistant Staphylococcus aureus: a case report and literature review

BackgroundEmpyema necessitans (EN) is a rare condition characterized by pleural infection with pus spreading into adjacent soft tissues. Although Mycobacterium tuberculosis and Actinomyces israelii are common causative agents, methicillin-resistant Staphylococcus aureus (MRSA) is relatively rare, but it is associated with high mortality in empyema cases. We aimed to report a unique case of EN caused by MRSA and present a literature review to better understand this rare condition.Case presentationA 69-year-old man with a history of right ureteral stone presented with fever and left anterior thoracic pain. A physical examination revealed redness and swelling in the left thoracic region. Imaging studies confirmed EN with fluid accumulation around the sternocostal joint of the left first rib. MRSA was identified from blood and pleural fluid cultures. The patient received antimicrobial therapy, and a chest tube was inserted for drainage. Despite initial improvement, vertebral osteomyelitis was diagnosed on day 17. The antimicrobials were subsequently terminated after 6 weeks, but vertebral osteomyelitis recurred, and treatment was resumed and completed on day 215.ConclusionEN caused by MRSA is rare, and the literature review revealed 14 cases from human sources. Positive blood cultures were observed in 40% of cases, and metastatic infections were present in 30% of cases. Osteomyelitis was the most common type of metastatic lesion. All the patients underwent drainage. Patients with MRSA-associated EN frequently develop disseminated lesions and should therefore be carefully examined. Moreover, appropriate treatment with antibiotics and drainage is necessary for a good prognosis. Although the prognosis appeared to be favorable in our review, publication bias and treatment challenges for metastatic infections should be considered.

Benefit of intrapleural fibrinolytic therapy in the treatment of complicated parapneumonic effusion and empyema.

Our study aimed to assess the benefit of intrapleural fibrinolysis before resorting to surgery to treat complicated parapneumonic effusion and empyema. We conducted a retrospective and descriptive study, including all patients hospitalized in the intensive care unit (ICU) of the Abderhaman Mami hospital, Tunisia for empyema treated with instillation of intrapleural fibrinolytic therapy between the 1st January 2000 and 31st December 2016. In all patients, empyema was diagnosed on clinical features, imaging findings (chest X-ray, thoracic echography and/or computed tomography (CT), and microbiological data. The fibrinolytic agent used was streptokinase. The efficiency of intrapleural fibrinolytic therapy was judged on clinical and paraclinical results. Among 103 cases of complicated parapneumonic effusion and empyema, 34 patients were included. The mean age was 34 years [15-81] with a male predominance (sex ratio at 2.77). Median APACH II score was 9. Fifty (50%) of the patients (n=17) had no past medical history; addictive behavior was described in 17 patients (50%). All patients were admitted for acute respiratory failure and one patient for septic shock. Pleural effusion was bilateral in 7 patients. Bacteria isolated were Streptococcus pneumonia (6 cases), Staphylococcus aureus (3 cases, including one which methicillin-resistant), Staphylococcus epidermidis (1 case), anaerobes (5 cases), and Klebsiella pneumoniae (1 case). First-line antimicrobial drug therapy was amoxicillin-clavulanate in 20 patients. A chest drain was placed in all cases in the first 38 hours of ICU admission. The median number of fibrinolysis sessions was 4 [2-9] and the median term of drainage was 7 days [3-16]. No side effects were observed. Video-assisted thoracoscopic surgery was proposed in 5 patients. The median length of hospitalization stay was 15 days [6-31]. One patient died due to multi-organ failure.

Fungal empyema thoracis, a rare but an emerging entity: a retrospective case series from Pakistan.

Fungal empyema is a rare entity which is associated with high mortality. It is mostly seen in immune-compromised hosts. However, there is limited data available on fungal empyema from developing countries regarding risk factors, treatment, and outcome. This study was conducted to determine the risk factors, clinical features, treatment, and outcome of fungal empyema. A retrospective observational study was performed on proven fungal empyema cases, admitted at Aga Khan University Hospital, Karachi, Pakistan during January 2018 to May 2021. We excluded all those patients with polymicrobial bacterial and fungal empyema or with negative pleural fluid cultures. A preformed questionnaire was filled out for each case. A total of 26 patients were diagnosed with fungal empyema with a mean age of 43.6 ± 20.3 years. Of these, 16 (61.5%) patients were male. Diabetes mellitus was the most frequent comorbidity (n = 11, 42.3%), followed by hypertension (n = 9, 34.6%), malignancy (n = 6, 23.1%), and asthma (n = 1, 3.8%). Ten (38.5%) patients had multiple comorbidities. Candida spp. was isolated in 21 (80.8%) patients and Aspergillus spp. in 7 (26.9%) patients. Fusarium spp. was isolated from one (3.9%) patient. Video-assisted thoracoscopy surgery was done in 14 (53.8%) patients and 12 (46.1%) patients were managed with tube thoracostomy. Twenty-one (80.8%) patients received antifungal agents. Overall, in-hospital mortality was 38.5% (n = 10) and all patients developed respiratory failure. Clinical improvement was seen in 16 (61.5%) patients. Our data suggest that fungal empyema has a poor outcome as almost one-third of our patients died. Early diagnosis and intervention can improve outcome.