Case Of Empyema Research Articles

Uniportal video-assisted thoracoscopy is a safe approach in patients with empyema requiring surgery.

BackgroundEmpyema is a well-known complication of pneumonia, with high morbidity and mortality rates. This warrants direct treatment either with antibiotics and chest tube drainage or surgery. With less invasive surgical approaches such as uniportal video-assisted thoracoscopic surgery (uVATS), surgical intervention gets a more prominent role early on in the treatment of empyema. The aim of this study was to compare uVATS with the complete VATS (cVATS) approach in empyema, with respect to postoperative complications, hospital length of stay and mortality.MethodsAll cases of empyema that were treated surgically in our hospital between 2006 and 2019 were included in a retrospective database. The preferential surgical approach changed from cVATS from 2006 to 2015, towards uVATS from 2016 and on, based on the experience of the surgical team. The database included pre- and postoperative data, as well as peropartive characteristics.ResultsOne hundred and thirty-seven patients were treated with cVATS and 49 with uVATS. Apart from a slightly reduced kidney function in the uVATS group (57.3±6.3 vs. 71.4±17.2 mL/min/1.73 m2, P≤0.001), there were no significant baseline differences in patient characteristics. The duration of uVATS was comparable to cVATS (70±17 vs. 56±23 min, P=0.240), and with low per- and postoperative complications. The postoperative hospital stay was equal in both groups (19±13 vs. 20±15 days, P=0.320). There were no statistically significant differences in postoperative complications or death.ConclusionsUniportal VATS is a feasible and safe technique for the use in patients with empyema requiring surgery. Even if decortication in stage III empyema is required this can be performed by uniportal VATS.

Paediatric empyema: worsening disease severity and challenges identifying patients at increased risk of repeat intervention

ObjectiveEmpyema is the most common complication of pneumonia. Primary interventions include chest drainage and fibrinolytic therapy (CDF) or video-assisted thoracoscopic surgery (VATS). We describe disease trends, clinical outcomes and factors...

A Rare Case of Achromobacter Species Subdural Empyema and Brain Abscess in an Adult Patient with Hematologic Malignancy.

A Rare Case of Achromobacter Species Subdural Empyema and Brain Abscess in an Adult Patient with Hematologic Malignancy.

Empyema: do we know enough?

Introduction Pleural empyema is an uncommon but serious condition defined by infected fluid in the pleural space. These patients are often given long courses of empirical broad-spectrum antibiotics as the yield from conventional culture methods is notoriously low. The literature shows that with conventional culture methods of the pleural fluid up to 40-60% of causative pathogens remain unidentified. In recent years methods such as DNA analysis have been developed in an attempt to increase identification rates of pathogens. This paper aims to review the literature to determine the additional benefit of DNA analysis methods above conventional culture of fluid in pleural empyema. Methods A review of the literature searching for studies investigating bacteria present in pleural fluid in patients with empyema was carried out. Studies in which adult patients had a diagnosis of empyema and where conventional culture and molecular methods were used to identify the causative bacteria were included. Descriptive statistics were used to compare the increased yield from molecular methods. Results Five studies which compared conventional culture techniques and molecular methods for identification of the pathogen in pleural empyema cases were identified. The mean culture-positive rate and molecular-positive rate in these studies was 37.5% (range 10-58%) and 80.0% (range 22.5-82%) respectively. All the studies concluded that molecular techniques provided a greater identification rate than conventional culture techniques. Conclusion Pleural empyema is often culture negative leading to broad-spectrum antibiotic use. This review shows that molecular methods significantly increase the yield of causative bacteria present in pleural fluid.

Pyothorax in Antillean Manatee (Trichechus manatus) in Brazil

Background: Manatees are the most endangered aquatic mammals in Brazil. The current conservation scenario, together with their biological characteristics, raises concern with the future of this species. Pyothorax, also known as septic pleural effusion or pleural empyema, is characterized by the accumulation of a septic purulent exudate within the pleural space. Although this infection often has a multifactorial etiology, it is most commonly associated with respiratory tract disorders and trauma. Here, we report a case of pyothorax in a Antillean manatee (Trichechus manatus) held in captivity for acclimatization in Brazil.Case: A young, male Antillean manatee, aged 4 years and 11 months, measuring 227 cm in total length, and weighing 258 kg was held in captivity for acclimatization (natural environment) in Porto de Pedras in the State of Alagoas, Brazil. The animal died in February 2013 and was sent for necropsy at the CMA/ICMBio laboratory. The study was developed with authorisation from the Ethics Committee on Animal Use (License number 020/2009) and under the license SISBIO/ICMBio number 20685-1. Externally, the carcass of the animal showed swelling and bulging of the right antimere and purulent secretion from the right nostril. After external examination, a window was opened in the layers of skin, fat, and muscles from the level of the anus to the navel. Subsequently, the abdominal cavity was opened for inspecting the internal organs. The subcutaneous muscles had a slightly friable, swollen, and pale texture, in addition to petechial hemorrhage, suffusions, and marked edema of the subcutaneous tissue. The right hemidiaphragm was elevated, filling the abdominal and thoracic spaces. Depending on the elevation, all organs were moved to the left antimere. After dissecting the surrounding structures and analyzing the causes for the increase in volume, it was observed that the right lung formed a structure containing a large amount of purulent exudate, which was delimited by the right hemidiaphragm. It had a length of 111 cm, width of 40 cm, and wingspan of 137 cm, starting from the first thoracic rib to the last lumbar rib, near the peduncle region. After making an incision in the right hemidiaphragm and visceral pleura, approximately 70 L of purulent exudate and caseous material were removed. Since the right lung was severely damaged, visualizing the pulmonary parenchyma was not possible, and only remains of the main right bronchus could be seen.Discussion: Domestic species, such as dogs and cats, when affected by pleural empyema, usually have a restrictive breathing pattern (shallow and rapid breaths) and fever. Interpreting the clinical signs may be difficult for manatees because of their slow metabolism. In the United States, 44 (6%) cases of pleural empyema were recorded in manatees from a total of 731 animals evaluated, and shock with boats was determined as the primary cause. In the present animal, no signs of bone fractures were found, suggesting that the infection may have been caused by the use of an orogastric tube or even acquired in the environment prepared for acclimation. Based on the pathognomonic macroscopic findings, one can conclude that the animal had a characteristic clinical picture of pleural empyema (pyothorax) associated with an infection of unknown origin. This situation resulted in complete degeneration of the right lung and massive thoracic and abdominal distensions, resulting in decreased expansion capacity of the left lung, making breathing impossible, thus leading to death.

A Case of Empyema with Fistula due to Nontubuerculous Mycobacteriosis Treated with EWS and Vacuum-assisted-closure (VAC) Therapy

A Case of Empyema with Fistula due to Nontubuerculous Mycobacteriosis Treated with EWS and Vacuum-assisted-closure (VAC) Therapy

Surgical stabilization of rib fractures after penetrating thoracic injury: A chest wall injury society multicenter study

Introduction: Surgical stabilization of rib fractures (SSRF) has emerged as an acceptable modality to manage chest wall injuries in select patients after blunt thoracic injury; however, its use in penetrating trauma has not been described. Materials and Methods: An international, retrospective study was carried out in two centers who reported experience with SSRF following penetrating chest wall trauma. All adult patients (≥18 years) who underwent SSRF after penetrating thoracic trauma between January 1, 2008, and December 13, 2017 were included. Results: Thirteen patients were enrolled in the study. The entire cohort was male with a median age of 28 years (interquartile range [IQR] 22, 33). Chest wall injury was due to firearm and impalement injuries in 10 (77%) and 3 (23%) patients, respectively. Indications for SSRF included chest wall instability (n = 8), mechanical ventilation or impending respiratory failure (n = 7), and pain (n = 4). Median time to SSRF was 24 h (IQR 20, 48). A median of 3 rib fracture lines (IQR 2, 4) were identified on imaging, and a median of 3 plates (IQR 2, 4) were placed in each patient. Six patients (46%) were extubated immediately after SSRF and the remainder required 3 (IQR 2, 6) days of mechanical ventilation. No patient required a tracheostomy. There were no cases of hardware failure, empyema, hemothorax, or death during hospitalization. Conclusion: In this series, 13 patients with penetrating thoracic injuries underwent SSRF with improved clinical outcomes. These data demonstrate that SSRF can be safely and effectively utilized in patients with penetrating chest wall injuries.

Brain abscesses and intracranial empyema due to dental pathogens: Case series

IntroductionSpontaneous brain abscess and intracranial empyema are rare but life-threatening diseases. They can result from potential complications of oral chronic infections. Given the similarity between most of the germs commonly found both in cerebral abscess and in oral cavity and its anatomic proximity, the oral cavity represents a major source of cerebral infections. Presentation of casesWe report here a series of seven cases of intracranial abscesses and empyema due to dental pathogens that occurred in the neurosurgery department of our institute. Five of those seven cases were then cared in the oral surgery department of our institute. DiscussionBacteriological examination of the brain abscesses identified an oral commensal bacterium belonging to streptococci group in six patients (85.7%) and Porphyromonas Gingivalis, a pathogen oral germ involved in periodontal diseases in the seventh patient. For all patients examined, oral status and oral health were poor or moderate with the presence of dental caries, missing teeth and abundant dental plaque. Except the oral cavity, no other front door or infectious site were found. ConclusionThis rare series of cases highlights the importance of systematically explore the oral cavity in presence of intracranial infection and to radically eradicate the potential infectious foci.

A retrospective study of etiology, clinical features, management, and outcomes in children with necrotizing pneumonia

Introduction: Necrotizing pneumonia (NP) is a severe and emerging complication in children with community-acquired pneumonia (CAP). The study was conducted to analyze the etiology, clinical features, treatment strategies, and outcome of NP in children admitted in a single pediatric tertiary referral care center. Materials and Methods: The study is a retrospective chart review which included children above 1 month and below 18 years who were admitted at Indira Gandhi Institute of Child Health, from January 2015 to December 2018, with community-acquired NP. Results: During the study period, 1393 cases of CAP were admitted in our institute. Three hundred and fifty-two cases (25.2%) of complicated pneumonia were admitted which include cases of NP, lung abscess, and empyema. Children who were diagnosed with NP were 3.3% (n = 46) of all CAP cases. All the cases with NP were immunocompetent, with the most common organism isolated being Staphylococcus aureus followed by Streptococcus pneumoniae. NP is associated with complications such as empyema, pneumothorax, and bronchopleural fistula. All the children in the study group survived except for mortality in one case. Conclusion: NP can be well managed with conservative approaches such as prolonged antibiotic therapy and pleural drainage. Although there are commonly associated with local complications, in general the clinical outcome is good.

A Case of Postpneumonectomy Empyema Managed by Pectoralis Major Myocutaneous Flap Reconstruction of the Chest Wall

A Case of Postpneumonectomy Empyema Managed by Pectoralis Major Myocutaneous Flap Reconstruction of the Chest Wall

Tissue plasminogen activator for a rare case of neonatal empyema

Abstract Empyema is an infection of the pleural space, often secondary to pneumonia. Although frequently encountered in pediatric surgical practice, it is rarely encountered in neonatal patients, and little data exists to guide treatment of neonatal empyema. One strategy is to extrapolate from pediatric treatment paradigms, specifically involving the use of intrapleural fibrinolytic therapy. Herein, we report on a rare case of neonatal empyema successfully treated using tissue plasminogen activator (tPA) via chest tube at a dose of 0.1 mg/kg in 5 mL normal saline daily for 3 days.

Clinical observation of bronchoscopy alveolar lavage combined with thoracoscopy in the treatment of empyema in children.

The objective of this study was to investigate the therapeutic effects of bronchoscopy alveolar lavage (BAL) combined with thoracoscopy in the treatment of empyema in children.Retrospectively analyzed 174 cases of pediatric empyema treated with thoracoscopy combined with BAL from January 2010 to December 2016 in our hospital. All the cases, according to admission order, were randomly divided into 2 groups, the control group (group A), which contained 89 cases, was treated with thoracoscopy; and the experimental group (group B), which contained 85 cases, was treated with BAL combined with thoracoscopy. The results of BAL treatment, the inflammatory indexes including body temperature, total leukocyte count in peripheral blood and CRP, and the therapeutic effect and prognosis including the days of antibiotic use, hospital stay, the incidence of thoracotomy and lobectomy were compared between the 2 groups.1.There was no significant difference in inflammatory indexes between the 2 groups: body temperature (oC), (39.06 ± 0.047 and 39.08 ± 0.050), P > .855; routine leukocyte count (∗10^9/L), (25.93 ± 1.035 and 24.76 ± 1.019), P > .425); C-reactive protein (mg/L), (128.7 ± 6.653 and 138.6 ± 7.53), P > .328.2.The results of BAL: hyperemia and edema was detected in trachea intima of all cases, including 32 cases of purulent secretion and ulcer, 21 cases of lumen deformation and 5 cases of foreign body.3.There were statistical significances in the curative effects of the control group and the experimental group: the duration of antibiotic use (days), (21.07 ± 0.342 and 17.07 ± 0.288), P < .0001); the average hospital stay (days), (22.91 ± 0.347 and 18.79 ± 0.287), P < .0001; secondary surgery (thoracotomy), 15 cases in the control group, 5 cases in the experimental group, P < .023; lung lobectomy (disability rate), 13 cases in the control group and 3 cases in the experimental group, P < .011.There was statistical difference in all the therapeutic indexes (P < .05).Bronchoscopy alveolar lavage combined with thoracoscopy has a higher success rate in the treatment of pediatric empyema, and is more comprehensive, safe and effective in controlling inflammation.

Increasing Rates of Pediatric Empyema and Disease Severity With Predominance of Serotype 3 S. pneumonia: An Australian Single-center, Retrospective Cohort 2011 to 2018.

The impact of universal 13-valent pneumococcal conjugate vaccine immunization on pediatric empyema rates and pathogens in Australia is not known. We aimed to describe empyema epidemiology, clinical characteristics and treatment during an 8-year period. A retrospective study between 2011 and 2018 of empyema cases admitted to a large pediatric referral hospital, for management with either pleural drainage and fibrinolytics or surgical intervention. There were 195 cases in 8 years. Empyema incidence and ICU admission rates significantly increased during the study with a peak incidence of 7.1/1000 medical admissions in 2016 (χ for trend of incidence 37.8, P < 0.001 and for ICU admissions 15.3, P < 0.001). S. pneumoniae was the most common pathogen (75/195, 39%) with serotype 3 the most detected (27/75: 27%). S. pyogenes compared with S. pneumoniae had significantly fewer days of fever before admission (3.9 vs. 6.4, mean difference 2.4, 95% CI: 0.84-4.08, P = 0.003) and higher proportion requiring direct ICU admission (6/75; 8% vs. 7/15; 47%, P < 0.001). Compared with S. pneumoniae, cases with no pathogen detected by culture or PCR had fewer days of fever post intervention (4.4 vs. 7.4 days, mean difference 2.7 days, P = 0.002). S. aureus occurred more commonly in infants (10/25; 40% vs. 1/75; 1%, P < 0.001) and children of indigenous background (5/25; 20% vs. 1/75; 1%, P < 0.001) compared with S. pneumoniae. We report increasing rates of pediatric empyema with higher proportions requiring ICU treatment. The most common pathogens detected were S. pneumoniae, S. aureus and S. pyogenes. Despite high 13-valent pneumococcal conjugate vaccine coverage, serotype 3 was the most common S. pneumoniae serotype identified.

A Case of Empyema with Rare Chest Findings.

A Case of Empyema with Rare Chest Findings.

A Case of Empyema and a Review of Practice in a District General Hospital

The authors describe an empyema in an immunosuppressed patient. Thoracentesis was attempted and only 60 mL of pus was obtained from her pleural space. She was treated as an outpatient with antibiotic therapy. The authors have recently performed a review of all cases of pleural infection between December 2016 and December 2017 in their trust, of which there were 36. Here, they describe failings that have now been addressed and which helped in managing this particular case. As a result of this review, the authors have developed a pleural procedure form that encompasses all of the recommendations from their case review.

A Case of Empyema and a Review of Practice in a District General Hospital

The authors describe an empyema in an immunosuppressed patient. Thoracentesis was attempted and only 60 mL of pus was obtained from her pleural space. She was treated as an outpatient with antibiotic therapy. The authors have recently performed a review of all cases of pleural infection between December 2016 and December 2017 in their trust, of which there were 36. Here, they describe failings that have now been addressed and which helped in managing this particular case. As a result of this review, the authors have developed a pleural procedure form that encompasses all of the recommendations from their case review.

A case of chronic empyema with pulmonary fistula after right upper lobectomy effectively treated via plombage of a pedicled latissimus dorsi musculocutaneous flap

A case of chronic empyema with pulmonary fistula after right upper lobectomy effectively treated via plombage of a pedicled latissimus dorsi musculocutaneous flap

A case report of multiple cerebral abscess formation complicating serogroup B Neisseria meningitidis meningitis

BackgroundInvasive meningococcal disease (IMD) presenting with meningitis causes significant mortality and morbidity. Suppurative complications of serogroup B meningococcal sepsis are rare and necessitate urgent multidisciplinary management to mitigate long-term morbidity or mortality.Case presentationWe present a rare case of invasive meningococcal disease in a 28-month old boy complicated by multiple abscess formation within a pre-existing antenatal left middle cerebral artery territory infarct. Past history was also notable for cerebral palsy with right hemiplegia, global developmental delay and West syndrome (infantile spasms). Two craniotomies were performed to achieve source control and prolonged antimicrobial therapy was necessary. The patient was successfully discharged following extensive multidisciplinary rehabilitation.ConclusionsLongstanding areas of encephalomalacia in the left MCA distribution may have facilitated the development of multiple meningococcal serogroup B abscess cavities in the posterior left frontal, left parietal and left temporal lobes following an initial period of cerebritis and meningitis. A combination of chronic cerebral hypoperfusion and some degree of pre-existing necrosis in these areas, may also have facilitated growth of Neisseria meningitidis, leading ultimately to extensive cerebral abscess formation following haematogenous seeding during meningococcemia. In this case report we review similar cases of cerebral abscess or subdural empyema complicating serogroup B meningococcal meningitis.

CHYLOPYOPNEUMOTHORAX IN A PATIENT WITH RHEUMATOID LUNG DISEASE

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: While non-tuberculous mycobacteria (NTM) can cause a wide spectrum of human disease, their association with pleural effusion is unusual (1). We describe a case of Mycobacterium fortuitum empyema in a patient with rheumatoid lung disease who presented with spontaneous secondary pneumothorax. Incidentally, his pleural fluid also revealed chylomicrons suggesting chylothorax. CASE PRESENTATION: A 52 yo male with history of Rheumatoid Arthritis (RA), IV methamphetamine use, chronic asymptomatic bilateral pulmonary nodules and pleural effusions (presumed rheumatoid lung disease) presented with shortness of breath and cough for 5 days. He was hemodynamically stable except for mild tachycardia. Chest X ray revealed right sided pneumothorax. A 9 Fr anterior chest tube was placed with improvement in pneumothorax. Subsequently, milky fluid started draining from the tube. Fluid analysis showed: pH 7.61, RBC 50,000/cu.mm, WBC 64,000/cu.mm with 94% neutrophils, glucose 5 mg/dl, LDH 4344 u/L, protein 5.0 g/dL, amylase 30 U/L, triglyceride 114 mg/dL, ADA 111.8 U/L, chylomicrons present. CT scan showed pulmonary nodules some of which increased in size and cavitated when compared to old scans. Pleural fluid cultures grew mycobacterium within 48 hours which eventually speciated as M. fortuitum. VATS guided right pleural biopsy was performed and multiple biopsy samples grew M. fortuitum. Of note, the same organism grew in his sputum samples as well. DISCUSSION: Rapidly growing mycobacteria rarely cause pulmonary infection, and when it does occur, it is typically from abscessus (2). Pulmonary infection may occur from M. fortuitum, in a patient with known underlying lung disease or immunosuppression (3). Our patient had known asymptomatic pleural effusion and bilateral pulmonary nodules. He presented with spontaneous pneumothorax associated with increase in size of nodules and cavitation. He was on leflunomide and hydroxychloroquine for RA and has also been getting steroids intermittently for RA flares, last given 2 months prior to presentation. It is possible that underlying lung disease and immunosuppression predisposed him to develop M. fortuitum infection, which in turn lead to cavitation of peripheral nodules and pneumothorax. Incidentally, pleural fluid testing also revealed chylomicrons, confirming component of chylous effusion This case suggests that rheumatoid lung disease, especially in setting of steroid therapy is a risk factor for NTM infection, and development of such infection may be heralded by an acute complication such as pneumothorax. CONCLUSIONS: NTM are rarely associated with pleural disease. They should be considered in the differential when an immunocompromised individual with chronic lung disease presents with acute worsening. We describe a rare association of rheumatoid lung disease with M. fortuitum pulmonary infection which lead to acute presentation with chylopyopneumothorax. Reference #1: Johnson MM, Odell JA. Nontuberculous mycobacterial pulmonary infections. J Thorac Dis. 2014;6(3):210-20. Reference #2: Griffith DE, Girard WM, Wallace RJ Jr. Clinical features of pulmonary disease caused by rapidly growing mycobacteria. An analysis of 154 patients. Am Rev Respir Dis. 1993 May;147(5):1271-8. Reference #3: Park S, Suh GY, Chung MP, Kim H, Kwon OJ, Lee KS, Lee NY, Koh WJ. Clinical significance of Mycobacterium fortuitum isolated from respiratory specimens. Respir Med. 2008 Mar;102(3):437-42. Epub 2007 Nov 9. PubMed PMID: 17997087. DISCLOSURES: No relevant relationships by Spyridon Fortis, source=Web Response No relevant relationships by Vikas Koppurapu, source=Web Response no disclosure on file for Matthew McGee; No relevant relationships by Tayyab Rehman, source=Web Response No relevant relationships by Roger Struble, source=Web Response

EP1.17-31 30 Days Major Morbidity and Mortality After Lung Cancer Surgery. Outcomes of Five Years in a Single Center Experience

Lung cancer is the leading cause of cancer-related death in the world. Surgery offers the best potential cure, but as in any surgery there are some complications that will be minimized with the improvement of surgical practice and treatment protocols. The aim of this study was to clarify the level of service we are providing in order to improve it and to add more information in the global database on the Thoracic Morbidity and Mortality classification system for patients undergoing lung resection. This is a retrospective study that included all patients who underwent lung resection in our department from January 2011 to January 2015. The parameters examined were postoperative mortality thirty days and postoperative complications. Both patients were evaluated prior to surgery according to the Karnofsky score and the intervention was performed by postero-lateral thoracotomy. There were 216 patients who were operated on for lung cancer in which 37 (17%) of them underwent pneumonectomy meanwhile the rest lobectomies, bilobectomies and anatomical segmentectomies. The average age was 62.4 years (± 12SD). 12% of patients were women and 88% males. 79% were smokers and 21% non-smokers. According to TNM classification, 10.2% of cases were in the first stage, 44% in the second stage, 21.3% in the third stage and 5.6% in the fourth stage. 40.4% of cases had another illness (cardiovascular disease 24.2%, COPD 11.8%, diabetes mellitus 3.7% and other diseases 0.6%). 17% of patients had complications 30 days after surgery and only 2.3% died. As for pneumonectomy, the complication rate was 24% and the mortality rate was 8%. The main complications that have been observed were 19 cases of empyema, 4 cases of broncho-pleural fistula, 4 cases of pneumonia, 3 cases of prolonged air loss, 3 cases of heart attack and in 4 cases different complications were observed. 2 of mortality occurred due to a heart attack, in 2 cases occurred due to severe pneumonia and in one case a vascular accident occurred during the operation. Hospital stay was 8.5±3 days. In our specialty, the complication rate following a surgical operation is a parameter very often used to check the quality level provided by health professionals. Our results show average mortality and morbidity after lung cancer surgery. However, patients with reduced lung capacity and undergoing pneumonectomy should be treated with the utmost care, since they run a considerable risk of major complications or death during the first 30 days after surgery.