Empyema Necessitatis Research Articles

Methicillin-resistant Staphylococcus aureus-associated empyema necessitans in a child: A case report and a literature review.

Empyema is a known complication of severe pleuropneumonia. In rare cases, if poorly treated, it could result in dissemination and fistulization and transformation into empyema necessitans. The manifestation may appear as a superficial abscess. However, as management highly differs, the recognition of potentially severe phenomenon is required. We describe a case of empyema necessitans on a 4-year-old girl secondary to methicillin-resistant Staphylococcus aureus. It represents the sixth pediatric case reported in the literature. It was managed by open drainage and prolonged antibiotherapy. The outcome was favorable as guidelines were extracted from similar reported cases. Empyema necessitans remains a rare complication with significant morbidity. Prompt diagnosis and adapted management have relied on limited literature. As such, further reports are necessary to establish proper guidelines.

Tuberculous Empyema Necessitans – Case Series

Abstract Empyema necessitans (EN) is a rare complication of untreated pleural infection. Tuberculosis is the most common cause. It can be found in both immunocompromised and immunocompetent patients, especially in endemic areas. Diagnosis can be challenging due to long duration and indefinite symptoms. Here, we present a case series of three patients with EN.

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.

Empyema Necessitans Following Bacille Calmette-Guérin Administration for Urothelial Carcinoma

Background Bacille Calmette-Guérin wash for urothelial carcinoma is a very common adjuvant treatment with a low potential for serious systemic adverse events. We present a case of a rare serious complication, empyema necessitans, following treatment with BCG. Case Presentation A 77-year-old patient with urothelial cancer treated with adjuvant BCG wash developed empyema due to Mycobacterium bovis related to his previous BCG exposure, which progressed to empyema necessitans treated with antituberculosis medications in conjugant with multiple thoracic drainages. Despite treatment, the patient's condition deteriorated slowly leading to death. Conclusion Rare adverse events of common treatments should be considered when evaluating a patient, as BCG wash could potentially lead to empyema necessitans.

Closed Catheter Drainage for Klebsiella pneumoniae Empyema Necessitans

Empyema necessitans is a rare complication of pneumonia, which can be seen more frequently with tuberculosis (TB). In this case report, we include a 47-year-old female with empyema necessitans; closed drainage has been sought as a sole treatment based on the clinical presentation and radiological findings of an empyema necessitans. Scarce evidence with regard to adult empyema necessitans with Klebsiella was found in the literature where adult cases were managed exclusively using combination of intravenous (IV) antibiotic and closed drainage, reporting such case can help guiding management for similar presentation.

Perinephric and psoas abscesses leading to empyema: An unusual tuberculosis presentation

Tuberculous psoas abscess usually results from tuberculous spondylitis but may also develop from direct spread or via hematogenous route [1]. Our case involves direct spread from an adjacent perinephric abscess with associated thoracic extension from suspected direct erosion or a diaphragmatic defect. We present a case of pleural empyema arising from abdominal tuberculous abscesses. This is an 11-year-old male who initially presented with a three-week history of cough, intermittent fever, and dyspnea. Congenital diaphragmatic hernia was first suspected at the emergency department when an opacified left hemithorax with cystic lucencies was noted. Further imaging of the chest and upper abdomen was done in our institution revealing large left perinephric and psoas abscesses with intra-thoracic extension resulting in empyema thoracis and necessitans. Culture of the abscess fluid yielded no growth but GenExpert tested positive for M. tuberculosis. Tuberculosis remains a major illness in developing countries and has a multitude of infection sites and clinical presentation. Our case presented as an ascending thoracic extension of a perinephric and psoas abscess, likely from a diaphragmatic defect. The absence of spinal involvement proves its renal origin. The importance of CT scan is highlighted in medically-confounding cases such as this one.

Isolation of salmonella typhi from pleural empyema necessitans- A case report from a tertiary care hospital, Bangalore, Karnataka

Pleural Empyema necessitans refers to the extension of an empyema out of the pleural space and in to the neighbouring chest wall and surrounding soft tissues.Salmonella typhi is a versatile pathogen with amazing potential of infecting almost all organs of its host. Globally, the life threatening illness caused by Salmonella typhi have made this pathogen a serious health concern for infection control professionals. Salmonella typhi usually manifests as a febrile illness with bacteremia after initial entry through the gastrointestinal route, but it can occasionally cause significant disease in extraintestinal sites. Various microbes have been found associated with pleural cavity abscesses that ultimately lead to high morbidity and mortality rates, but pulmonary involvement due to Salmonella infection is rare. We are reporting an unusaual and rare case of pleural cavity abscess caused by Salmonella typhi in a 44 years old febrile patient, admitted to a tertiary care hospital, Bangalore with a complaints of swelling on the left sided chest wall. Diagnosis was made by HRCT THORAX which revealed an well defined hypodense collection with peripheral rim enhancement in anterior chest wall around 7th to 8th costochondral junction, communication with left pleural cavity. Pus was collected from the abscess by incision and drainage. Salmonella enterica serotype typhi was isolated from the sample. Patient was put on appropriate antimicrobial therapy.

Empyema Necessitans Secondary to Tuberculosis: A Case Report

Empyema necessitans (EN) is a sporadic disease in the 21st century. It is a condition where the empyema has diffused and is loculated in the extrapleural space. It is usually caused by Tuberculosis (TB) infection or immunocompromised condition. Its manifestation, which is often vague in the beginning, leads to diagnostic dilemmas and delays in management. This has considerably affected patients adversely and incurred avoidable healthcare costs. We describe a rare case of empyema necessitans secondary to pulmonary tuberculosis in a 43-year-old male who presented to the emergency department with right anterior chest wall swelling, which was associated with pain, lethargy, malaise and significant loss of weight. Targeted ultrasonography of the anterior chest wall revealed a right anterior chest wall collection with intrathoracic extension. Contrast-enhanced computed tomography of the chest showed a multiloculated right chest wall collection with intrathoracic extension. Percutaneous drainage of the collection was performed, and the pus sent for Mycobacterium tuberculosis culture was positive. This case highlights the importance of a high index of suspicion and clinical awareness for this dangerous and silent disease.

EMPYEMA NECESSITANS DUE TO MULTIDRUG-RESISTANT (MDR) PSEUDOMONAS AERUGINOSA: A CASE REPORT

EMPYEMA NECESSITANS DUE TO MULTIDRUG-RESISTANT (MDR) PSEUDOMONAS AERUGINOSA: A CASE REPORT

Empyema Necessitatis Due to Streptococcus pneumoniae: Case Report

Empyema necessitatis is a rare complication of empyema characterized by extension of suppuration from the pleural space through the chest wall. The most common etiologies are tuberculosis and actinomycosis. We describe a 60-year-old woman with Streptococcus pneumoniae empyema necessitatis. Empyema necessitans should be kept in the differential diagnosis of patients with left chest masses or abscesses.

Empiema necessitatis por Campylobacter rectus. Identificación rápida por MALDI-TOF MS

Empyema necessitatis (EN) is a very rare complication of a pleural empyema, in which the infection extends to adjacent soft tissues. Anaerobic bacteria are very rare etiologic agents of EN, which occurs in the course of chronic infections. We present the first case of empyema necessitatis caused by Campylobacter rectus. Bacterial identification was carried out by mass spectrometry (MALDI-TOF MS) and antimicrobial susceptibility was determined by the epsilometer method.

A rare case of empyema necessitatis sustained by Nocardia farcinica in a kidney transplant recipient

Dengue virus (DENV) is a frequent travel-related infection, but longitudinal data on its incidence is limited. We aimed to study temporal trends of travel-related DENV burden and its geographical sources.All cases of laboratory-confirmed DENV infection diagnosed at the Central Virology Laboratory of the Israeli Ministry of Health during 2008–2019 were evaluated. Numbers of Israeli tourist-entries to DENV endemic countries were available from the UN World Tourist Organization (UNWTO) database. DENV attack rates were calculated as cases per 100,000 traveler-entries. In addition, for Thailand and India incidence rates were calculated, using the average duration of stay reported in diagnosed DENV cases.During 2008–2019, 425 Israeli travelers were diagnosed with DENV: 80.3%, 12.8% and 6.9% were acquired in Asia, America and Africa respectively. The average global DENV attack rate increased from 2.5 cases per 100,000 tourist-entries in 2008 to 10.7 cases per 100,000 tourist-entries in 2019. Region-specific DENV attack rates were 4.4, 3.2 and 2.1 cases per 100,000 tourist-entries to Asia, Africa, and America respectively.The highest number of DENV cases were reported from Thailand and India; DENV incidence rates increased from 94.5 to 142.2 cases per 100,000 travel-years, and from 49.3 to 90.4 cases per 100,000 travel-years for Thailand and India respectively.Among Israeli travelers, worldwide DENV attack-rates have quadrupled during 2008–2019, reflecting both a growing DENV burden in Asia, but also the emergence of Africa as an important source of DENV. The need to protect travelers through vaccination remains urgent.

Esophagopleural fistula due to empyema necessitans.

Empyema necessitans is a rare entity that consists on the development of an abscess that begins in the pleural space and then extends to the adjacent tissues. This case shows a rare and very late complication of a total pneumonectomy, emphasizing the importance of the multidisciplinary approach and the potential of endoscopic therapy with over-the-scope clips.

A RARE CASE OF METHICILLIN-RISISTANT STAPHYLOCOCCUS AUREUS EMPYEMA NECESSITANS VISUALIZED ON POINT-OF-CARE ULTRASOUND

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Empyema necessitans is a rare complication of bacterial pneumonia that occurs when empyema invades the parietal pleura and extends into the surrounding chest wall; if left unchecked it will eventually drain through the skin. Here we present a case of empyema necessitans in a previously healthy 25 year-old man caused by MRSA pneumonia, visualized with bedside ultrasound. CASE PRESENTATION: This gentleman originally presented to an outside hospital with two months of worsening dyspnea, cough, and pleuretic chest pain. He reported night sweats and fever after a recent upper respiratory infection. He denied having any past medical conditions, however his social history endorses intravenous drug use. Prior to his final presentation he presented to an emergency department twice, being diagnosed with costochondritis, and discharged with oral pain medications. He was then treated with two courses of oral antibiotics from an urgent care. During this time he began to develop a fluctuant erythematous anterior chest wall mass. At this point he presented again to an outside hospital, who then obtained a computed tomography (CT) scan of his chest, revealing a large loculated pleural effusion concerning for empyema that may have been communicating with the mass. He was then transferred to our facility to evaluate this complicated pleural effusion. At our facility a point-of-care ultrasound exam was performed, showing a heterogeneous, echogenic pleural effusion that was freely communicating and flowing across a defect in the intercostal muscles directly into the anterior chest wall mass, highly concerning for empyema necessitans. A small chest tube was placed, with purulent fluid that grew MRSA on culture, confirming the diagnosis. Ultimately the patient required surgical intervention for decortication and pleurectomy along with intravenous vancomycin. DISCUSSION: Rapid identification of empyema necessitans is crucial to facilitate the appropriate treatment, which often involves surgical management, in a timely manor to avoid morbidity and mortality. CONCLUSIONS: POCUS in the hands of a trained clinician provides a rapid, accurate, and cost effective diagnostic approach to those with pneumonia and a chest wall mass, to diagnosis empyema necessitans. REFERENCE #1: Elyashiv D, Alpert EA, Granat N. Empyema Necessitans Diagnosed by Point-of-Care Ultrasound. J Emerg Med. 2020 Dec;59(6):e221-e223. doi: 10.1016/j.jemermed.2020.09.020. Epub 2020 Oct 13. PMID: 33059991. DISCLOSURES: Advisory Committee Member relationship with EchoNous Please note: 11/12/2020 Added 04/30/2021 by Keith Barron, source=Web Response, value=Ownership interest Stock ownership relationship with Butterfly IQ Please note: 04/30/2021 Added 04/30/2021 by Keith Barron, source=Web Response, value=Ownership No relevant relationships by Stephanie Scott, source=Web Response

Novel Treatment of Widespread Empyema Necessitatis

A 59-year-old man presented with high fever and tenderness extending from the left side of the chest to the flank. Computed tomography showed a large encapsulated pleural effusion in the left thoracic cavity with subfascial fluid extending from the left chest wall to the abdominal wall (Figure 1). He was diagnosed with empyema necessitatis. The patient developed septic shock and underwent urgent lavage and drainage of the abscess cavity. Because a large bronchopulmonary fistula was detected at the level of the segmental bronchus, temporary closure was considered difficult and fenestration was performed.

Empyema necessitans with osteomyelitis of fifth rib due to Nocardia farcinica: a case report

BackgroundEmpyema necessitans is a rare pulmonary condition described as the presence of pus in the pleural cavity with insidious extension into the surrounding soft tissue. The common microbial aetiology of empyema necessitans is tuberculosis. Nocardiosis a cause of empyema necessitans is rarely described in the literature. We herein present a case of an 80-year-old male with empyema necessitans with osteomyelitis of rib caused by Nocardia farcinica.Case presentationAn 80-year-old male presented with complaints of soft swelling on the left lower posterior chest wall associated with dry cough and breathlessness on exertion. Computed Tomography (CT) thorax demonstrated empyema necessitans with features of left fifth rib osteomyelitis. Radiological guided aspiration of the chest wall collection revealed Nocardia species and surgical drainage of abscess was performed. Matrix-assisted laser desorption/ionization time-of-flight-mass spectrometry (MALDI-TOF-MS) identified the isolate as Nocardia farcinica. He was treated with three-drug regimen: Trimethoprim-sulfamethoxazole, amikacin and ceftriaxone for 2 weeks. After showing improvement patient was discharged and advised to take oral Trimethoprim-sulfamethoxazole for the next 6 months with periodic follow-up.ConclusionsAs our case demonstrates, the possibility of invasive Nocardiosis should not be overlooked even in immunocompetent patients. Clinicians should aware of this rare entity while treating patients with empyema necessitans.

A Baffling Bump: A Case Report of an Unusual Chest Wall Mass in a Pediatric Patient.

IntroductionChest wall masses are rare in children, but the differential diagnosis is broad and can include traumatic injury, neoplasm, and inflammatory or infectious causes. We report a novel case of an eight-year-old, previously healthy female who presented to the emergency department (ED) with one month of cough, fevers, weight loss, and an anterior chest wall mass.Case ReportThe patient’s ultimate diagnosis was necrotizing pneumonia with pneumatocele extending into the chest wall. This case is notable for the severity of the patient’s pulmonary disease given its extension through the chest wall, and for the unique speciation of her infection.ConclusionAlthough necrotizing pneumonia is a rare complication of community-acquired pneumonia, it is important for the emergency physician to recognize it promptly as it indicates severe progression of pulmonary disease even in children with normal and stable vital signs, as in this case. The emergency physician should consider complications of pneumonia including pneumatocele and empyema necessitans when presented with an anterior chest wall mass in a pediatric patient. Additionally, point-of-care ultrasound was used in the ED to facilitate the diagnosis of this illness and was particularly useful in determining the continuity of the patient’s lung infection with her extrathoracic chest wall mass.

Microbial Aetiology and Clinical Course of Pleural Space Infections in a Tertiary Care Hospital- A Cohort Study

Introduction: Infection of pleural space that arises due to complicated parapneumonic effusion and empyema is a common worldwide problem that is known since very ancient times. The microbial aetiology of pleural space infections has changed since introduction of antibiotics. Gram positive organisms are slowly and steadily losing their foothold in the pleural space to the more resilient and resistance gram negative bacteria. Incidence of these infections are increasing and delayed treatment causes significant morbidity and mortality. Aim: To study the age-sex profile, symptoms, microbiological findings, aetiology, management and treatment outcome of pleural space infections. Materials and Methods: This cohort study was conducted at Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India, from November 2016 to October 2017 on 48 consecutive patients. Each patient was followed-up for a minimum period of two months. The demographic data, clinical presentation, microbiological findings, aetiology, clinical course and management information were collected in a predesigned proforma and analysed. Results: The study population comprised of 33 (68.8%) male, 15 (31.2%) female patients. The mean age of the study population was 46±14 years. The most common presenting complaints were fever {43 (89.5%)}, shortness of breath {42 (87.5%)}, chest pain {38 (79.1%)} and cough {36 (75%)}. Pneumonia was diagnosed in 30 (62.5%) cases as the major cause of pleural space infection. Common organisms isolated were Streptococcus pneumoniae 11 (23%), Streptococcus pyogenes 9 (18.7%), Staphylococcus aureus 7 (14.5%) and Escherichia coli 7 (14.5%). The treatment was with Intravenous (i.v.) antibiotics followed by oral antibiotics. Most cases 46 (95.8%) required both thoracocentesis and Intercostal Tube Drainage (ICTD). Follow-up chest X-ray after two weeks showed complete lung expansion in 25 (52%) cases. Pleural thickening of <2 cm found in 22 (45.8%) cases and >2 cm found in 26 (54.2%) cases. At the end of one month of discharge 35 (73%) patient had complete resolution, 8 (16.7%) patients had persistent infection, 3 (6.2%) died and 2 (4.1%) patients were loss to follow- up. Out of the eight patients with persistent infection one patient had empyema necessitans and seven patients had bronchopleural fistula. On follow up after 2nd month out of the 8 (16.6%) persistence cases, 5 (10.4%) cases were cured and remaining 3 (6.2%) cases the infection persisted (pus) and ICTD was kept in-situ. Conclusion: Pneumonia is the most common cause of pleural space infections. Most common pathogen isolated was gram positive organism Streptococcus pneumoniae. In significant number of cases gram negative organism Escherichia coli was isolated. Most cases required both thoracocentesis and ICTD for resolution. The key to successful management of pleural infection remains to be early diagnosis, initiation of empirical broad spectrum antibiotics, followed by specific antimicrobial therapy after microbial identification and drug sensitivity testing.

Pediatric Empyema Thoracis: Jabalpur Image-Based Staging and Stage-Directed Decision-Making Algorithm

Pneumonia in the pediatric age group is common and it can commonly progress to pediatric empyema thoracis (PET). The American Thoracic Society has described three stages of PET which have been the following: exudative, fibrinopurulent, and organized. We describe a new Jabalpur image-based staging system for empyema thoracis in children which has allowed focused intervention and improved outcomes. Pre-empted focused observation, gaps in the treatment and outcomes, and the triangulation of these resulted in the evolution of a new, image-based staging system for pediatric empyema thoracis. From 2009 to 2014, our team was a participant-observer of the usual practices to treat children up to 18 years of age with pneumonia who developed empyema. The prevalent classification into exudative, fibrinopurulent, and organized empyema was treated as per practice. Patients with chronic empyema, empyema necessitans, and tubercular and those with incomplete data were excluded. A staging system purely based on ultrasound (US) and computed tomography (CT) findings was evolved, and we call it Jabalpur image-based staging (JIBS) system for pediatric empyema thoracis. A decision-making algorithm was further evolved using the JIBS system to provide stage-directed treatment. This staging system and algorithm after a pilot run was prospectively applied to a set of patients accrued from January 2015 to December 2019 with PET which was strictly allocated as per new evolved staging and treated with discrete choices by all the methods inclusive of general supportive care, nutritional support, tube drainage, and open and video-assisted thoracoscopic surgery (VATS). The successful early outcome was defined statistically significant reduction of mean ICTD days, the number of CXRs, and the mean hospital days, which reflects earlier recovery. The long-term successful outcome was defined as the absence of fever, breathlessness, and adequate weight gain (according to age) at a minimum follow-up of 3 months. On the prospective evaluation of JIBS and the stage-directed decision-making algorithm on a set of 187 children accrued from January 2015 to December 2019, there was a significant improvement in the success of drainage and the number of VATS procedures, and their success significantly improved. There was a significant reduction in mean preoperative stay, mean intercostal tube drainage (ICTD) days, the number of chest x-rays (CXRs), mean hospital stay, and the number of open procedures in the prospective group. Accuracy of a new staging system to identify exudative, fibrinopurulent, and organized stages of PET was found to be 94.65%, 94.65%, and 97.86% respectively. The long-term successful outcome was observed in 179 (95.72%) children while 8 patients had chest deformity and a minimum secondary scoliosis which was addressed with physiotherapy. This study proposes a simple image-based staging system and stage-directed decision-making algorithm for empyema thoracis in children, which sharply defines the stages and allows the selection of appropriate surgical modality in cases of PET.

Aggregatibacter actinomycetemcomitans Causing Empyema Necessitans and Pyomyositis in an Immunocompetent Patient

Empyema necessitans is a relatively rare clinical entity in which the empyema extends through the parietal pleura into the adjacent soft tissue and musculature of the chest wall. It usually occurs due to inadequate treatment of a primary lung infection. Aggregatibacter (formerly Actinobacillus) actinomycetemcomitans is a facultative anaerobic gram-negative coccobacillus that is part of the normal oral flora. Infections due to this organism usually result from aspiration in conjunction with dental disease or trauma to the oral mucosa resulting in pneumonia or empyema. It often coinfects with Actinomyces and is known to cause empyema necessitans. Cases of monomicrobial empyema necessitans due to Aggregatibacter actinomycetemcomitans in adults have rarely been reported with four such publications found on review of the literature. We present a patient with severe periodontitis who developed empyema necessitans due to Aggregatibacter actinomycetemcomitans likely from aspiration complicated by pyomyositis of the right triceps brachii and a left posterior thigh abscess.