Pleural Decortication Research Articles

Complicated parapneumonic effusion and empyema: Pleural decortication and video-assisted thoracic surgery

Complicated parapneumonic effusion or empyema, in which the fluid becomes more exudative, develops in 10% to 20% of patients with parapneumonic effusions. Early diagnosis and effective treatment strategies are required. New treatment strategies such as fibrinolytic therapy and decortication or debridement through video-assisted thoracoscopic surgery, have changed the choice of treatment for different stages of empyema or complicated pleural effusion. This review discusses the definition, clinical presentations, diagnosis, and treatment of these conditions, focusing on the value and comparison of video-assisted thoracoscopic surgery decortication and fibrinolytic therapies.

Failure to wean caused by cryptogenic fibrosing pleuritis and bilateral lung trapping: case report.

Cryptogenic fibrosing pleuritis is an extremely rare disease, which can affect both lungs from a very young age. The most common finding is severe lung restriction resulting in both hypoxemic and ventilatory failure. Male patient, 26 year old with acute deterioration of chronic respiratory failure. Following admission prolonged mechanical ventilation was necessary. An atypical clinical presentation made the diagnosis difficult, but eventually cryptogenic fibrosing pleuritis and lung fibrosis were established. The prognostic outcome of patients with the final diagnosis of cryptogenic fibrosing pleuritis is extremely poor, especially in an advanced phase of this disease. We recommend early treatment with corticosteroids or surgical pleural decortication.

RELATIONSHIP BETWEEN SERUM AND PLEURAL FLUID PRO- AND ANTI-INFLAMMATORY CYTOKINES WITH OUTCOME IN INFECTIOUS PLEURAL EFFUSIONS

PURPOSE: Infectious pleural effusions (IPEs) are common clinical problems that require an adequate approach to avoid the risk of pleural thickness and pleural decortication. The imbalance between serum and pleural fluid pro- and anti-inflammatory cytokines may be important in guiding the strategies of treatment and thus influence the outcome of the IPEs.

SPIROMETRIC CHANGES AFTER PLEURAL DECORTICATION IN YOUNG ADULTS

The collection of pleural fluid and thickened pleura restrict the movement and expansion of lung. The main treatment strategy is lung decortication for the thickened pleura. The aim of this study was to investigate lung functions before and after pleural decortication in young adults. A total of 63 patients with thickened pleura were retrospectively evaluated. Before the operation, patients with tuberculosis (n = 36) were treated with anti-tuberculosis therapy for 3-6 months. Patients with non-tuberculosis causes (n = 27) had been treated with broad-spectrum antibiotics. Forced expiratory volume in 1 s (FEV1, %), forced vital capacity (%) and vital capacity (litre) were measured before and after decortication. Spirometric parameters FEV1 (68.1 +/- 16.7 vs 71.01 +/- 14.4), forced vital capacity (67.6 +/- 16.4 vs 71.3 +/- 14.4) and vital capacity (2.6 +/- 0.6 vs 2.8 +/- 0.7) significantly improved after the operation (P +/- 0.01). Spirometric changes were not significantly different between tuberculosis and non-tuberculosis groups. Pleural decortication may improve the lung restoration in patients with thickened pleura and also improve lung functions significantly in young adults.

Chest wall defect and chronic pleural infection: surgical treatment with thoracomyoplasty and open window thoracostomy

We report a rare case of a 75-year-old hemiplegic man with a chronic pleural infection, a bronchopleural fistula, and a full-thickness defect of the chest. In one operation we performed open-window thoracostomy and pleural decortication as well as reconstruction of the chest defect and reclosure of the bronchopleural fistula with a latissimus dorsi muscle flap. The patient made a good recovery and was sent for rehabilitation in good condition. Surgical treatment was essential to control and ultimately halt the septic process. Use of a muscle transplant in a hemiplegic patient did not reduce mobility.

Bilateral Choroidal Metastases from Mesothelioma

CASE REPORT A 69-year-old retired carpenter with previous asbestos exposure was diagnosed with pleural epithelioid mesothelioma in 2003. He was treated with a pleural decortication but subsequently relapsed in supraclavicular and axillary lymph nodes and in the peritoneum. He was treated with palliative radiotherapy to symptomatic sites and then with chemotherapy, including pemetrexed, carboplatin, and gemcitabine. After initial response, his disease progressed. In late 2005, he presented with rapidly progressive loss of vision. Ophthalmologic assessment revealed bilateral choroidal lesions consistent with metastatic deposits (Figures 1 and 2). Differential diagnoses included choroidal melanomas, especially amelanotic melanomas, and benign lesions such as hemangiomas, and inflammatory granulomas.1 The presence of multiple lesions in one eye and the involvement of both eyes in the setting of known metastatic mesothelioma established the diagnosis of choroidal metastases.1 Computed tomography scans of the brain, orbit, chest, abdomen, and pelvis were also performed showing overall progression of disease within the mediastinum, abdomen, peritoneum, and lungs and possible cerebellar metastasis (Figure 3). He was treated with dexamethasone and bilateral orbital irradiation to a dose of 30 Gy in 10 fractions using 6-MV photons. Following completion of radiotherapy, his vision stabilized, and 2 months after treatment, he is able to read, although with some difficulty. The patient is

Massive empyema caused by Mycoplasma pneumoniaein an adult: A case report

BackgroundMycoplasma pneumoniae is responsible for more than 20% of community acquired pneumonia cases, and capable of causing upper respiratory illness as well. Complications of M.pneumoniae infections include CNS involvement but other as pericarditis were also reported. The lack of feasible culture methods and under appreciation of the pathogens ability to cause invasive disease leads to reduced number of diagnosed M.pneumoniae related complications. In contrast to many other respiratory pathogens causing pneumonia, M. pneumoniae related severe pleural complications were almost never reported.Case presentationWe report a previously healthy 57 years old woman presented with indolent massive right pleural effusion, leukocytosis and elevated ESR. Extensive microbiological evaluation didn't reveal any pathogen in the pus even before antibiotic treatment was started. Surprisingly, M.pneumoniae DNA was detected in the pus from the empyema using PCR designed to detect M.pneumoniae. A serological assay (Serodia-Myco II) using convalescent serum was indeterminate with a titer of 1:80. The patient responded well to a treatment that included right thoracotomy with pleural decortication and a combination of antibiotics and anti-inflammatory medications.ConclusionM.pneumoniae related empyema was never reported before in adult patients and was reported in only a few pediatric patients. In our patient there was no evidence to any common pathogens even before initiating antibiotic treatment. The only pathogen detected was M.pneumoniae. In this patient, serology was not helpful in establishing the diagnosis of M.pneumoniae related diseases, as was suggested before for older patients. We suggest that M.pneumoniae related empyema is probably under-diagnosed complication due to insensitivity of serology in older patients and under use of other diagnosis methods.

Mycoplasma pneumoniae infection complicated by necrotizing pneumonitis with massive pleural effusion

Mycoplasma pneumoniae is recognized as an important and frequent cause of community-acquired respiratory illness in school-aged children [4]. The clinical course of mycoplasma pneumonia is typically mild and self-limited. Pleural effusion is not a common feature of M. pneumoniae, and when it occurs there is usually a small amount of effusion which does not require chest tube insertion [6]. We report here on a child with M. pneumoniae infection complicated by necrotizing pneumonitis (NP) who presents with respiratory distress secondary to massive pleural effusion. A 7-year-old – previously healthy – girl presented to our hospital with a 10-day history of fever and cough. Shortness of breath developed on the day before admission. Antibiotics had not been administered by mouth previously, and no known allergy to drug or food was elicited. Upon arrival to our Emergency Department, she appeared to be acutely ill with respiratory distress. Her body temperature was 39.5°C, pulse rate was 163 beats/min, respiratory rate was 50/min with a blood pressure of 107/55 mmHg. Tachypnea with subcostal retraction was present, and examination of the chest revealed dullness to percussion, with decreased breath sounds to auscultation over the left lower lung field. A chest roentgenogram showed consolidation of the left lower lobe and partial atelectasis of left upper lobewith massive pleural effusion. Complete blood cell counts and biochemical examination revealed a white blood cell count of 17,600/μl with 89% neutrophils and 5% lymphocytes and an increased C-reactive protein level of 337.8 mg/l (normal: <5 mg/l). A chest ultrasonography with diagnostic thoracocentesis was performed, and yellow, not turbid fluid was aspirated. Analysis of the pleural effusion showedwhite blood cells at 980/mm (neutrophils: 54%; lymphocytes: 29%; monocytes: 11%), red blood cells at 70/mm, protein at 3.6 g/ dl, glucose at 105 mg/dl and lactate dehydrogenase at 2,002 U/l. No organisms were found on Gramand acid faststained smears. The latex agglutination test of the pleural fluid for Streptococcus pneumoniae, Haemophilus influenzae type b and group B Streptococcus was negative. Empiric ceftriaxone (100 mg/kg body weight per day) was prescribed, but spiking high fever and pleural effusion with respiratory distress persisted for 1 week. Cultures for bacteria, Mycobacterium tuberculosis, fungi and viruses were all negative. A computed tomography (CT) of the chest was performed for further evaluation, and the scan revealed consolidation of the left lower lobe with multiple low attenuation areas and a massive pleural effusion with left lung entrapment (Fig. 1a). Subsequent video-assisted thoracic surgery (VATS) with pleural decortication was performed, and a chest tube was placed with effective drainage of the pleural effusion. Initially, the cold hemagglutinin titer was 1:4 and the complement-fixation immunoglobulin G (IgG) titer for M. pneumoniae was 1:160. One week later, the tests were repeated; the second time the cold hemagglutinin titer was 1:16 and complement-fixation IgG titer had increased to 1:2,560. Mycoplasma IgM by enzyme immunoassay (EIA) was positive on two occasions. The earlier prescribed antibiotics were continued, and azithromycin (10 mg/kg body weight per day) was administered concomitantly for 10 days until the fever had subsided as well as vigorous postural drainage. Multiple pneumatoceles were present on the chest roentgenogram taken 14 days after admission (Fig. 1b). The young patient recovered completely from this acute episode and was discharged with a hospital stay of 22 days. M. pneumoniae pneumonia usually follows a benign course and the patient normally does not require hospitalization. The most common radiographic features of C.-Y. Chiu (*) . L.-M. Chiang Department of Pediatrics, Chang Gung Memorial Hospital, 222, Mai-chin Road, Keelung, Taiwan e-mail: pedchest@adm.cgmh.org.tw Tel.: +886-2-24313131 Fax: +886-2-24335342

Le pneumothorax tuberculeux

The tubercular pneumothorax is a rare and severe form of tuberculosis which persists in Tunisia. We reviewed retrospectively our experience at the Pneumology-Allergology Department of the Sousse Hospital with 23 cases of tubercular pneumothorax observed between 1985 and 2003. The suggestive symptom, pneumothorax, always occurred within a context poor general health and fever. The chest roentgengraph showed pneumothorax (n=8) or hydropneumothorax (n=15), and pulmonary lesions associated in 82.5% of patients. Bacteriological proof was obtained in 21 cases; in the two other patients, histological examination of the surgical specimen was highly suggestive of tuberculosis. Treatment associated antitubercular chemotherapy in compliance with the National Plan of against Tuberculosis (n=23), chest drainage (n=21) and respiratory physiotherapy (n=18). Five patients underwent surgery: pleural decortications (n=3), pulmonary resections (n=2). Two were lost to follow-up. The course was favourable in 78% of patients; there were two cases of partitioned pyopneumothorax and one post-operative death. In our experience, tubercular pneumothorax was always associated with active cavitated tuberculosis. The course was almost favorable with antitubercular chemotherapy and chest drainage.

Factors Influencing Length of Hospital Stay in Patients with Bacterial Pleural Effusion

Background: Factors influencing length of hospital stay have been poorly analyzed in parapneumonic pleural effusions (PPE). Objectives: The aim of this work is to identify the variables that determine increased hospital stay in patients with infectious pleural effusion (PE). Patients and Methods: We analyzed 112 patients with PE: empyema, complicated parapneumonic and non-complicated parapneumonic. Epidemiologic, biochemical, therapeutic and radiological variables were analyzed. Correlations with hospital stay were studied using the Student’s t test, analysis of variance, Mann-Whitney U-test and linear regression model. Results: Among the 112 patients studied, there were 32 empyema, 50 complicated and 30 non-complicated parapneumonic cases. The median of length stay for all patients was 17 days. Longer hospitalization was required in patients with empyemic PE (p = 0.015), patients with underlying diseases (p = 0.003), those needing pleural drainage (p = 0.005) or decortication (p = 0.043) and those presenting unfavorable radiological outcome after treatment (p = 0.02). Biochemical parameters associated with longer hospital stay were elevated pleural fluid polymorphonuclear elastase (p = 0.001, r = 0.307) and lactate dehydrogenase (p = 0.001, r = 0.312). After linear regression analysis, only underlying disease, pleural drainage and pleural fluid polymorphonuclear elastase values remained in the model, explaining 23.1% of the variability of days of hospitalization. Conclusions: The patients with PPE and empyema who required longer hospitalization were those with purulent fluid, underlying disease, surgical drainage and/or decortication, with unfavorable radiological outcome and higher pleural fluid levels of lactate dehydrogenase and polymorphonuclear elastase.

Phase II Study of a Liposome-Entrapped Cisplatin Analog (L-NDDP) Administered Intrapleurally and Pathologic Response Rates in Patients With Malignant Pleural Mesothelioma

To determine pathologic response rates to liposome-entrapped cis-bisneodecanoato-trans-R,R-1,2-diaminocyclohexane platinum(II) (L-NDDP) administered intrapleurally in patients with malignant pleural mesothelioma. Thirty-three patients with malignant pleural mesothelioma and free-flowing pleural effusions received intrapleural L-NDDP once every 3 weeks at a dose of 450 mg/m2. Thoracoscopic evaluation with pleural biopsies was performed before therapy and then after every two cycles. The primary end point was pathologic response as determined by thoracoscopic biopsy. After at least two cycles, post-treatment pleural biopsy analysis was negative in 14 patients for a pathologic response rate of 42% (95% CI, 25% to 61%). Median survival was 11.2 months. There were three treatment-related deaths secondary to peritonitis, cellulitis at the thoracoscopy site, and empyema. Grade 3 nonhematologic toxicities included infection, fever, dyspnea, and anorexia, which occurred in five (15%), one (3%), one (3%), and one (3%) patients, respectively. There were no grade 4 nonhematologic toxicities. Grade 3 or 4 neutropenia, thrombocytopenia, and anemia occurred in five (15%), three (9%), and two (6%) patients, respectively. Two patients with pathologic responses subsequently underwent pleural decortication. Both surgical specimens revealed residual tumor in regions that were not in direct communication with the pleural space. Intrapleural L-NDDP therapy in this patient population is feasible with significant but manageable toxicity. Although pathologic responses are highly encouraging, areas of mesothelioma that are not in direct communication with the pleural space will evade drug exposure and limit efficacy in some patients. The optimal role of intrapleural L-NDDP therapy currently remains to be determined.

Continuous pleural lavage may decrease postoperative morbidity in patients undergoing thoracotomy for stage 2 thoracic empyema

To assess the impact of postoperative continuous pleural lavage (PCPL) after thoracotomy for the treatment of stage 2 pleural empyema in relation to postoperative length of stay and morbidity. Stage 2 pleural empyema was diagnosed with computer tomography. Conservative treatment including antibiotics and pleural aspiration was introduced. 89 patients treated for stage 2 pleural empyema by thoracotomy, pleural discharge evacuation and irrigation after pleural decortication were identified after unsuccessful conservative treatment for 10 days. Whenever pleural discharge remained opaque after operation, PCPL was administered daily through the cranial chest tube and discharge evacuated through the caudal pleural suction (10-15 mmHg) tube. Risk factors related to pleural pus and patient outcome were sought for. Seventy-seven out of 89 patients (86.5%) had clear empyema discharge immediately after pleural decortication and irrigation. Pleural discharge remained opaque despite surgery in 12 out of 89 patients (13.5%) and PCPL was introduced. Presence of a combination of risk factors for pleural empyema, such as dental caries, alcohol abuse or previous inflammatory reaction, was predictive for persistence of opaque pleural discharge after operation (P<0.05). Need for re-thoracotomies (in 11 cases, P=ns) and postoperative deaths (P<0.05) were related with patients who did not have PCPL. The length of the hospital treatment was 20.1+/-3.1 (days+/-SEM) among patients with PCPL and 19.2+/-1.8 without PCPL before possible re-thoracotomy, respectively (P=ns). Early postoperative (1 day-11 months) mortality was statistically associated with patients having fibrinopurulent empyema but no PCPL. PCPL is a feasible method to clear pleural pus discharge without prolongation of hospitalization and may be recommended after thoracotomy for patients with fibrinopurulent stage 2 empyema.

The pathology associated with therapeutic procedures in malignant mesothelioma

To describe iatrogenic pathological lesions in malignant pleural mesothelioma. All cases of malignant pleural mesothelioma confirmed by antemortem pleural biopsy and undergoing post mortem examination over a 7-year period (1995-2001) formed the study group. This comprised 48 malignant pleural mesotheliomas [epithelioid (n = 21), biphasic (n = 14) and sarcomatoid (n = 13)]. Twenty-eight of 48 (58%) had received chemical (talc) pleurodesis, 30/48 (63%) palliative localized radiotherapy, 6/48 (13%) chemotherapy, and 14/48 (30%) surgery [12/48 (26%) pleural decortication and 2/48 (4%) pleuropneumonectomy]. Talc pleurodesis induces a marked pseudosarcomatous fibroblastic proliferation which may impart a biphasic pattern to the neoplasm. In more chronic cases, paucicellular fibrosis with a foreign body giant cell reaction is noted. The talc is polarizable and deposited in linear fashion within the tumour. In 2/28 (7%) pleurodesis cases platyform ferruginous bodies were seen in the peripheral alveolated lung parenchyma and these mimicked asbestos bodies. An awareness of this is important to prevent false attribution to asbestos. Talc could be identified by transmission electron microscopic mineral analysis in 5/15 (33%) cases examined. Tumour nodules developing subjacent to iatrogenic wound sites were noted in 8/48 (17%) cases. In 6/8 (75%) of these cases, comparative assessment of the locally irradiated subcutaneous chest wall tumour, with background pleural mesothelioma, showed no morphological difference in architectural tumour growth pattern, extent of necrosis, cytological or nuclear pleomorphism, mitotic activity or tumour immunophenotype. In 2/8 (25%) cases the locally irradiated tumour showed prominent bizarre multinucleated tumour giant cells and intense mixed inflammation, a feature not seen in the background (non-irradiated) tumour. All six malignant pleural mesotheliomas receiving chemotherapy appeared refractory to treatment in that chemotherapy did not appear to have any significant effect on the tumour morphology, cytonuclear pleomorphism, mitotic activity, extent of necrosis or immunophenotype. In the 12 decortication specimens and two pleuropneumonectomy resections, post mortem examination identified evidence of residual malignant mesothelioma of similar morphological subtype and immunophenotype to the resected tumour.

Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema

Background Video-assisted thoracoscopic surgery (VATS) for decortication or debridement in the management of empyema thoracis has increased the available treatment options but requires validation. We present and evaluate our technique and experience with thoracoscopic management of pleural empyema, irrespective of chronicity. Methods From May 1, 2000, to April 30, 2002, VATS debridement and decortication in 70 consecutive patients presenting with pleural space infections was performed with endoscopic shaver system. A retrospective review was performed and the effect of this technique on perioperative outcome was assessed. Results The VATS evacuation of infected pleural fluid and decortication was successfully performed in 65 of 70 patients. The mean duration of preoperative symptoms before referral was 23 ± 1.8 days. The mean duration of hospitalization before transfer was 13.5 ± 1.5 days. Blood loss was 330 ± 200 mL. Intercostal drainage was required for 5 ± 3 days. The postoperative hospital stay was 5 ± 0.7 days. There were no operative mortalities. Conclusions Video-assisted thoracoscopic decortication with endoshaver system is a simple and effective method in the management of the fibropurulent or organic pleural empyema.

Perforation et rupture de l'œsophage : prise en charge et pronostic

Aim of the study. – To analyze treatment and prognosis of perforations and ruptures of the oesophagus. Material and methods. – This retrospective study included 40 patients (26 men and 14 women; mean age = 59 ± 17 years) with a perforation or a rupture of the oesophagus. Seven perforations were cervical: iatrogenic ( n = 6) or following ingestion of a foreign body ( n = 1). Thirty-three perforations were thoracic: iatrogenic ( n = 15), spontaneous rupture ( n = 14), following ingestion of foreign body ( n = 3) or traumatic ( n = 1). All patients with cervical perforations were operated on (suture or drainage). One patient with thoracic perforation died before surgery, 2 underwent non-operative treatment and 30 were operated on. Twenty-eight underwent an oesophageal procedure: suture ( n = 13), oesophagectomy ( n = 11) or double exclusion ( n = 4). Two uderwent surgery without oesophageal procedure (one pleural decortication, and one ablation of a pleural foreign body). Results. – The overall mortality rate was 17% (7/40), 21% (3/14) after spontaneous ruptures and 19% (4/21) after iatrogenic perforations (no death for other aetiologies). The mortality rate was 14% (1/7) for cervical lesions and 18% (6/33) for thoracic ones. It was 8% (1/13) after intrathoracic suture, 18% (2/11) after oesophagectomy and 50% (2/4) after double exclusion. Conclusion. – Iatrogenic perforation and spontaneous rupture had the same poor prognosis. Non-surgical treatment is rarely indicated. oesophagectomy is a good option in case of non suturable oesophagus or delayed operation.

Pleural Fluid Analysis in Tuberculous Pleurisy Progressing into Severe Pleural Thickening Underwent Pleural Decortication

Background : Although most patients with tuberculous pleurisy respond well to anti-tuberculous drugs, some are known to progress into severe pleural thickening which needs decortication despite adequate anti-tuberculous treatment. Therefore, the purpose of this study was to identify factors associated with the development of severe pleural thickening in patients who finally underwent pleural decortication in tuberculous pleurisy. Patients and Methods : From retrospective medical records review, 121 patients initially diagnosed as tuberculous pleurisy without initial pleural fluid loculation were enrolled between January 1998 and December 2002. They were separated into two groups: 85 patients in group 1 who improved by anti-tuberculous drugs only, and 36 patients in group 2 who had progressed into pleural adhesion and finally underwent pleural decortication despite adequate (more than 6 months) anti-tuberculous treatment. Results : Males were more common in group 2 (M/F=31/5) than in group 1 (M/F=53/32) (p=0.010). Group 2 patients tended to have lower pleural fluid glucose level (58±4 mg/dL) than group 1 (89±3 mg/dL) (p=0.001) and higher pleural fluid adenosine deaminase level (86±5 IU/L) than group 1 (76±

The value of early CT in complicated childhood pneumonia.

To investigate the value of CT in complicated childhood pneumonia and its role in early intervention when chest radiography (CXR) is non-contributory. Forty-two immunocompetent children, aged 1-11 years, admitted for community-acquired pneumonia from October 1997 to September 1999, had 42 contrast-enhanced CT scans and frontal chest radiographs on the same day, which were assessed independently. CT was performed when the patient remained unwell and the CXR images showed failure of resolution despite 7-10 days of antibiotics and/or drainage with urokinase therapy. Compared to CT, CXR revealed suboptimal accuracy rates of lobar involvement (84%), chest tube placement (73%), fluid loculation (42%), abscess formation (40%) and bronchopleural fistulae (33%). It could not assess parenchymal or pleural complications such as cavitary necrosis, early abscess formation, empyemas or pericardial effusions. On the basis of the CT findings and poor clinical progress, 16 patients underwent surgical intervention with the aid of video-assisted thorascopic surgery (VATS). The CT features correlated well with surgical findings. Ten cases required pleural decortication while six with destructive or necrotic lung lesions had surgical resection. Debridement was difficult when the pleura had become thick and fibrotic. Streptococcus pneumoniae was the offending organism in 81% of cases. The right side was affected in 67% of cases. In complicated childhood pneumonia, CT is far superior to CXR in revealing pleural and parenchymal complications, which may require early surgical intervention.

Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema

Background. We evaluated a technique of video-assisted thoracoscopic (VAT) decortication of the visceral cortex to reexpand entrapped lung in cases of chronic postpneumonic pleural empyema.Methods. A prospective cohort study of 48 consecutive patients with multiloculated postpneumonic pleural empyema in whom visceral pleural decortication was required was studied. The effect of VAT decortication on perioperative outcome and factors affecting its success were assessed.Results. Before the introduction of VAT decortication 12 patients were treated by thoracotomy (group T). In the subsequent 36 patients VAT decortication was attempted with success in 21 (group VS) but lung expansion was not observed in 15 patients (group VF) who required thoracotomy. There was no difference in the age or sex distribution of the 3 groups. Operating time was significantly longer in group T than group VS, mean difference 30.3 minutes (p = 0.001) and postoperative hospital stay was longer in group T than group VS, mean difference 2.9 days (p = 0.004). The success of VAT decortication was not related to either the delay between onset of symptoms or hospital admission and surgery; indeed the operating time decreased with increasing preoperative delay. However, success was related to increasing operative experience (p = 0.001).Conclusions. VAT decortication is a feasible new technique to achieve lung reexpansion in chronic postpneumonic pleural empyema and has perioperative benefits over thoracotomy.

Disseminated septic arthritis in a patient with common variable hypogammaglobulinemia

HISTORY OF PRESENT ILLNESS The patient was a 38-year-old man with a long history of common variable immunodeficiency (CVID) who was admitted to the hospital with a 3-day history of progressive obtundation followed by lethargy and coma. Fever, swelling, and pain of the left ankle were also noted on admission. Very little additional history was obtainable because the patient lived alone and his family was unable to provide further information. One month earlier, the patient was hospitalized for peritonitis, pneumonia, right-sided empyema, possible splenic abscesses, chronic anemia, and arthralgias of the right wrist and shoulder. All the routine bacterial cultures of blood, peritoneal, and empyema fluids were negative, and he was treated with broad-spectrum antibiotics (ampicillin, gentamicin, metronidazole, ciprofloxacin) and pleural decortication. During that hospitalization, he complained of arthralgias (wrists and right shoulder) that were interpreted as being tenosynovitis. The patient had not received intravenous Ig treatment for 3 years before this hospitalization. During the hospitalization, he received a dose of intravenous immunoglobulin (IVIG; 200 mg/kg), and his symptoms of tenosynovitis improved.

Factors Associated with Residual Pleural Thickening After Chemotherapy in Tyberculous Pleurisy

Background Residual pleural thickening is frequently seen following treatment for tuberculous pleurisy, and pleural decortication is performend occasionally in patients with severe residual pleural thickening. However, predictive factors for the development of residual pleural thickening are uncertain at the initial diagnosis of the tuberculous pleurisy. Therefore, the purpose of this study was to identify the associated factors for residual pleural thickening at initial diagnosis. Methods We separated 63 patients diagnosed as tuberculous pleurisy into two groups; group 1 consisted of patients without residual pleural thickening and group 2 comprised patients with residual pleural thickening at the end of tuberculous pleurisy treatment. We analyzed the clinical characteristics, radiological findings, pleural biopsy and characteristics of pleural fluid between group 1 and group 2. Results The study population and clinical symptoms of the two groups were not significantly different and the duration of symptoms before treatment and the peripheral WBC were similar between the two groups. The presence of pulmonary tuberculosis, pleural fluid loculation or the amount of pleural effusion sid not differ significantly between the thwo groups. The incidence of positive AFB staining(group 1 : 8%, group 2 : 38%) and granuloma(group 1 : 30%, group 2 : 62%) on pleural biopsy specimens was significantly higher in group 2 than in group 1. Pleural fluid WBC and differential count, adenosine deaminase level, pH, preotein level or glucose level did not differ between the two groups. However, group 2 had higher LDH levels (1370±208mg/dl) than group 1 (860±71mg/dl, p<0.05). Conclusion In tuberculous pleurisy, patients with residual pleural thickening following treatment demonstrated a higher incidence of posivive AFB staining and granuloma on the pleural biopsy specimens or higher LDH level in the pleural fluid than patients wihtout residual pleural thickening From these results, we speculate that the amonut of tuberculous bacilli and granuloma are probably correlated with residual pleural thickening in the tuberculous pleurisy.