MEDICAL NEWS in Brief

Excision of an empyema sac and thickened pleura from the lung and chest wall has been performed for over 70 years. The most appropriate fields of application of this procedure are in treatment of tuberculous empyema, empyema complicating pneumonic processes (most frequently caused by staphylococcal infection), and clotted hemothorax following chest injury. The authors'' experience with 33 such decortications in the past five years is described, observations concerning the techniques, complications, and end results of the procedure are discussed, and illustrative case reports are presented.     

Staphylococcal Pneumonia and Empyema in Infants and Children

One hundred and seventy-six cases of staphylococcal pneumonia and 35 cases of empyema in infants and children have been studied. There were seven deaths, five in patients with empyema and two in patients without this complication. Early diagnosis on the basis of clinical symptoms and signs and institution of therapy without awaiting radiological or bacteriological confirmation are necessary to prevent development of empyema and to reduce the mortality rate. Chloramphenicol and erythromycin, administered systemically, were generally effective. In severely toxic subjects antitoxin appeared to be of value. Blood transfusion was used to correct the rapidly progressive anemia. A chest radiograph was essential to diagnose empyema. Treatment of this condition by closed intercostal catheter drainage was effective. Pneumatoceles were encountered, but resolved spontaneously. Although there has been no significant decrease in the number of cases of pneumonia encountered, there have been no deaths since 1958 on the treatment outlined.     

A Simple Method for Differentiating Complicated Parapneumonic Effusion/Empyema from Parapneumonic Effusion Using the Split Pleura Sign and the Amount of Pleural Effusion on Thoracic CT

Background

Pleural separation, the “split pleura” sign, has been reported in patients with empyema. However, the diagnostic yield of the split pleura sign for complicated parapneumonic effusion (CPPE)/empyema and its utility for differentiating CPPE/empyema from parapneumonic effusion (PPE) remains unclear. This differentiation is important because CPPE/empyema patients need thoracic drainage. In this regard, the aim of this study was to develop a simple method to distinguish CPPE/empyema from PPE using computed tomography (CT) focusing on the split pleura sign, fluid attenuation values (HU: Hounsfield units), and amount of fluid collection measured on thoracic CT prior to diagnostic thoracentesis.

Methods

A total of 83 consecutive patients who underwent chest CT and were diagnosed with CPPE (n=18)/empyema (n=18) or PPE (n=47) based on the diagnostic thoracentesis were retrospectively analyzed.

Results

On univariate analysis, the split pleura sign (odds ratio (OR), 12.1; p<0.001), total amount of pleural effusion (≥30 mm) (OR, 6.13; p<0.001), HU value≥10 (OR, 5.94; p=0.001), and the presence of septum (OR, 6.43; p=0.018), atelectasis (OR, 6.83; p=0.002), or air (OR, 9.90; p=0.002) in pleural fluid were significantly higher in the CPPE/empyema group than in the PPE group. On multivariate analysis, only the split pleura sign (hazard ratio (HR), 6.70; 95% confidence interval (CI), 1.91-23.5; p=0.003) and total amount of pleural effusion (≥30 mm) on thoracic CT (HR, 7.48; 95%CI, 1.76-31.8; p=0.006) were risk factors for empyema. Sensitivity, specificity, positive predictive value, and negative predictive value of the presence of both split pleura sign and total amount of pleural effusion (≥30 mm) on thoracic CT for CPPE/empyema were 79.4%, 80.9%, 75%, and 84.4%, respectively, with an area under the curve of 0.801 on receiver operating characteristic curve analysis.

Conclusion

This study showed a high diagnostic yield of the split pleura sign and total amount of pleural fluid (≥30 mm) on thoracic CT that is useful and simple for discriminating between CPPE/empyema and PPE prior to diagnostic thoracentesis.     

On a Fatal Case of <Emphasis Type="Italic">Candida krusei</Emphasis> Pleural Empyema in a Pregnant Woman with Spontaneous Esophagus Perforation

Introduction  

Candida empyema thoracis can be a consequence of operation, gastropleural fistula, and esophageal perforation. Case report and review of the literature. A fatal case of a 45-year-old pregnant woman with Candida krusei empyema thoracis secondary to spontaneous esophagus perforation associated with candida esophagitis is reported. The case is contextualized among similar cases found through a PubMed search.     

Pyogenic Postpneumonectomy Empyema

The Clagett method of managing postpneumonectomy empyema was used on two patients and proved efficacious. After tube drainage (if a bronchopleural fistula is present), treatment is begun by creating a pleurostomy in a dependent site. The patient may then be cared for as an outpatient, and dressings may be changed at home. After a few months, when the pleura is clean, the pleurostomy is closed surgically and the space is filled with ¼% neomycin solution. If a fistula is present, this is closed at the same time. The treatment depends on the ability of the neomycin to sterilize any residual infection, after temporary drainage of the empyema. It makes unnecessary a major and mutilating thoracoplasty or even permanent tube drainage, which is usually difficult to manage on an outpatient basis.     

At one time,operations outside the hospital were not uncommon.

Before World War II, it was not uncommon for a person with influenza caused by streptococcus to develop empyema. Retired surgeon Harry Morton recalls two well-known patients who had empyema-related operations outside the hospital.     

Group-F streptococcal pleuro-pericarditis in a mesothelioma patient after dental surgery (case report)

A 71-year-old mesothelioma patient developed pleuro-pericarditis and pleural empyema. Bacteriological examinations and serological identification proved group F Streptococcus in the pleural fluid. Anamnestic data suggested that the source of infection might have been the oral cavity after dental surgery.     

Fine needle aspiration biopsy of mastitis secondary to empyema necessitatis. A report of two cases.

BACKGROUND: Empyema necessitatis is a relatively rare entity. Two instances of mastitis secondary to empyema necessitatis, diagnosed by fine needle aspiration biopsy are reported. CASES: One case was tuberculous in etiology and was initially recognized by cytologic findings of epithelioid and granulomatous cellular reactions and the presence of acid-fast bacilli, which were subsequently cultured and speciated as Mycobacterium tuberculosis. The other case was due to coexisting Actinomyces and Actinobacillus. These organisms were cytologically suggested by "sulfur" granules of filamentous, gram-positive bacilli, admixed gram-negative coccobacilli and Splendore-Hoeppli phenomenon in an exudative cell background and were confirmed by microbiologic culture as Actinomyces israelii and Astinomyces actinomycetemcomitans, respectively. CONCLUSION: The usefulness of fine needle aspiration cytology in the diagnosis of empyema necessitatis, supported by ancillary microbial culture, histochemistry, and radiographic imaging, is well illustrated by these two cases.     

Actinomyces naeslundii as an Agent of Human Actinomycosis

The repeated isolation of Actinomyces naeslundii from clinical materials associated with disease led to a comparison of isolates from the normal mouth with isolates from pathological clinical materials not from the mouth area. No important differences were observed between the isolates from these two sources. A human case of empyema of the gall bladder, apparently due to A. naeslundii, is described.     

Serum protein and zinc levels in patients with thoracic empyema

The element Zn is the metal component or activator of many important enzymes. The tissue concentrations and activities of Zn metalloenzymes direct the rate of protein and nucleic acid syntheses, thereby influencing tissue growth and reperative processes. Most of the serum Zn is normally bound to circulating proteins. Low serum Zn concentrations might result from depletion of Zn-binding proteins. Serum protein and Zn concentrations have been reported to be depressed in patients with acute and chronic diseases. We compare the serum protein and Zn values of patients with thoracic empyema (n=20) with those of a control group (n=20). The values obtained in the empyema group were significantly lower than those in the control group before the study. Test group administered 220 mg zinc sulfate (ZnSO₄. 7H₂O) over 20 d and there was a significant increase in the values for serum protein and Zn after the oral administration of the zinc sulfate.     

Bacterial induction of pleural mesothelial monolayer barrier dysfunction

Pneumonia remains one of the most common infectious causes of mortality. Patients with pneumonia develop parapneumonic effusions with a high neutrophil count as well as high protein concentrations. We hypothesized that pulmonary parenchymal bacterial infection causes a permeability change in the pleural mesothelium by inducing the production of vascular endothelial growth factor (VEGF). Complicated parapneumonic pleural effusions (empyema) have a 19-fold higher VEGF level than pleural fluids secondary to congestive heart failure and a 4-fold higher level than pleural fluids secondary to uncomplicated parapneumonic effusions. We also analyzed the influence of live Staphylococcus aureus on mesothelial barrier function using a model of confluent mesothelial monolayers. There was a significant drop in electrical resistance across S. aureus-infected pleural mesothelial cell (PMC) monolayers. Recombinant VEGF also decreases PMC electrical resistance. Neutralizing antibodies to VEGF significantly inhibited the drop in PMC electrical resistance caused by S. aureus. S. aureus infection also caused a significant increase in protein leak across confluent mesothelial monolayers. Our results suggest that bacterial pathogens induce VEGF release in mesothelial cells and alter mesothelial permeability, leading to protein exudation in empyema.     

Intrathoracic muscle flaps: a 10-year experience in the management of life-threatening infections

From 1977 to 1987, 87 consecutive patients underwent intrathoracic muscle transposition. Indications for the operation were bronchopleural fistula, postpneumonectomy empyema, perforation of the heart or great vessels, esophageal fistula, tracheal fistula, empyema, and prophylactic reinforcements of the airway. Of the 118 muscles transposed, the serratus anterior was used in 48 patients, the latissimus dorsi in 33, the pectoralis major in 26, and other muscles in 11. Depending on the wound status at the time of muscle transposition, the chest either was left open for dressing changes or was closed primarily. The number of operations per patient ranged from 1 to 16 (median 2). There were 13 operative deaths (14.9 percent). The follow-up period ranged from 3.9 to 130.9 months (median 28.3 months). Overall results were excellent in 65 patients (74.7 percent). There was no difference in results when considered according to treatment indication. We conclude that when there is an actual or potential leak of the tracheobronchial tree, heart and great vessels, or intrathoracic gastrointestinal tract, intrathoracic muscle transposition can be a lifesaving adjunct.     

Reconstruction of irradiated postpneumonectomy empyema cavity with chain-link coupled microsurgical omental and TRAM flaps

We present the first case of complete hemithoracic reconstruction of an irradiated postpneumonectomy recurrent empyema cavity that was unresponsive to multiple conventional treatments. The procedure described used a chain-link of two coupled free flaps consisting of an omental and TRAM flap. A single abdominal donor site and single operative position are other advantages of this technique that provides sufficient volume to obviate the need for thoracoplasty even in the largest wounds.     

Thoracic empyema: a 12-year study from a UK tertiary cardiothoracic referral centre

Background

Empyema is an increasingly frequent clinical problem worldwide, and has substantial morbidity and mortality. Our objectives were to identify the clinical, surgical and microbiological features, and management outcomes, of empyema.

Methods

A retrospective observational study over 12 years (1999–2010) was carried out at The Heart Hospital, London, United Kingdom. Patients with empyema were identified by screening the hospital electronic ‘Clinical Data Repository’. Demographics, clinical and microbiological characteristics, underlying risk factors, peri-operative blood tests, treatment and outcomes were identified. Univariable and multivariable statistical analyses were performed.

Results

Patients (n = 406) were predominantly male (74.1%); median age = 53 years (IQR = 37–69). Most empyema were community-acquired (87.4%) and right-sided (57.4%). Microbiological diagnosis was obtained in 229 (56.4%) patients, and included streptococci (16.3%), staphylococci (15.5%), Gram-negative organisms (8.9%), anaerobes (5.7%), pseudomonads (4.4%) and mycobacteria (9.1%); 8.4% were polymicrobial. Most (68%) cases were managed by open thoracotomy and decortication. Video-assisted thoracoscopic surgery (VATS) reduced hospitalisation from 10 to seven days (P = 0.0005). All-cause complication rate was 25.1%, and 28 day mortality 5.7%. Predictors of early mortality included: older age (P = 0.006), major co-morbidity (P = 0.01), malnutrition (P = 0.001), elevated red cell distribution width (RDW, P<0.001) and serum alkaline phosphatase (P = 0.004), and reduced serum albumin (P = 0.01) and haemoglobin (P = 0.04).

Conclusions

Empyema remains an important cause of morbidity and hospital admissions. Microbiological diagnosis was only achieved in just over 50% of cases, and tuberculosis is a notable causative organism. Treatment of empyema with VATS may reduce duration of hospital stay. Raised RDW appears to associate with early mortality.     

New cause of penicillin treatment failure.

A large empyema infected with a penicillin-sensitive haemolytic group B streptococcus failed to respond to high doses of penicillin. After two weeks'' treatment the pus aspirated was found not only to contain no penicillin, but also to inactivate penicillin added to it. We believe that the inactivating agent is an enzyme that may destroy various penicillins and cephalosporins but has no effect on other common antibiotics. When treatment was changed to doxycycline the patient made a rapid recovery.     

Anaerobic Bacteriology in 75 Cases of Thoracic Empyema in Sofia,Bulgaria

The aim of this study was to evaluate the prevalence of anaerobes in patients with thoracic empyema over a period of 30 months and to assess the susceptibility of the isolates to penicillin, clindamycin and metronidazole. Seventy-nine pleural fluid specimens were obtained from 75 adult patients with empyema. Anaerobic isolates were identified by Crystal anaerobes identification system and routine methods. Susceptibility testing was conducted using broth microdilution method and limited agar dilution test. Anaerobic bacteria were found in 50 (66.7%) of the patients and included 96 isolates representing 16 genera. The predominant Gram-positive anaerobes were Peptostreptococcus species (19 isolates) and Streptococcus intermedius (10), and the commonest Gram-negative species were Fusobacterium nuleatum (13),Fusobacterium necrophorum (6) and Prevotella inermedia (3). From two to four anaerobes per specimen were present in 57.4% of the specimens yielding anaerobic bacteria. The susceptibility of the Gram-negative anaerobic isolates to penicillin and that of the Gram-positive anaerobes to clindamyin and metronidazole were unpredictable. The variable resistance patterns among anaerobes and the predominance of mixed anaerobic infections highlight the role of the anaerobic dignostics in case of serious pleuropulmonary diseases.     

Pleuropulmonary amebiasis

Pleuropulmonary amebiasis may be manifest without diarrhea or dysentery.In obscure lesions of the right lower lung field, one should always consider pleuropulmonary amebiasis-especially with low grade fever and moderate leukocytosis. Abscess and empyema contents should be examined promptly microscopically or kept warm to preserve the motility of the trophozoites until satisfactory examination is possible. Conservative therapy will successfully manage most cases of pleuropulmonary amebiasis. If a thorough search fails to reveal Entameba histolytica, and the diagnosis is still entertained, a medical therapeutic trial is in order.     

Anaerobic microbiology in 198 cases of pleural empyema: a Bulgarian study

The aim of the study was to evaluate the incidence of anaerobic bacteria in 198 patients with pleural empyema and the susceptibility of isolates to eight antibacterial agents. Isolates were identified by the Crystal anaerobes identification system, API System rapid ID 32 A and/or routine methods. Susceptibility was tested by Sceptor MIC system for anaerobic bacteria and limited agar dilution method. Anaerobic bacteria were found in 74.2% of the patients and included 247 strains within 21 genera. The predominant anaerobes were Gram-positive anaerobic cocci (52 isolates), Fusobacterium (51), microaerophilic streptococci (24), Prevotella (19) and Bacteroides species (11). Common species/groups were Fusobacterium nucleatum (in 27.2% of specimens yielding anaerobes), Micromonas micros (8.2%), Finegoldia magna (7.5%), Bacteroides fragilis group (6.8%), Peptostreptococcus anaerobius (6.1%) and F. necrophorum (5.4%). No resistance to chloramphenicol and ampicillin/sulbactam was detected. The susceptibility rates of Gram-negative anaerobic isolates to penicillin, cefoxitin, clindamycin, clarithromycin, metronidazole and tetracycline were 63.8%, 90.2%, 87.8%, 58.6%, 98.8% and 71%, and those of Gram-positive anaerobes were 79.2%, 100%, 84.3%, 68.4%, 41.9% and 75%, respectively. The wide diversity of isolated anaerobic genera and species and the susceptibility patterns of the isolates emphasize the role of the anaerobic microbiology in cases of pleural empyema.     

An unusual presentation with persistent left superior vena cava

Persistent left superior vena cava (LSVC) is the most common congenital systemic venous anomaly, which may give rise to several problems. We present a case in which a persistent LSVC was an unsuspected finding. A 70-year-old male presented with intracerebral empyema which may have been caused by venous septic emboli from the left arm and facilitated by a persistent LSVC draining directly into the left atrium. Visualisation of the anomaly was performed with echocardiography and magnetic resonance angiography. In addition we present a brief review of the literature concerning this disorder.