Wiesman, Irvin M.; Hernan, M. Janeen; Sekosan, Marin; Vigneswaran, Wickii T.
Blastomycosis is endemic in river valley areas of the south-eastern and Midwestern United States. Pulmonary manifestations include chronic cough and pleuritic pain. Radiographie appearance of the infection can mimic bronchogenic lung carcinoma. Pleural effusion is rarely associated with this pulmonary infection, and empyema has not been previously reported. We report a case of pulmonary and pleural Blastomyces dermatitidis infection presenting as empyema thoracis. Diagnosis and treatment were attained with video-assisted thoracoscopic (VATS) pleural and lung biopsy and debridement. PMID:10323175
Robinson, Clayton L. N.
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. ImagesFig. 1Fig. 2Fig. 3Fig. 4 PMID:5928526
Robinson, C L
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 (1/4)% 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.
Zimmerman, R.D.; Leeds, N.E.; Danziger, A.
CT scans in 49 patients with surgically proven subdural empyema were evaluated. The empyemas were crescentic or lentiform extra-axial hypodense collections (density approximating that of cerebrospinal fluid) with prominent, sharply etched medial rim enhancement. Enhancement of the adjacent cerebral cortex was identified in many cases. Mass effect was always present and in 10 cases so extensive that it overshadowed a small extra-axial collection. CT allowed for precise localization of the lesion, including contiguous or isolated involvement of the interhemispheric subdural space. Mortality was 12% (6/49 cases), a marked improvement when compared with mortality figures obtained prior to the advent of CT (40%). CT findings indicative of involvement of the adjacent parenchyma via retrograde thrombophlebitis with resultant infarction and/or abscess formation were associated with poor prognosis. Improvement in prognosis since the advent of CT is the direct result of early accurate diagnosis and timely intervention.
Mayall, B C; Snashall, E A; Peel, M M
We report the isolation of Clostridium tetani (along with Fusobacterium mortiferum) from empyema pus. The patient, a 68 year old retired farmer from rural NSW, had recently undergone cholecystectomy, had heart failure and developed an empyema. He improved after drainage of the empyema and penicillin therapy, but died suddenly during convalescence.
Fields, C L; Ossorio, M A; Roy, T M
Sporothrix schenckii produces an insidious debilitating illness in humans. The lungs are seldom involved and pleural involvement is distinctly unusual, with only four patients described in the literature. We have described a patient with both parenchymal lung disease and pleural effusion. The characteristics of the pleural fluid were unlike those previously reported, and suggest that the coexistence of a parenchymal Sporothrix infiltrate may alter the nature of the pleural fluid to mimic an empyema rather than a self-limited hypersensitivity reaction.
Ampofo, Krow; Sheng, Xiaoming; Pavia, Andrew T.; Cannon-Albright, Lisa; Byington, Carrie L.
Bacterial pneumonia with empyema is a serious complication of influenza and commonly resulted in death during the 1918 influenza pandemic. We hypothesize that deaths caused by parapneumonic empyema are increasing in Utah once again despite advances in critical care and the availability of antimicrobial drugs and new vaccines. In this study, we analyzed the historical relationship between deaths caused by empyema and influenza pandemics by using 100 years of data from Utah. Deaths caused by empyema have indeed increased from 2000–2004 when compared with the historic low death rates of 1950–1975. Vaccine strategies and antimicrobial drug stockpiling to control empyema will be important as we prepare for the next influenza pandemic. PMID:19116048
Bender, Matthew T; Ferraris, Victor A; Saha, Sibu P
Historically, surgical management of empyema was performed predominantly via open thoracotomy; however, during the past decade the use of video-assisted thoracoscopic surgery (VATS) as an alternative has increased. This study retrospectively compared the outcomes and management of patients with empyema at the University of Kentucky Medical Center who had undergone VATS versus those receiving open thoracotomy to determine whether VATS decortication provided comparable results. Adult patients who had undergone open thoracotomy or VATS decortication for empyema between 2005 and 2009 at the University of Kentucky were identified by querying the hospital's cardiothoracic surgery database. Patients were sorted by procedure on an intent-to-treat basis. Comorbid conditions, preoperative course, operative outcomes, and postoperative outcomes were compared. Quantitative data were analyzed with either an unpaired t test or the Mann-Whitney U test. Qualitative data were analyzed using the Fisher exact test. Fifty-three patients were identified, 18 of whom underwent VATS and 35 underwent open thoracotomy. Eight of the 18 VATS procedures (44.4%) were converted to open thoracotomy. Patients undergoing VATS had a significantly shorter median length of stay (11 vs 18 days, respectively; P = 0.044), chest tube duration (6 vs 12 days, respectively; P < 0.001), operative blood loss (55.6 vs 344 mL, respectively; P = 0.003), and fewer postoperative respiratory failures (0% vs 22.9%, respectively; P = 0.0451). The two groups did not differ significantly in overall morbidity, reoperation, mortality, or preoperative comorbidities. In adults, VATS offers results comparable to those of open thoracotomy, and lengths of stay, chest tube durations, and postoperative outcomes are superior. Although the conversion rate of VATS to open thoracotomy at our institution was high (38.1%) compared with studies at other institutions, the data still indicate that VATS is both a safe and reliable
... which worsens when you breathe in deeply (pleurisy) Dry cough Excessive sweating , especially night sweats Fever and chills General discomfort, uneasiness, or ill feeling ( malaise ) Shortness of breath Weight loss (unintentional) Exams and Tests The health care provider may note decreased breath ...
Open window thoracostomy for thoracic empyema: Open window thoracostomy is a simple, certain and final drainage procedure for thoracic empyema. It is most useful to drain purulent effusion from empyema space, especially for cases with broncho-pleural fistulas, and to clean up purulent necrotic debris on surface of empyema sac. For changing of packing gauzes in empyema space through a window once or twice every day after this procedure, thoracostomy will have to be made on the suitable position to empyema space. Usually skin incision will be layed along the costal bone just at the most expanded position of empyema. Following muscle splitting to thoracic wall, a costal bone just under the incision will be removed as 8-10 cm as long, and opened the empyema space through a costal bed. After the extension of empyema space will be preliminarily examined through a primary window by a finger or a long forceps, it will be decided costal bones must be removed how many (usually 2 or 3 totally) and how long (6-8 cm) to make a window up to 5 cm in diameter. Thickened empyema wall will be cut out just according to a window size, and finally skin edge and empyema wall will be sutured roughly along circular edge. Muscle flap transposition for empyema space: Pediclued muscle flap transposition is one of space-reducing operations for (chronic) empyema Usually this will be co-performed with other several procedures as curettages on empyema surface, closure of bronchopleural fistula and thoracoplasty. This is radically curable for primarily non fistulous empyema or secondarily empyema after open window thoracostomy done for fistula. Furthermore this is less invasive than other radical operations as like pleuro-pneumonectomy, decortication or air-plombage for empyema. There are 2 important points to do this technique. One is a volume of muscle flap and another is good blood flow in flap. The former suitable muscle volume is need to impact empyema space or to close fistula, and the
Allam, Naglaa A. H.
Spontaneous bacterial empyema, defined as spontaneous infection of the pleural fluid, represents a distinct complication of hepatic hydrothorax with a different pathogenesis, clinical course and treatment strategy from those of empyema secondary to pneumonia. Nearly 40% of episodes of spontaneous empyema are not associated with spontaneous bacterial peritonitis (SBP) or even ascites. The condition portends a poor prognosis, and is frequently under-diagnosed. This article reviews the pathogenesis, diagnosis and management of spontaneous bacterial empyema. PMID:19568497
Allam, Naglaa A H
Spontaneous bacterial empyema, defined as spontaneous infection of the pleural fluid, represents a distinct complication of hepatic hydrothorax with a different pathogenesis, clinical course and treatment strategy from those of empyema secondary to pneumonia. Nearly 40% of episodes of spontaneous empyema are not associated with spontaneous bacterial peritonitis (SBP) or even ascites. The condition portends a poor prognosis, and is frequently under-diagnosed. This article reviews the pathogenesis, diagnosis and management of spontaneous bacterial empyema.
Andrade-Alegre, Rafael; Garisto, Juan D.; Zebede, Salomón
OBJECTIVES Traditionally, chronic empyema has been treated by thoracotomy and decortication. Some recent reports have claimed similar clinical results for videothoracoscopy, but with less morbidity and mortality than open procedures. Our experience with thoracotomy and decortication is reviewed so that the results of this surgical procedure can be adequately evaluated. MATERIALS AND METHODS From March 1992 to June 2006, 85 patients diagnosed with empyema were treated at Santo Tomás Hospital by the first author. Diagnosis of chronic empyema was based on the duration of signs and symptoms before definitive treatment and imaging findings, such as constriction of the lungs and the thoracic cage. Thirty-three patients fulfilled the criteria for chronic empyema and underwent open thoracotomy and decortication. RESULTS Twenty-seven patients (81.8 %) were male and the average age of the study group was 34 years. The etiology was pneumonia in 26 patients (78.8%) and trauma in 7 (21.2%). The duration of symptoms and signs before definitive treatment averaged 37 days. All patients had chronic empyema, as confirmed by imaging studies and operative findings. Surgery lasted an average of 139 min. There were 3 (9%) complications with no mortality. The post-operative length of stay averaged 10 days. There were no recurrences of empyema. CONCLUSIONS Open thoracotomy and decortication can be achieved with low morbidity and mortality. Long-term functional results are especially promising. We suggest that the validation of other surgical approaches should be based on comparative, prospective and controlled studies. PMID:19061002
Teng, Chung-Jen; Hu, Yu-Wen; Yeh, Chiu-Mei; Chen, Tzeng-Ji; Liu, Chia-Jen
Abstract This study aimed to evaluate cancer risk and possible risk factors in patients diagnosed with empyema. A total of 31,636 patients with newly diagnosed empyema between January 1, 1999 and December 31, 2010 were included in this study. Standardized incidence ratios (SIRs) were calculated to compare the cancer incidence in these empyema patients to that in the general population. Adjusted hazard ratios were also calculated to investigate whether characteristics increased cancer risk. During the 12-year study period, 2,654 cancers occurred in 31,636 patients with empyema, yielding an SIR of 2.67 (95% confidence interval [CI] 2.57–2.78). We excluded cancer that occurred within 1 year to avoid surveillance bias. The cancer risk remained significantly increased (SIR 1.50, 95% CI 1.41–1.58). Specifically, patients with empyema had higher SIR of cancers of the head and neck (1.50, 95% CI 1.41–1.58), esophagus (2.56, 95% CI 1.92–3.33), stomach (1.49, 95% CI 1.16–1.89), liver and biliary tract (2.18, 95% CI 1.93–2.45), and lung and mediastinum (1.62, 95% CI 1.39–1.86). Age ≥ 60, male sex, diabetes mellitus, and liver cirrhosis were independent risk factors for cancer development. Our study demonstrates an increased incidence of cancer development in patients with empyema, and patients’ age ≥ 60, men, and those with diabetes mellitus and liver cirrhosis showed a higher incidence of developing cancer compared to the general population. The association between such kind of infection and secondary malignancy may be elucidated by further study. PMID:26945399
Ballantyne, K C; Sethia, B; Reece, I J; Davidson, K G
Over the past 9 years, ten patients have presented to the Thoracic Unit, Glasgow Royal Infirmary, with 12 empyemas secondary to intra-abdominal sepsis. In eight patients, the presenting signs and symptoms were wrongly attributed to primary intra-thoracic pathology. All were subsequently found to have intra-abdominal sepsis. The presence of empyema after recent abdominal surgery or abdominal pain strongly suggests a diagnosis of ipsilateral subphrenic abscess. Adequate surgical drainage is essential. In our experience, limited thoracotomy with subdiaphragmatic extension offers the best access to both pleural and subphrenic spaces and provides the greatest chance of eradicating infection on both sides of the diaphragm.
Biswas, Abhishek; Jantz, Michael A; Penley, Andrea M; Mehta, Hiren J
Objectives: High preoperative risk precludes decortication and other surgical interventions in some patients with chronic empyema. We manage such patients by converting the chest tube into an “empyema tube,” cutting the tube near the skin and securing the end with a sterile clip to allow for open pleural drainage. The patient is followed serially, and the tube gradually withdrawn based on radiological resolution and amount of drainage. Methods: Between 2010 and 2014, patients with chronic empyema and unexpandable lung, deemed high-risk surgical candidates, had staged chest tube removal, and were included for the study. The volume of fluid drained, culture results, duration of drainage, functional status, and comorbidities were recorded. Measurements and Results: Eight patients qualified. All had resolution of infection. The tube was removed after an average of 73.6 ± 49.73 (95% confidence interval [CI]) days. The mean duration of antibiotic treatment was 5.37 ± 1.04 (95% CI) weeks. None required surgery or experienced complications from an empyema tube. Conclusion: A strategy of empyema tube drainage with staged removal is an option in appropriately selected patients with chronic empyema, unexpandable lung, and poor surgical candidacy. PMID:27185989
Ogata, Tomoyuki; Urata, Teruo; Nemoto, Daisuke; Hitomi, Shigemi
We report a case of thoracic empyema caused by Campylobacter rectus, an organism considered as a periodontal pathogen but rarely recovered from extraoral specimens. The patient fully recovered through drainage of purulent pleural fluid and administration of antibiotics. The present case illustrates that C. rectus can be a cause of not only periodontal disease but also pulmonary infection.
Flores-Franco, René Agustín
Hepatobiliary conditions should be considered in the differential diagnosis of right pleural effusion. Here we present the illustrative images of thoracic empyema due to migrated gallstones in a woman who was treated for laparoscopic cholecystectomy one year before. The gallstones were obtained unexpectedly during a thoracentesis with aid of an Abrams needle. This rare complication is discussed under current literature review.
Iskandar, Said B; Al Hasan, Muhanad A; Roy, Thomas M; Byrd, Ryland P
Despite the evolution of modern antibiotics, pleural space infection remains a common illness with significant morbidity and mortality. Every year up to 60 percent of the 1.2 million patients in the United States who present with community-acquired pneumonia develop parapneumonic pleural effusions. Few of these parapneumonic effusions progress to an empyema. Interestingly, in about 10 percent of the cases of empyema, no underlying pulmonary infection can be identified. These pleural space infections are called primary empyemas. We present a patient with a primary empyema caused by Streptococcus intermedius. Relatively few studies have investigated primary empyema caused Streptococcus intermedius. This case presentation serves as a reminder to the clinician about primary empyema caused by this micro-organism.
Chang, R; Higgins, M; DiLisio, R; Hawasli, A; Camaro, L G; Khatib, R
An 81-year-old man, previously a shepherd in Italy, presented with recurrent Escherichia coli empyema over an 8-month period. His empyema was caused by an infected, nonviable hepatic Echinococcus cyst that eroded the diaphragm and led to intermittent spillage and pleural seeding. This case demonstrates that when dealing with Escherichia coli empyema, a subdiaphragmatic source ought to be suspected, and among immigrants from areas with prevalent hydatid disease, infected hepatic Echinococcus cyst might rarely be the cause.
Keeman, J N
In the past while the diagnosis was primarily made by the physician, the treatment of thoracic empyema was a surgeon's job. Carrying out this treatment was something of a hit and miss affair. With the change from belief in the Hippocratic principles ofhumours towards organs and tissues being the cause of disease, the way diagnoses were made also changed. The technique of percussing the thorax developed by Auenbrugger two centuries ago, was the beginning of diagnosing based on meticulous physical examination. Chirurgeons were expected to treat thoracic empyema adequately and by employing this technique, were able to make a more exact diagnosis and consequently provide better treatment. Modern imaging techniques have rendered manual thoracic percussion less often necessary. Percussion is now carried out much more often by pulmonologists than by surgeons. Nevertheless, Auenbrugger's 'inventum novum' will continue to be a gratefully employed technique.
DeLong, J F
A patient with a subdural empyema demonstrated a late arterial "blush" during a 99mTc-pertechnetate cerebral dynamic flow study which "washed out" in the delayed images. Cerebral arteriography and subsequent autopsy documented inflammatory tissue surrounding the empyema, resulting in this scintigraphic pattern.
costo - organism in classic postpneu- phrenic angle if 500 ml or more mococcal empyema- Other or- of fluid is present. Lateral de- ganisms are found in...is created by suturing margin of superior Pleura skin flap to edge of empyema cavity (b, c). This keeps wound Ski flapL from closing without use ot
Kaga, Akihito; Higo, Ryuzaburo; Yoshikawa, Hiroshi; Yokoi, Naoko; Haruyama, Takuo; Komatsu, Hiroaki; Yabe, Ayumi; Kusunoki, Takeshi; Ikeda, Katsuhisa
We report the case of a patient with multiple empyema present throughout his body, including chronic sinusitis and chronic suppurative otitis media, as well as subsequent epidural empyema, all caused by Streptococcus intermedius. A 38-year-old man presented with chief complaints of headache, left ear discharge, and nasal congestion. Imaging studies revealed pansinusitis, soft tissue signs in the mastoid cells, and otitis media. The patient was treated with meropenem hydrate, 6g/day. While clinical findings indicated improvement of the sinusitis, his headache did not improve. Further examination with contrast computerized tomography (CT) 'a chest radiography' blood cultures were performed, and the patient was diagnosed with multiple empyema (with an epidural empyema, pulmonary suppuration) caused by S. intermedius. Subsequent burr hole drainage was implemented to drain the epidural empyema. Long-term administration was required to treat pulmonary suppuration. While they remain rare, there has been a recent upward trend in the frequency of cases in which a young, previously healthy patient has developed multiple empyema throughout their body despite the absence of complicating diseases that pose an immune deficiency risk, such as diabetes or infection with the human immunodeficiency virus (HIV). In order to properly diagnose and treat patients presenting with multiple empyema infection with S. intermedius should be included in the differential diagnosis.
Waldrep, Vanessa B; Sloand, Elizabeth
This case study provides a discussion of the diagnosis, management and comprehensive plan of care for empyema in children for the advanced practice registered nurse (APRN) working in primary care. The incidence of complicated pneumonias including those progressing to empyema is on the rise among pediatric patients. The ambiguous signs and symptoms of complicated pneumonias create a challenge for the provider when developing an accurate diagnosis and plan of care. Pediatric nurse practitioners must be cognizant of the increased incidence of complicated pneumonias and manage their patients accordingly. If left untreated, empyema may result in severe pulmonary complications.
The author presents an overview of the current diagnostic procedures and the scheme used at the author's Department. The article also deals with therapeutical trends including arthroscopic treatment of empyema. Antibiotics necessary for the treatment of the disease are administered empirically. Most often as antibiotics of "the first choice" are recommended penicilin antibiotics with the inhibitor of beta-lactamase. The author points out the necessity of an early and adequate treatment of the empyema of the knee joint as a prevention of serious sequelae on the affected joint. Key words: empyema of the knee joint, diagnosis, therapy.
Martinón-Torres, F; Bernaola Iturbe, E; Giménez Sánchez, F; Baca Cots, M; de Juan Martín, F; Díez Domingo, J; Garcés Sánchez, M; Gómez Campderá, J A; Picazo, J J; Pineda Solas, V
There is a widespread perception among Spanish pediatricians that the incidence of empyema has significantly increased in the last few years, even though the objective information available is limited, and there is no specific active epidemiological surveillance system for this condition. In the present article, we review the situation of empyema in Spain, and discuss the main hypotheses put forward in the international literature to explain this increase, as well as the limitations of the sources available. Despite the scarcity of information, we draw the following conclusions: 1) the incidence of pediatric empyema is increasing in Spain, both generally and when caused by pneumococcus in particular; 2) the reason for this increase remains unknown, and to date no firm link has been established between this phenomenon and the heptavalent conjugate pneumococcal vaccine; and 3) this situation justifies the establishment of prospective systems for the surveillance and control of empyema and, once again, highlights the importance of developing active surveillance systems for pneumococcal disease.
Pastore Neto, Mario; Resende, Vivian; Machado, Carla Jorge; de Abreu, Emanuelle Maria Sávio; de Rezende Neto, João Baptista; Sanches, Marcelo Dias
to analyze the associated factors with empyema in patients with post-traumatic retained hemothorax. prospective observational study. Data were collected in patients undergoing PD during emergency duty. Variables analyzed were age, sex, mechanism of injury, side of the chest injury, intrathoracic complications of RH, laparotomy, specific injuries, rib fractures, trauma scores, days to diagnosis, diagnostic method of RH, primary indication of PD, initial volume drained, length of the first tube removal, surgical procedure. Cumulative incidence of empyema, pneumonia and pulmonary contusion and the proportion of patients with empyema or without empyema in each category of each variable analyzed were obtained. the cumulative incidence of PD among trauma patients was 1.83% and the RH among those with PD was 10.63%. There were 20 cases of empyema (32.8%). Most were male in the age from 20 to 29, victims of injury by firearm on the left side of the thorax. The incidence of empyema in patients with injury by firearms was lower compared to those with stab wound or blunt trauma; higher among those with drained volume between 300 and 599 ml. The median hospital lenght of stay was higher among those with empyema. the incidence of PD was 1.83% and RH was 10.63%, these results are consistent with the low severity of the patients involved in this study and consistent with the literature. The incidence of empyema proved to be negatively associated with the occurrence of injury by firearms and positively associated with a drained volume between 300 and 599 ml, compared with lower or higher volumes.
Coumans, Jean-Valery C E; Walcott, Brian P
Spinal subdural empyemas are rare. We describe a 53-year-old male who presented with back pain, mental status changes, and sepsis. Five days prior he had undergone a triamcinolone and lidocaine injection of the acromial bursa. He also had a remote history of epidural steroid injection for thoracic back pain. Two lumbar MRI conducted 62 hours apart revealed a newly developed subdural empyema that was successfully treated with surgical evacuation and post-operative antibiotics.
Al-Share, Bayan; Al Asad, Khaled
Amebiasis is a parasitic infection caused by the protozoan Entamoeba histolytica. While most infections are asymptomatic, the disease could manifest clinically as amebic dysentery and/or extraintestinal invasion in the form of amebic liver abscess or other more rare manifestations such as pulmonary, cardiac, or brain involvement. Herein we are reporting a case of a 24-year-old male with history of Down syndrome who presented with severe right side pneumonia complicated with multicystic empyema resistant to regular medical therapy. Further investigation revealed a positive pleural fluid for E. histolytica cysts and trophozoites. The patient was diagnosed with primary pleuropulmonary amebiasis and he responded promptly to surgical drainage and metronidazole therapy. In patients from endemic areas all physicians should keep a high index of suspicion of amebiasis as a cause of pulmonary disease. PMID:27478673
Zakaria, Ali; Al-Share, Bayan; Al Asad, Khaled
Amebiasis is a parasitic infection caused by the protozoan Entamoeba histolytica. While most infections are asymptomatic, the disease could manifest clinically as amebic dysentery and/or extraintestinal invasion in the form of amebic liver abscess or other more rare manifestations such as pulmonary, cardiac, or brain involvement. Herein we are reporting a case of a 24-year-old male with history of Down syndrome who presented with severe right side pneumonia complicated with multicystic empyema resistant to regular medical therapy. Further investigation revealed a positive pleural fluid for E. histolytica cysts and trophozoites. The patient was diagnosed with primary pleuropulmonary amebiasis and he responded promptly to surgical drainage and metronidazole therapy. In patients from endemic areas all physicians should keep a high index of suspicion of amebiasis as a cause of pulmonary disease.
Fujita, Kohei; Kim, Young Hak; Nakatani, Koichi; Mio, Tadashi
Key Clinical Message Refractory empyema occasionally reflects hidden malignant disease. We presented a rare case of rapidly progressive malignant mesothelioma of the pleura (MPM) mimicking empyema. Physicians should be aware of MPM when patients with empyema are refractory to the standard treatment, and PET-CT may be helpful in establishing a precise diagnosis in such cases. PMID:26509028
Fujita, Kohei; Kim, Young Hak; Nakatani, Koichi; Mio, Tadashi
Refractory empyema occasionally reflects hidden malignant disease. We presented a rare case of rapidly progressive malignant mesothelioma of the pleura (MPM) mimicking empyema. Physicians should be aware of MPM when patients with empyema are refractory to the standard treatment, and PET-CT may be helpful in establishing a precise diagnosis in such cases.
Jeon, Yeong Jeong; Shin, Sumin; Shim, Young Mog
Malignant tumors associated with chronic empyema have been reported in the literature, and a majority of these tumors are lymphomas. Epithelial tumors originating from the post-pneumonectomy space in patients with chronic empyema are extremely rare. Here, we present the cases of 2 patients with squamous cell carcinoma arising from the pleural cavity after pneumonectomy for chronic empyema. PMID:28382273
Mancini, P; Mazzei, L; Zarzana, A; Biagioli, D; Sposato, B; Croce, G F
The authors present 110 cases of patients hospitalized in the last 5 years, with long-term disabling sequelae of pulmonary tuberculosis. Twelve out of them (= 10.9%) suffered from post-tuberculous chronic empyema, with an average latency period of 44.83 years between the acute tuberculous illness and the clinical manifestation of the empyema. Nine of the patients had been treated with collapsotherapy, induced by artificial intrapleural pneumothorax, 1 with thoracoplasty, and 2 only with late and inadequate anti-mycobacterial chemotherapy. Eleven patients (91.6%) also had a cutaneous fistula (7 cases) and/or a bronchopleural fistula (4 cases). The authors show how the issue of tuberculous sequelae is a significant not only from the numerical standpoint, but also for the seriousness of the caused pathological conditions, often posing problems for differential diagnosis. Moreover, they stress how tuberculosis should never be neglected or considered last in the differential diagnosis of empyema and pyopneumothorax.
Ghritlaharey, Rajendra K; Budhwani, Keshav S; Shrivastava, Dhirendra K; Srivastava, Jyoti
The aim of this study was to review our experience with tube thoracostomy in the management of empyema thoracis in children. This retrospective study included 46 children (26 boys and 20 girls) who were admitted and managed for empyema thoracis, between January 1, 2010 and December 31, 2010 at the author's department of paediatric surgery. During the last 12 months, 46 children aged below 12 years were treated for empyema thoracis: Five (10.86%) were infants, 22 (47.82%) were 1 to 5 years and 19 (41.30%) were 6 to 12 years of age. All the patients presented with complaints of cough, fever and breathlessness of variable durations. Twenty three (50%) children had history of pneumonia and treatment prior to development of empyema. Thirty five (76.08%) children had right-sided and 11 (23.91%) had left-sided empyema. Thirty nine (84.78%) children were successfully treated with tube thoracostomy, systemic antibiotics and other supportive measures. Seven (15.21%) children failed to respond with above and needed decortications. Most commonly isolated bacteria were Pseudomonas (n = 12) and Staphylococcus aureus (n = 7). The average length of hospital stay in patients with tube thoracostomy was 15.35 days, and in patients who needed decortications was 16.28 days following thoracotomy. There was no mortality amongst above treated children. Majority of children with empyema thoracis are manageable with tube thoracostomy, antibiotics, physiotherapy and other supportive treatment. Few of them who fail to above measures need more aggressive management.
Zanotti, Giorgio; Mitchell, John D
Empyema after anatomic lung resection is rare but causes serious morbidity, particularly if associated with a bronchopleural fistula. Careful assessment of preoperative risk factors and proper surgical technique can minimize risks. Empyema after segmentectomy or lobectomy may respond to simple drainage and antibiotics, or may require decortication with or without muscle transposition. After pneumonectomy, treatment principles include initial drainage of the intrathoracic space, closure of the fistula if present, and creation of an open thoracostomy, which is packed and later closed. Success rates can exceed 80%.
Hornick, P.; Townsend, E. R.; Clark, D.; Fountain, S. W.
Seventeen consecutive patients were referred for management of empyema between April 1991 and March 1992. Fourteen patients defined as having an 'early' empyema were initially treated by videothoracoscopy. The other three patients, defined as having a 'late' empyema proceeded directly to thoracotomy. Videothoracoscopy was successful in 10 out of the 14 patients. The mean postoperative stay was 7.8 days. At a mean follow-up at 16.7 months, these patients were rendered apyrexial with full lung expansion and no residual pleural collection. The postoperative results were at least equivalent to other conventional forms of treatment without an undue level of complications. In this series, thoracoscopy was found to be successful when symptoms had been present up to 31 days before presentation at the first hospital, and the mean length of treatment before referral to Harefield was 47 days. It is now our policy to videothoracoscope all patients with empyema thoracis, regardless of the length of referral. It may circumvent the need for a thoracotomy, it does not add any increased risk of complications, and does not appreciably increase the length of hospital stay should thoracotomy ultimately be required. PMID:8659973
Filomeno, Luiz Tarcísio Brito; de Campos, José Ribas Milanez; Machuca, Tiago Noguchi; Neves-Pereira, João Carlos das; Terra, Ricardo Mingarini
OBJECTIVES We developed a prosthesis for open pleurostomy cases where pulmonary decortication is not indicated, or where post-pneumonectomy space infection occurs. The open pleural window procedure not only creates a large hole in the chest wall that is shocking to patients, also results in a permanent deformation of the thorax. prosthesis for open pleurostomy is a self-retained silicone tube that requires the removal of 3 cm of one rib for insertion, and acts as a mature conventional open pleural window. Herein, we report our 13–year experience with this device in the management of different kinds of pleural empyema. METHODS Forty-four consecutive patients with chronic empyema were treated. The etiology of empyema was diverse: pneumonia, 20; lung resections, 12 (pneumonectomies, 7; lobectomies, 4; non-anatomical, 1); mixed-tuberculous, 6; and mixed-malignant pleural effusion, 6. After debridment of both pleural surfaces, the prosthesis for open pleurostomy was inserted and attached to a small recipient plastic bag. RESULTS Infection control was achieved in 20/20 (100%) of the parapneumonic empyemas, in 3/4 (75%) of post-lobectomies, in 6/7 (85%) of post-pneumectomies, in 6/6 (100%) of mixed-tuberculous cases, and in 4/6 (83%) of mixed-malignant cases. Lung re-expansion was also successful in 93%, 75%, 33%, and 40% of the groups, respectively. CONCLUSIONS Prosthesis for open pleurostomy insertion is a minimally invasive procedure that can be as effective as conventional open pleural window for management of chronic empyemas. Thus, we propose that the use of prosthesis for open pleurostomy should replace the conventional method. PMID:19330246
Filomeno, Luiz Tarcísio Brito; Campos, José Ribas Milanez de; Machuca, Tiago Noguchi; das Neves-Pereira, João Carlos; Terra, Ricardo Mingarini
We developed a prosthesis for open pleurostomy cases where pulmonary decortication is not indicated, or where post-pneumonectomy space infection occurs. The open pleural window procedure not only creates a large hole in the chest wall that is shocking to patients, also results in a permanent deformation of the thorax. prosthesis for open pleurostomy is a self-retained silicone tube that requires the removal of 3 cm of one rib for insertion, and acts as a mature conventional open pleural window. Herein, we report our 13-year experience with this device in the management of different kinds of pleural empyema. Forty-four consecutive patients with chronic empyema were treated. The etiology of empyema was diverse: pneumonia, 20; lung resections, 12 (pneumonectomies, 7; lobectomies, 4; non-anatomical, 1); mixed-tuberculous, 6; and mixed-malignant pleural effusion, 6. After debridement of both pleural surfaces, the prosthesis for open pleurostomy was inserted and attached to a small recipient plastic bag. Infection control was achieved in 20/20 (100%) of the parapneumonic empyemas, in 3/4 (75%) of post-lobectomies, in 6/7 (85%) of post-pneumonectomies, in 6/6 (100%) of mixed-tuberculous cases, and in 4/6 (83%) of mixed-malignant cases. Lung re-expansion was also successful in 93%, 75%, 33%, and 40% of the groups, respectively Prosthesis for open pleurostomy insertion is a minimally invasive procedure that can be as effective as conventional open pleural window for management of chronic empyemas. Thus, we propose that the use of prosthesis for open pleurostomy should replace the conventional method.
Matsumoto, Takeshi; Otsuka, Kojiro; Tomii, Keisuke
Mycobacterium fortuitum is a rapidly growing nontuberculous mycobacterium. This microorganism is an uncommon etiological agent of lung lesions; among lung lesions caused by M. fortuitum, thoracic empyema is particularly rare. A 61-year-old man who had been treated for chronic hypercapnic respiratory failure with noninvasive ventilation was admitted because of breathing difficulty and was found to have M. fortuitum thoracic empyema. He improved after the administration of amikacin, imipenem/cilastatin, and clarithromycin following sulfamethoxazole/trimethoprim and clarithromycin. This is the first report of M. fortuitum thoracic empyema in a patient without human immunodeficiency virus infection. The thoracic empyema may have developed via a pulmonary fistula in this case. This case highlights the fact that we must be aware of the possibility of M. fortuitum thoracic empyema, especially in patients with M. fortuitum lung infection and treatment with noninvasive ventilation. Multidrug therapy may be effective and important to the resolution of M. fortuitum thoracic empyema.
Hajjar, Waseem M; Ahmed, Iftikhar; Al-Nassar, Sami A; Alsultan, Rawan K; Alwgait, Waad A; Alkhalaf, Hanoof H; Bisht, Shekhar C
Video-assisted thoracoscopic surgical decortication (VATSD) is widely applicable in fibrinopurulent Stage II empyema. While, more chronic thick walled Stage III empyema (organizing stage) needs conversion to open thoracotomy, and existing reports reveal a lacuna in the realm of late stage empyema patient's management through VATS utilization, particularly Stage III empyema. We prospectively evaluated the application of VATSD regardless of the stage of pleural empyema for the effective management of late stage empyema in comparison to open decortications (ODs) to minimize the adverse effects of the disease. All patients with pyogenic pleural empyema (Stage II and Stage III) in King Khalid University Hospital (KKUH) (admitted from January 2009 to December 2013) who did not respond to chest tube/pigtail drainage and/or antibiotic therapy were treated with VATSD and/or open thoracotomy. Prospective evaluation was carried out, and the effect of this technique on perioperative outcomes was appraised to evaluate our technical learning with the passage of time and experience with VATS for late stage empyema management. Out of total 63 patients, 26 had Stage II empyema and 37 had Stage III empyema. VATSD was employed on all empyema patients admitted in the KKUH. VATSD was successful in all patients with Stage II empyema. Twenty-five patients (67.6%) with Stage III empyema completed VATSD successfully. However, only 12 cases (32.4%) required conversions to open (thoracotomy) drainage (OD). The median hospital stay for Stage III VATSD required 9.65 ± 4.1 days. Whereas, patients who underwent open thoracotomy took longer time (21.82 ± 16.35 days). Similarly, Stage III VATSD and Stage III open surgery cases showed significance difference among chest tube duration (7.84 ± 3.33 days for VATS and 15.92 ± 8.2 days for open thoracotomy). Significantly, lower postoperative complications were detected in patients treated with VATSD in terms of atelectasis, prolonged air leak
Hajjar, Waseem M.; Ahmed, Iftikhar; Al-Nassar, Sami A.; Alsultan, Rawan K.; Alwgait, Waad A.; Alkhalaf, Hanoof H.; Bisht, Shekhar C.
BACKGROUND: Video-assisted thoracoscopic surgical decortication (VATSD) is widely applicable in fibrinopurulent Stage II empyema. While, more chronic thick walled Stage III empyema (organizing stage) needs conversion to open thoracotomy, and existing reports reveal a lacuna in the realm of late stage empyema patient's management through VATS utilization, particularly Stage III empyema. We prospectively evaluated the application of VATSD regardless of the stage of pleural empyema for the effective management of late stage empyema in comparison to open decortications (ODs) to minimize the adverse effects of the disease. METHODS: All patients with pyogenic pleural empyema (Stage II and Stage III) in King Khalid University Hospital (KKUH) (admitted from January 2009 to December 2013) who did not respond to chest tube/pigtail drainage and/or antibiotic therapy were treated with VATSD and/or open thoracotomy. Prospective evaluation was carried out, and the effect of this technique on perioperative outcomes was appraised to evaluate our technical learning with the passage of time and experience with VATS for late stage empyema management. RESULTS: Out of total 63 patients, 26 had Stage II empyema and 37 had Stage III empyema. VATSD was employed on all empyema patients admitted in the KKUH. VATSD was successful in all patients with Stage II empyema. Twenty-five patients (67.6%) with Stage III empyema completed VATSD successfully. However, only 12 cases (32.4%) required conversions to open (thoracotomy) drainage (OD). The median hospital stay for Stage III VATSD required 9.65 ± 4.1 days. Whereas, patients who underwent open thoracotomy took longer time (21.82 ± 16.35 days). Similarly, Stage III VATSD and Stage III open surgery cases showed significance difference among chest tube duration (7.84 ± 3.33 days for VATS and 15.92 ± 8.2 days for open thoracotomy). Significantly, lower postoperative complications were detected in patients treated with VATSD in terms of
Fujiwara, Kiyohiro; Kobayashi, Shinya; Fujioka, Nobuhiro; Teramoto, Kanako; Itoh, Takefumi; Sugimura, Hiroko; Takezawa, Yuichi
A 60-year-old man had a medical examination because of fever in the emergency hospital and had a diagnosis of pneumonia and was treated, but he was admitted to our hospital 2 days later because there was not the improvement of his symptom. The chest computed tomography(CT)image showed multilocular pleural effusions and lower lobe atelectasis with the air bronchogram on the left side. We diagnosed the case as empyema and inserted a catheter, but drainage was very few and injected 60,000 urokinase units for 3 days from the next day. We removed a drain 2 days after the 3rd infusion, and the pleural thickening became mild, and atelectasis was gradually improved in the chest CT image, and the inflammatory reaction was reduced, too. The intrathoracic washing with urokinase was thought to be effective for empyema with atelectasis.
Doan, Ninh; Patel, Mohit; Nguyen, Ha Son; Mountoure, Andrew; Shabani, Saman; Gelsomino, Michael; Janich, Karl; Kurpad, Shekar
Intracranial subdural empyema (ISDE) is a life-threatening condition. The risk for ISDE increases in patients that have undergone prior intracranial procedures. The non-specificity in its clinical presentation often makes ISDE difficult to diagnose. Here, we present a rare case of ISDE mimicking a recurrent chronic subdural hematoma, emphasizing the significance of obtaining early magnetic resonance images of the brain for early diagnosis and treatment to achieve the optimal outcome. PMID:27651110
Suthers, Elizabeth; Rosenstengel, Andrew; Hart, Julie; Lewis, Joshua R; Kay, Ian; Waterer, Grant; Lee, Y C Gary; Brims, Fraser
We report on 19 patients from Western Australia of pleural empyema with Klebsiella oxytoca, an organism never before reported in association with this condition. Median age was 65 years, 14/17 (83%) had been in hospital within 30 days prior to diagnosis, 12/18 (67%) had active cancer, 9/17 (53%) had been in intensive care and 7/17 (41%) had prior surgery. Nine patients died at the time of censure, five within 90 days of infection.
Ota, Hideki; Kawai, Hideki
A 74-year-old man who survived the tsunami after the Great East Japan Earthquake, was admitted to our department because of respiratory distress. He developed aspiration pneumonia and pleural empyema of the right thorax. Decortication was performed by video-assisted thoracoscopic surgery. An unsuspected aspirated pine tree branch and pulmonary pleural fistula were discovered. The branch was removed, the pleural fistula was opened for drainage of the intrapulmonary abscess, and the patient made a good recovery.
Tronina, E Yu; Shipulin, P P; Baydan, V I; Severgin, V E; Baydan, V V; Ageyev, S V; Kirilyuk, A A; Kozyar, O N; Polyak, S D; Agrakhari, A
The data, concerning videothoracoscopic operations application in the acute pleural empyema treatment in 462 patients, were adduced. Efficacy of videothoracoscopic operations, using electrowelding and radiofrequency surgical complexes with possibility to eliminate pulmonary-pleural fistulas, was shown. Positive clinical effect was noted in 443 (95.9%) patients, duration of stationary treatment have constituted 11.1 days at average. The complications have had occurred in 19 (4.1%) patients. All the patients are alive.
Strachan, Roxanne E.; Cornelius, Anita; Gilbert, Gwendolyn L.; Gulliver, Tanya; Martin, Andrew; McDonald, Tim; Nixon, Gillian M.; Roseby, Rob; Ranganathan, Sarath; Selvadurai, Hiran; Smith, Greg; Soto-Martinez, Manuel; Suresh, Sadasivam; Teoh, Laurel; Thapa, Kiran; Wainwright, Claire E.
An increase in the incidence of empyema worldwide could be related to invasive pneumococcal disease caused by emergent nonvaccine replacement serotypes. To determine bacterial pathogens and pneumococcal serotypes that cause empyema in children in Australia, we conducted a 2-year study of 174 children with empyema. Blood and pleural fluid samples were cultured, and pleural fluid was tested by PCR. Thirty-two (21.0%) of 152 blood and 53 (33.1%) of 160 pleural fluid cultures were positive for bacteria; Streptococcus pneumoniae was the most common organism identified. PCR identified S. pneumoniae in 74 (51.7%) and other bacteria in 19 (13.1%) of 145 pleural fluid specimens. Of 53 samples in which S. pneumoniae serotypes were identified, 2 (3.8%) had vaccine-related and 51 (96.2%) had nonvaccine serotypes; 19A (n = 20; 36.4%), 3 (n = 18; 32.7%), and 1 (n = 8; 14.5%) were the most common. High proportions of nonvaccine serotypes suggest the need to broaden vaccine coverage. PMID:22000353
Keeling, A. N.; Leong, S.; Logan, P. M.; Lee, M. J.
Empyema and complicated pleural effusion represent common medical problems. Current treatment options are multiple. The purpose of this study was to access the outcome of image-guided, small-bore catheter drainage of empyema and effusion. We evaluated 93 small-bore catheters in 82 patients with pleural effusion (n = 30) or empyema (n = 52), over a 2-year period. Image guidance was with ultrasound (US; n = 56) and CT (n = 37). All patients were followed clinically, with catheter dwell times, catheter outcome, pleural fluid outcome, reinsertion rates, and need for urokinase or surgery recorded. Ninety-three small-bore chest drains (mean=10.2 Fr; range, 8.2-12.2 Fr) were inserted, with an average dwell time of 7.81 days for empyemas and 7.14 days for effusions (p > 0.05). Elective removal rates (73% empyema vs 86% effusions) and dislodgement rates (12% empyema vs 13% effusions) were similar for both groups. Eight percent of catheters became blocked and 17% necessitated reinsertion in empyemas, with no catheters blocked or requiring reinsertion in effusions (p < 0.05). Thirty-two patients (51%) required urokinase in the empyema group, versus 2 patients (6%) in the effusion group (p < 0.05). All treatment failures, requiring surgery, occurred in the empyema group (19%; n = 12; p < 0.05). In conclusion, noninfected pleural collections are adequately treated with small-bore catheters, however, empyemas have a failure rate of 19%. The threshold for using urokinase and larger-bore catheters should be low in empyema.
Yauba, M. S.; Ahmed, H.; Imoudu, I. A.; Yusuf, M. O.; Makarfi, H. U.
Background. Empyema necessitans, a rare complication of pleural effusion, could result in significant morbidity and mortality in children. It is characterized by the dissection of pus through the soft tissues and the skin of the chest wall. Mycobacterium tuberculosis and Actinomyces israelii are common causes but Gram negative bacilli could be a rare cause. However, there were challenges in differentiating between Mycobacterium tuberculosis and nontuberculous empyema in a resource poor setting like ours. We report a child with pleural effusion and empyema necessitans secondary to Proteus spp. infection. Methods. We describe a 12-year-old child with empyema necessitans complicating pleural effusion and highlight management challenges. Results. This case was treated with quinolones, antituberculous drugs, chest tube drainage, and nutritional rehabilitation. Conclusion. Empyema necessitatis is a rare condition that can be caused by Gram negative bacterial pathogens like Proteus species. PMID:25893125
Karmy-Jones, Riyad; Holevar, Michele; Sullivan, Ryan J; Fleisig, Ani; Jurkovich, Gregory J
BACKGROUND: Empyema complicates tube thoracostomy following trauma in up to 10% of cases. Studies of potential risk factors of empyema have included use of antibiotics, site of injury and technique of chest tube placement. Residual fluid has also been cited as a risk factor for empyema, although the imaging technique to identify this varies. OBJECTIVE: To determine whether residual hemothorax detected by chest x-ray (CXR) after one or more initial chest tubes predicts an increased risk of empyema. METHODS: A study of patients admitted to two level I trauma centres between January 7, 2004, and December 31, 2004, was conducted. All patients who received a chest tube in the emergency department, did not undergo thoracotomy within 24 h, and survived more than two days were followed. Empyema was defined as a pleural effusion with positive cultures, and a ratio of pleural fluid lactate dehydrogenase to serum lactate dehydrogenase greater than 0.6 in the setting of elevated leukocyte count and fever. Factors analyzed included the presence of retained hemothorax on CXR after the most recent tube placement in the emergency room, age, mechanism of injury and injury severity score. RESULTS: A total of 102 patients met the criteria. Nine patients (9%) developed empyema: seven of 21 patients (33%) with residual hemothorax developed empyema versus two of 81 patients (2%) without residual hemothorax developed empyema (P=0.001). Injury severity score was significantly higher in those who developed empyema (31.4±26) versus those who did not (22.6±13; P=0.03). CONCLUSIONS: The presence of residual hemothorax detected by CXR after tube thoracostomy should prompt further efforts, including thoracoscopy, to drain it. With increasing injury severity, there may be increased benefit in terms of reducing empyema with this approach. PMID:18716687
Adeyemo, Adebayo O.; Adejuyigbe, O.; Taiwo, O. O.
Of 298 infants and children with empyema thoracis seen, 62 percent were under 2 years of age. The majority of the cases had underlying pulmonary infection, and Staphylococcus aureus was dominant among the organisms isolated. The diagnosis was made in all cases on the basis of chest x-ray films and thoracentesis. Full expansion of the lung and resolution of the underlying pneumonia occurred on administration of appropriate antibiotics and catheter drainage in all cases except in two patients who had decortication. The mortality rate was 5 percent; delayed presentation and suboptimal prehospitalization antibiotics influenced the morbidity. ImagesFigure 1Figure 2Figure 3Figure 4Figure 5 PMID:6471117
Bobek, Vladimir; Majewski, Andrzej; Kolostova, Katarina; Rzechonek, Adam; Lischke, Robert; Schutzner, Jan; Kacprzak, Grzegorz
Introduction: Pleural empyema is a severe complication of various diseases. The essential is the inserting a drain into the pleural cavity and evacuation of the pus. Sometimes the pus is very thick and its evacuation and re-expansion of the lung is very difficult. Methods: We report a group of 10 patients with intrapleural administration of Pulmozyme (dornase alpha) in dosages of either 2.5 mg once or on two separate occasions. All of the patients had a chest tube inserted into the pleural cavity. Measurement of viscosity was done before and after the instillation of the dornase alpha. Results: In six patients dornase alfa was introduced into the pleural cavity once. Three of them received this on the 4th whilst the rest were treated with the agent on the 6th day. Four patients received the dornase alpha twice because of the small amount of drainage fluid after the previous instillation. Five patients were discharged from hospital with complete re-expansion of their lungs. Two patients were qualified for a surgical operation since the lung was trapped and did not re-expand. Three patients had to be discharged with a drain as a result of incomplete re-expansion of the lung. In all the patients the density of the pus after administering the dornase alpha decreased and the amount of the pus drainage increased. Conclusions: Dornase alpha may be used in some patients with pleural empyema with good results. PMID:26885174
Karachalios, Kostis; Siagris, Dimitrios; Lekkou, Alexandra; Anastassiou, Evangelos D.; Spiliopoulou, Iris; Gogos, Charalambos
Introduction: Pleural empyema as a focal infection due to Salmonella enterica serovar Enteritidis is rare and most commonly described among immunosuppressed patients or patients who suffer from sickle cell anaemia and lung malignancies. Case presentation: Here, we present an 81-year-old immunocompetent Greek woman with bacteraemia and pleural empyema due to Salmonella Enteritidis without any gastrointestinal symptoms. Conclusion: In our case, we suggest that patient’s pleural effusion secondary to heart failure was complicated by empyema and that focal intravascular infection was the cause of bacteraemia. PMID:28348773
Spicer, P E
A 5-week-old male child was admitted to Tabubil Hospital with a rapidly progressive, fulminating right-sided empyema which necessitated thoracotomy and drainage. The causative organism was a haemolytic Streptococcus.
Yukumi, Shungo; Suzuki, Hideaki; Ishimaru, Kei; Watanabe, Akira; Tanaka, Michiyo; Tanigawa, Kazufumi; Sano, Yoshifumi
Since general thoracic surgery requires a short fasting period, the number of cases that require nutrition support after surgery is limited and few reports exist about nutrition in general thoracic surgery and chronic empyema. Here we report 2 cases of chronic empyema treated with nutritional support team (NST) followed by omentopexy. For chronic empyema, a long period is required to sterilize the thoracic cavity by closed or open drainage before radical treatment. During this period, improvement of the nutrition status is important to control local infection, and to increase the volume of the omentum or muscle flaps used for filling the empyema space effectively. In our 2 cases, radical surgeries using omental flap were successfully performed after the improvement of general condition by aggressive nutritional support.
Piscopo, Tonio; Cassar, Karen
Actinomycosis is a relatively rare infection caused by Gram-positive bacteria. We present the case of a 54-year-old, previously healthy, male patient with a history of severe penicillin allergy who developed severe pneumonia and empyema caused by Actinomyces meyeri. Presenting symptoms included productive cough, right upper quadrant pain, and chills and rigors. He required drainage of the empyema via tube and prolonged antibiotic treatment with intravenous ceftriaxone for 2 weeks followed by oral doxycycline for 6 months. PMID:27752374
Nguyen, Ha Son; Foy, Andrew; Havens, Peter
Background: Surgery is routinely recommended for lumbar lipomyelomeningocele, especially in the setting of tethered cord syndrome. The most common complications are wound infections and cerebrospinal fluid (CSF) leak, which remain confined to the surgical site. To the best of our knowledge, there have been no prior reports relating an intracranial subdural empyema following detethering surgery. Prompt diagnosis is essential since subdural empyema is a neurosurgical emergency. Case Description: The patient was an 11-month-old male who underwent detethering surgery for a lumbar lipomyelomeningocele. This was followed by wound drainage consistent with CSF leak, requiring revision. Cultures grew three aerobes (Escherichia coli, Enterococcus, and Klebsiella) and three anaerobes (Clostridium, Veillonella, and Bacteroides). He was started on cefepime, vancomycin, and flagyl. The patient required two more wound revisions and placement of an external ventricular drain (EVD) secondary to persistent wound leakage. A subsequent magnetic resonance imaging (MRI) brain was carried out due to protracted irritability, which revealed extensive left subdural empyema along the parietooccipital region and the inferior and anterior temporal lobe. He underwent evacuation of the subdural empyema where cultures exhibited no growth. Subsequently, he progressed well. His lumbar incision continued to heal. Serial MRI brains and inflammatory markers were reassuring. He weaned off his EVD and went home to complete a 6-week course of antibiotics. Upon completion of his antibiotics, he returned for a clinic visit; he exhibited no interim fevers or wound issues; cranial imaging documented no evidence of a residual or recurrent subdural empyema. Conclusion: Intracranial subdural empyema may occur after wound complications from detethering surgery despite early initiation of broad-spectrum antibiotics. Possible etiology may be local wound infection that seeds the subdural space and travels to the
Rabiou, Sani; Younssa, Hama; Didier, James; Ibrahim, Magagi; Harissou, Adamou; Adakal, Ousseini; Sani, Rachid
Chronic pleural pocket has well-known diagnosis and treatment principles since first described by Hippocrates 2,400 years ago. However, its treatment remains constant even though its causes, severity during management, and terrain vary considerably. In well-structured health care systems, posttuberculous empyema has become rare; its well-codified medical treatment relies on early diagnosis and adapted antibiotherapy, punctures/drainage, and appropriate intrapleural antifibrinolytics. In developing countries, a poor health organizational system increases the incidence of pleural pocket, which can progress until surgery is indicated. In such a context, the general principles of treatment include pleural decortication along with pulmonary resection. This technique remains difficult, risky, and, sometimes, impossible due to the chronicity of the lesion. In patients debilitated by several months of septic evolution, a simplified thoracostomy technique permits complete resection of the pocket. Georg Thieme Verlag KG Stuttgart · New York.
Janicki, Adam; Capraro, Geoffry
The prompt identification of sepsis in children is challenging, but once sepsis is identified, initiation of care and determination of proper disposition may be insufficient to ensure optimal outcomes. The best opportunity for full recovery also requires rapid identification and treatment of the infectious source. Acute bacterial sinusitis is common in the pediatric population, and although intracranial complications of sinusitis are rare, they are associated with significant morbidity and mortality. History and physical examination may be imperfectly sensitive for the presence of acute bacterial sinusitis and its intracranial complications. We present a case of pediatric sepsis in which the diagnosis of intracranial extension of bacterial sinusitis was not made during the first phase of care and describe complications that followed. Emergency physicians should consider subdural empyema in patients presenting with fever, nausea and headache with worrisome vital signs and laboratory values suggestive of a severe infection.
Shokunbi, M T; Malomo, A O
An analysis of 19 confirmed cases of subdural empyema treated in our unit during a 29-month period ending in May 1990 revealed that this was a disease of young males (mean age 19.6 yrs: male:female ratio 5:1) that was frequently associated with paranasal sinusitis. We have identified a characteristic symptom complex which when present together with focal neurological deficits makes the diagnosis highly probable. This consists of fever, headache, altered level of consciousness and frontal scalp swelling. In a practice setting where neuroradiological confirmation of the diagnosis is not always practicable, this clinical syndrome is helpful and should prompt early burr hole exploration of the subdural space. The only deaths (2 patients; 11%) occurred in patients who presented in coma. The remaining were either normal (6 patients) or continued to improve after treatment, which consisted of multiple burr hole drainage, broad spectrum antimicrobial treatment and eradication of the source of infection.
Kim, Jiha; Kim, Choonghyo; Ryu, Young-Joon
Intracranial tuberculous subdural empyema (ITSE) is extremely rare. To our knowledge, only four cases of microbiologically confirmed ITSE have been reported in the English literature to date. Most cases have arisen in patients with pulmonary tuberculosis regardless of trauma. A 46-year-old man presented to the emergency department after a fall. On arrival, he complained of pain in his head, face, chest and left arm. He was alert and oriented. An initial neurological examination was normal. Radiologic evaluation revealed multiple fractures of his skull, ribs, left scapula and radius. Though he had suffered extensive skull fractures of his cranium, maxilla, zygoma and orbital wall, the sustained cerebral contusion and hemorrhage were mild. Eighteen days later, he suddenly experienced a general tonic-clonic seizure. Radiologic evaluation revealed a subdural empyema in the left occipital area that was not present on admission. We performed a craniotomy, and the empyema was completely removed. Microbiological examination identified Mycobacterium tuberculosis (M. tuberculosis). After eighteen months of anti-tuberculous treatment, the empyema disappeared completely. This case demonstrates that tuberculosis can induce empyema in patients with skull fractures. Thus, we recommend that M. tuberculosis should be considered as the probable pathogen in cases with posttraumatic empyema. PMID:27226867
Kalfa, Nicolas; Allal, Hossein; Lopez, Manuel; Saguintaah, Magali; Guibal, Marie-Pierre; Sabatier-Laval, Edith; Forgues, Dominique; Counil, François; Galifer, René-Benoit
The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision. From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization. The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia. The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.
Eryigit, Hatice; Orki, Alpay; Unaldi, Mehmet; Ozdemir, Attila; Orki, Tulay; Kosar, Altug; Demirhan, Recep; Arman, Bulent
The most common cause of pleural empyema are parapneumonic effusions, and lung cancer is a rare cause of empyema. The aim of the present study is to analyse the results of the thoracoscopic treatment of empyema before definitive oncological treatment. Retrospective descriptive study of 332 patients including different clinical variables between 2002 and 2010. Among 332 patients with empyema, the etiology of this disease was lung cancer in 11 patients. Ten of these patients were male and one was female (median age, 57.9 years; range, 46-76). The initial treatment was tube thoracostomy in 8 patients and video-assisted thoracoscopic surgery in 3 patients. Thoracoscopic debridement was performed in 4 patients whose tube thoracostomy underperformed because of insufficient drainage. The methods used for diagnosis of lung cancer were fiberoptic bronchoscopy and video-assisted thoracoscopic surgery. Surgical resection was performed on 7 suitable patients following infection control. Postoperative bronchopleural fístula and empyema occurred after pneumonectomy in one case. No operative mortality was observed. The mean survival time was 32.8 months for patients undergoing resection. Empyema could be a rare presentation of lung cancer and those suitable for surgical treatment should undergo standard treatment with reasonable results. Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.
Redden, Mark D; Chin, Tze Yang; van Driel, Mieke L
Empyema refers to pus in the pleural space, commonly due to adjacent pneumonia, chest wall injury, or a complication of thoracic surgery. A range of therapeutic options are available for its management, ranging from percutaneous aspiration and intercostal drainage to video-assisted thoracoscopic surgery (VATS) or thoracotomy drainage. Intrapleural fibrinolytics may also be administered following intercostal drain insertion to facilitate pleural drainage. There is currently a lack of consensus regarding optimal treatment. To assess the effectiveness and safety of surgical versus non-surgical treatments for complicated parapneumonic effusion or pleural empyema. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 9), MEDLINE (Ebscohost) (1946 to July week 3 2013, July 2015 to October 2016) and MEDLINE (Ovid) (1 May 2013 to July week 1 2015), Embase (2010 to October 2016), CINAHL (1981 to October 2016) and LILACS (1982 to October 2016) on 20 October 2016. We searched ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for ongoing studies (December 2016). Randomised controlled trials that compared a surgical with a non-surgical method of management for all age groups with pleural empyema. Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach. We included eight randomised controlled trials with a total of 391 participants. Six trials focused on children and two on adults. Trials compared tube thoracostomy drainage (non-surgical), with or without intrapleural fibrinolytics, to either VATS or thoracotomy (surgical) for the management of pleural empyema. Assessment of risk of bias for the included studies was generally unclear for selection and blinding but low for attrition and reporting bias. Data analyses compared
Ueno, Tsuyoshi; Toyooka, Shinichi; Soh, Junichi; Miyoshi, Kentaroh; Sugimoto, Seiichiro; Yamane, Masaomi; Oto, Takahiro; Miyoshi, Shinichiro
OBJECTIVES Empyema is a well-known complication following lung resection. In particular, empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) is difficult to treat. Here, we present our experience of MRSA empyema treated with local irrigation using arbekacin. METHODS Six patients consisted of 4 males and 2 females with an average age of 65.7 years. They developed MRSA empyema following lung resection and were treated at our institution between 2007 and 2011. Cases comprised four primary and one metastatic lung cancer, and 1 patient was a living lung transplantation donor. The surgical procedure consisted of four lobectomies, one segmentectomy and one wedge resection. After diagnosis of MRSA empyema, anti-MRSA drugs were administered intravenously in all cases. In addition, arbekacin irrigation at a dose of 100 mg dissolved in saline was performed after irrigation with saline only. RESULTS The average number of postoperative days for the diagnosis of MRSA empyema was 13 (range 4–19). The period of irrigation ranged from 6 to 46 days. Arbekacin irrigation did not induce nephrotoxicity or other complications, and no bacteria resistant to arbekacin was detected in the thoracic cavity. We re-operated on 1 case because he had pulmonary fistula and severe wound infection. At the time of removing the thoracic catheter, MRSA in the pleural effusion disappeared completely in 3 patients. The period until MRSA concentration in the pleural effusion became negative after starting arbekacin irrigation ranged from 4 to 9 days. In the remaining cases, in which MRSA did not disappear, the catheter was removed because of no inflammatory reaction after stopping irrigation and clamping the catheters. All patients were discharged from our institution without thoracic catheterization and no patients had relapsed during the follow-up period ranging from 6 to 44 months. CONCLUSIONS Irrigation of the thoracic cavity with arbekacin proved to be an effective, safe and
Wiese, Andrew D; Griffin, Marie R; Zhu, Yuwei; Mitchel, Edward F; Grijalva, Carlos G
Parapneumonic empyema, a serious complication of pneumonia, started increasing among U.S. children before the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) in 2000, and continued afterwards. This increase was due in part to pneumococcal serotypes not included in PCV7 that were included in the new 13-valent (PCV13) vaccine introduced in 2010. We assessed changes in the incidence of empyema hospitalizations among U.S. children after PCV13 introduction. We calculated annualized empyema hospitalization rates among U.S. children <18years using Nationwide Inpatient Sample and Census data (1997-2013) for four periods based on PCV7 and PCV13 introductions. Relative rates (RR) and 95% confidence intervals (CI) were calculated by age group and sex, comparing PCV7 [early-PCV7 (2001-2005) and late-PCV7 (2006-2009)] and PCV13 (2011-2013) periods with the pre-PCV7 period (1997-1999). Secondary analyses examined changes in pneumococcal, streptococcal, staphylococcal and unspecified empyema. Among children <18years of age, annualized empyema hospitalization rates peaked at 3.6 per 100,000 in the late-PCV7 period compared with 2.1 per 100,000 in the pre-PCV7 period [RR: 1.70 (95% CI: 1.11-2.60)]. However, annualized rates in the post-PCV13 period declined to 2.0 per 100,000, similar to rates in the pre-PCV7 period. Empyema rates among children <2years were lower in the post-PCV13 period compared to the pre-PCV7 period [RR: 0.77 (95% CI: 0.61-0.96)], but rates in the two periods among children 2-4 and 5-17years were similar. Most empyema were of unspecified etiology. Pneumococcal and unspecified empyema declined after PCV13 introduction. Although empyema hospitalization rates among U.S. children peaked after PCV7 introduction, rates decreased substantially following the introduction of PCV13. Copyright Â© 2016 Elsevier Ltd. All rights reserved.
Xia, Zhaohua; Qiao, Kun; Wang, Haijiang; Ning, Xinzhong; He, Jianxing
Enhanced recovery after surgery (ERAS) protocols provide recommendations for care in various surgical fields. However, there is scarce information on the application of these protocols in tuberculous empyema surgery. The purpose of this research is to evaluate the outcomes of ERAS recommendations for patients who received tuberculous empyema surgery. A retrospective analysis was performed on patients who underwent tuberculous empyema surgery in our hospital from March 2011 to March 2016. The patients were divided into an ERAS group and a conventional control group. The main outcome measure was the postoperative median length of stay (including readmissions). Principles related to ERAS were documented, and the postoperative median hospital stay was analyzed statistically between the two groups. A total of 92 patients underwent 93 consecutive tuberculous empyema surgical treatments. The postoperative fasting time, chest tube duration, and length of stay were shorter in the ERAS group compared with the control group. The volume of chest tube drainage in the ERAS group was significantly smaller than that of the control group. No statistical differences were observed in the postoperative complications and reasons for readmission between the two groups. Application of ERAS recommendations in patients receiving tuberculous empyema operations decreased the length of stay and chest tube drainage compared to the control group.
García-Yuste, M; Ramos, G; Duque, J L; Heras, F; Castanedo, M; Cerezal, L J; Matilla, J M
The purpose of this study is to report our 15-year experience treating chronic empyemas after pulmonary resection and tuberculosis. Open-window thoracostomy and thoracomyoplasty were used to treat 40 patients with chronic pleural empyema characterized by residual empyematic cavity, bronchopleural fistula, and persistent pleural infections that were secondary to tuberculosis (n = 22) or pulmonary resection (n = 18). Between 2 and 7 months after thoracostomy, thoracomyoplasty was performed to eliminate a persistent pleural cavity. In 2 patients with postpulmonary resection empyema and a large bronchopleural fistula, intrathoracic transposition of the latissimus dorsi flap and open-window thoracostomy were performed simultaneously to close the fistula. The pleural space was eliminated per primam intentionem in 21 of 22 patients with tuberculosis and in 14 of 18 with a postpulmonary resection empyema. Another myoplasty was performed in an additional 3 patients to eliminate the pleural space. During open-window thoracostomy, the latissimus dorsi muscle was preserved with minimal injury to the anterior serratus muscle. One patient died postoperatively. Successful treatment of chronic pleural empyema requires adequate timing of surgical procedures. Our two-procedure technique is relatively simple and safe.
Tabarani, Christy M; Bennett, Nicholas J; Kiska, Deanna L; Riddell, Scott W; Botash, Ann S; Domachowske, Joseph B
An infant had a subdural empyema caused by the rare Salmonella species enterica subspecies houtenae (IV) serotype 44:z4,z23:- after only indirect exposure to exotic reptiles in her foster home. Infants recovering from preexisting subdural hematoma are at risk for development of empyema.
Kunyoshi, Valmir; Cataneo, Daniele Cristina; Cataneo, Antônio José Maria
To investigate the incidence, procedure type, characteristics of pleural fluid and pneumatoceles, and evolution of pneumonia complicated with empyema and/or pneumatoceles. Review of 394 pediatric pneumonia in patients at São Paulo State University Hospital during 2 years. We studied those with complications such as pleural effusion and pneumatocele. There were 121 (30.71%) with complications such as pleural effusion and pneumatocele; these were significantly higher in infants. One hundred and six children were needle aspirated, of these 78 underwent drainage, and 15 observation only. From the drained, seven needed thoracotomy or pleurostomy. Fluid was purulent in 50%, and pneumatoceles were seen in 33 cases (8.3%) with spontaneous involution in 28 (85%). Pleural fluid culture was negative in 51% cases; in positive cultures, Streptococcus pneumoniae was the most common agent. Complicated pneumonia incidence was higher in the second year of life and more than 70% occurred before 4 years of age. Closed thoracic drainage was effective in over 90%. Large effusions and mediastinal deviations were submitted to more aggressive procedures. Pneumatoceles predominated in the under 3s and were generally evident in the first chest X-ray. Most cases had spontaneous pneumatocele involution, and in almost half the cases were still present at drain tube removal.
Porcel, J M; Light, R W
About 20% of hospitalized patients with bacterial pneumonia have an accompanying pleural effusion. Parapneumonic effusions (PPE) are associated with a considerable morbidity and mortality. The main decision in managing a patient with a PPE is whether to insert a chest tube (complicated PPE). Imaging (i.e., chest radiograph, ultrasound and computed tomography) and pleural fluid analysis (i.e., pH, glucose, lactate dehydrogenase, bacterial cults) provide essential information for patient management. Therefore, all PPEs should be aspirated for diagnostic purposes. This may require image-guidance if the effusion is small or heavily loculated. According to the current guidelines, any PPE that fulfills at least one of the following criteria should be drained: size > or = 1/2 of the hemithorax, loculations, pleural fluid pH < 7.20 (or alternatively pleural fluid glucose < 60 mg/dl), positive pleural fluid Gram stain or culture, or purulent appearance. The key components of the treatment of complicated PPE and empyema are the use of appropriate antibiotics, provision of nutritional support, and drainage of the pleural space by one of the following methods: therapeutic thoracentesis, tube thoracostomy, intrapleural fibrinolytics, thoracoscopy with breakdown of adhesions or thoracotomy with decortication. The routine use of intrapleural fibrinolytic therapy remains controversial. (c) 2009 Elsevier España, S.L. All rights reserved.
Suárez, Pedro Rodríguez; Gilart, Jorge Freixinet; Pérez, José María Hernández; Serhal, Mohamed Hussein; Artalejo, Antonio López
Summary Background We performed this observational prospective study to evaluate the results of the application of a diagnostic and therapeutic algorithm for complicated parapneumonic pleural effusion (CPPE) and pleural parapneumonic empyema (PPE). Material/Methods From 2001 to 2007, 210 patients with CPPE and PPE were confirmed through thoracocentesis and treated with pleural drainage tubes (PD), fibrinolytic treatment or surgical intervention (videothoracoscopy and posterolateral thoracotomy). Patients were divided into 3 groups: I (PD); II (PD and fibrinolytic treatment); IIIa (surgery after PD and fibrinolysis), and IIIb (direct surgery). The statistical study was done by variance analysis (ANOVA), χ 2 and Fisher exact test. Results The presence of alcohol or drug consumption, smoking and chronic obstructive pulmonary disease (COPD) were strongly associated with a great necessity for surgical treatment. The IIIa group was associated with increased drainage time, length of stay and complications. No mortality was observed. The selective use of PD and intrapleural fibrinolysis makes surgery unnecessary in more than 75% of cases. Conclusions The selective use of PD and fibrinolysis avoids surgery in more than 75% of cases. However, patients who require surgery have more complications, longer hospital stay, and more days on PD and they are more likely to require admittance to the Intensive Care Unit. PMID:22739734
Greve, Thomas; Clemmensen, Dorte; Ridderberg, Winnie; Pedersen, Lisbeth N; Møller, Jens K
The authors report a case of a subdural empyema (SDE) caused by a coinfection with Streptococcus intermedius and Streptococcus pneumoniae, initially considered a S. intermedius infection only. An otherwise healthy 11-year-old female was admitted to the hospital after 5 days of illness. Symptoms were consistent with classical SDE symptoms and progressed rapidly with finally somnolence before the first neurosurgical procedure despite relevant antibiotic treatment. Primary MRI showed an interhemispheric SDE and a postoperative control CT scan showed progression of the empyema infratentorially. The empyema was evacuated twice, day 8 and 18, with good results. Primary samples showed growth of S. intermedius only. The severity of the clinical picture elicited supplementary samples, which were additionally positive for S. pneumoniae by an in-house specific lytA PCR and/or a commercial antigen test.
Bose, Kallol; Saha, Sudip; Mridha, Dhrubojyoti; Das, Kallol; Mondal, Piyasi; Das, Ira
Background: Empyema thoracis in children causes significant morbidity. Standard treatment of Empyema thoracis includes tube drainage and antibiotics. But the tube drainage often fails. Intrapleural Streptokinase has been used in empyema thoracis with good success rate. Objectives: We evaluated the efficacy of intra-pleural Streptokinase in management of empyema thoracis even in advanced stages. Patients and Methods: A total of 28 patients with empyema thoracis requiring intercostal tube drainage aged zero to twelve years were included in the study who were admitted in Pediatric intensive care unit. 15,000 units/kg of Streptokinase was instilled into the pleural cavity. Response was assessed by clinical outcome, after unclamping and subsequent chest radiography and serial chest ultrasounds. Results: Streptokinase enhanced drainage in all patients with complete resolution of empyema thoracis in 26 patients. Two patients were referred for surgery. Only 7.2% required surgery. Streptokinase was equally effective if started before or after seven days. Conclusions: Intrapleural Streptokinase is the preferred treatment for treating pediatric empyema thoracis even in advanced stages and can avoid surgery. PMID:26495096
Fernández-Cotarelo, María José; López-Medrano, Francisco; San Juan, Rafael; Díaz-Pedroche, Carmen; Lizasoain, Manuel; Chaves, Fernando; Aguado, José María
The aim of this study was to describe the clinical characteristics of pleural empyema caused by Streptococcus pneumoniae. A retrospective cohort analysis was conducted at the University Hospital 12 de Octubre, Madrid (Spain). We included all adult patients with pleural empyema caused by S. pneumoniae diagnosed from 1998 to 2004. Eighteen cases of pleural empyema due to S. pneumoniae were analyzed. Fourteen patients had symptoms of respiratory infection, three had other symptoms, and one patient was asymptomatic. One-third of the patients did not have a pneumonia infiltrate visible on chest radiogram. In 46%, bacteremia was detected. All pleural fluids had a high white blood cell count, either with polymorphonuclear or lymphocytic predominance. Drainage with a chest tube was used in 94.4% of cases. Nine patients had a favorable outcome, five had to be admitted to the intensive care unit, and two died within the first week (mortality rate of 11.1%). Pleural empyema caused by S. pneumoniae has to be considered an aggressive disease that, occasionally, affects young and previously healthy individuals. Clinical manifestations are variable and pleural fluid can be a lymphocytic exudate. It has a noticeable associated morbidity and mortality, which must be kept in mind by clinicians when approaching a patient with a pleural effusion.
Chan, Jasper F W; Teng, Jade L L; Li, Iris W S; Wong, Sally C Y; Leung, Sally S M; Ho, Po-On; To, Kelvin K W; Lau, Susanna K P; Woo, Patrick C Y; Yuen, Kwok-Yung
We report a fatal case of Schizophyllum commune empyema thoracis with cross-reactive cryptococcal antigenemia. In vitro testing confirmed the ability of the fungus to cause a positive cryptococcal antigen latex agglutination system (CALAS) test result. Such a result may lead to delay in diagnosis and treatment, as most strains of S. commune are resistant to fluconazole.
Majercik, Sarah; Vijayakumar, Sathya; Olsen, Griffin; Wilson, Emily; Gardner, Scott; Granger, Steven R; Van Boerum, Don H; White, Thomas W
Retained hemothorax (RH) is relatively common after chest trauma and can lead to empyema. We hypothesized that patients who have surgical fixation of rib fractures (SSRF) have less RH and empyema than those who have medical management of rib fractures (MMRF). Admitted rib fracture patients from January 2009 to June 2013 were identified. A 2:1 propensity score model identified MMRF patients who were similar to SSRF. RH, and empyema and readmissions, were recorded. Variables were compared using Fisher exact test and Wilcoxon rank-sum tests. One hundred thirty-seven SSRF and 274 MMRF were analyzed; 31 (7.5%) had RH requiring 35 interventions; 3 (2.2%) SSRF patients had RH compared with 28 (10.2%) MMRF (P = .003). Four (14.3%) MMRF subjects with RH developed empyema versus zero in the SSRF group (P = .008); 6 (19.3%) RH patients required readmission versus 14 (3.7%) in the non-RH group (P = .002). Patients with rib fractures who have SSRF have less RH compared with similar MMRF patients. Although not a singular reason to perform SSRF, this clinical benefit should not be overlooked. Copyright © 2015 Elsevier Inc. All rights reserved.
Passera, Eliseo; Guanella, Giovanni; Meroni, Alberto; Chiesa, Giuseppe; Rizzi, Adriano; Rocco, Gaetano
We present a case of lower bilobectomy complicated by a large bronchopleural fistula and empyema 1 month after primary surgery. The patient was immediately treated with an open window thoracostomy. After surgical debridement, an Amplatzer Septal Occluder device (AGA Medical Corp, Plymouth, MN) was positioned to close the fistula. Thereafter, the thoracostomy rapidly and spontaneously closed with vacuum-assisted closure therapy.
Renner, Christian; Reschke, Susanne; Richter, Wolfgang
We report the use of vacuum-assisted closure (V.A.C. Therapy, KCI Medical, Wiesbaden, Germany) to treat an intrathoracic empyema that occurred after resection of the right lung. Successful closure of the thoracic cavity was achieved with an omental plombage.
Chan, Jasper F. W.; Teng, Jade L. L.; Li, Iris W. S.; Wong, Sally C. Y.; Leung, Sally S. M.; Ho, Po-On; To, Kelvin K. W.; Lau, Susanna K. P.; Woo, Patrick C. Y.
We report a fatal case of Schizophyllum commune empyema thoracis with cross-reactive cryptococcal antigenemia. In vitro testing confirmed the ability of the fungus to cause a positive cryptococcal antigen latex agglutination system (CALAS) test result. Such a result may lead to delay in diagnosis and treatment, as most strains of S. commune are resistant to fluconazole. PMID:24478514
Peltola, Heikki; Pelkonen, Tuula; Bernardino, Luis; Monteiro, Lurdes; Silvestre, Silvia da Conceição; Anjos, Elizabete; Cruzeiro, Manuel Leite; Pitkäranta, Anne; Roine, Irmeli
In Angola during 2003-2012, we detected Haemophilus influenzae in 18% of 2,634 and 26% of 2,996 bacteriologically positive pleural or cerebrospinal fluid samples, respectively, from children. After vaccination launch in 2006, H. influenzae empyema declined by 83% and meningitis by 86%. Severe H. influenzae pneumonia and meningitis are preventable by vaccination.
In 2004, veterinary laboratories in the United Kingdom reported a novel Lancefield group B streptococcus, Streptococcus halichoeri, in seals. We report a case of Streptococcus halichoeri causing postoperative empyema in a patient. A search of the literature revealed that this is the first case of S. halichoeri ever reported in humans. PMID:24478513
Nakamoto, Kembu; Takeshige, Motohiro; Fujii, Toshiyuki; Hashiyada, Hiroshi; Yoshida, Kazuya; Kawamoto, Sadahiro
The empyema space is refractory to elimination of bacterial colonization. Electrolyzed saline (ES) was used as intra-pleural irrigation for rapid disinfection of the empyema space. Twenty consecutive patients with para-pneumonic empyema were reviewed in this study from 2007 to 2015. The empyema space was irrigated by miniaturized thoracoscopic surgery (mini VATS), and the efficacy and safety of the use of ES were evaluated. Sixteen patients were male and four were female, with a mean age of 66.5 ± 9.5 y (27-90 y). Bacterial cultures of the purulent effusions from all 20 patients had positive results. Seventeen patients subsequently underwent continuous catheter irrigation and drainage. No patient had chest pain during ES irrigation. Fever duration after mini VATS was 2.8 ± 1.8 d (0-5 d). Catheter indwelling time was 10.3 ± 7.2 d (3-33 d). Inflammatory markers significantly improved (p < 0.05) within a week after mini VATS. Eighteen patients achieved pleural disinfection, and two patients had residual pathogens, one of whom later died of lung abscess. Space closure was successful in 14 patients. No patient underwent subsequent open drainage. Nineteen (95%) patients were discharged from the hospital. This treatment was successful in 18 (90%) patients, and one (5.6%) patient experienced recurrence. The ES irrigation facilitates the rapid disinfection and closure of the empyema space.
Bishara, Jihad; Goldberg, Elad; Ashkenazi, Shai; Yuhas, Yael; Samra, Zmira; Saute, Milton; Shaked, Hila
Studies have shown that soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) is upregulated by microbial products in the bronchoalveolar lavage fluid, and cerebrospinal fluid of patients with pneumonia and bacterial meningitis, respectively. Our goal was to evaluate whether sTREM-1 in pleural fluid can distinguish pleural empyema from postthoracotomy-related pleural effusion and effusions of other etiologies. Patients who presented with pleural effusion were identified through laboratory records. In addition to routine biochemical markers, differential white blood cells, cytology, Gram stain, and pleural fluid culture, pleural fluid sTREM-1 was measured by enzyme-linked immunosorbent assay using a commercial kit (R&D Systems, Minneapolis, MN). Eighty-nine patients were included in the study: 17 with empyema, 7 simple parapneumonic effusion, 18 transudate, 12 postthoracotomy pleural effusion, 22 malignancy, 1 connective tissue disease, and 12 with undetermined effusion. Mean levels of sTREM-1 were significantly higher in empyema than in postthoracotomy pleural effusion (687 +/- 479 pg/mL vs 34 +/- 81 pg/mL, p < 0.0001, respectively) and in effusions of other etiologies (15 +/- 54 pg/mL, p < 0.0001). A cutoff value of 114 pg/mL for pleural sTREM-1 achieved a sensitivity of 94% and a specificity of 93% in differentiating empyema from pleural effusions of other etiologies. The area under the receiver operating characteristic curve for pleural effusion sTREM-1 as a predictor for empyema was 0.966. Our findings suggest that sTREM-1 in the pleural fluid can potentially assist clinicians in the differentiation of bacterial from nonbacterial pleural effusion, particularly in postthoracotomy pleural effusion.
Takeshige, Motohiro; Fujii, Toshiyuki; Hashiyada, Hiroshi; Yoshida, Kazuya; Kawamoto, Sadahiro
Abstract Background: The empyema space is refractory to elimination of bacterial colonization. Electrolyzed saline (ES) was used as intra-pleural irrigation for rapid disinfection of the empyema space. Patients and Methods: Twenty consecutive patients with para-pneumonic empyema were reviewed in this study from 2007 to 2015. The empyema space was irrigated by miniaturized thoracoscopic surgery (mini VATS), and the efficacy and safety of the use of ES were evaluated. Results: Sixteen patients were male and four were female, with a mean age of 66.5 ± 9.5 y (27–90 y). Bacterial cultures of the purulent effusions from all 20 patients had positive results. Seventeen patients subsequently underwent continuous catheter irrigation and drainage. No patient had chest pain during ES irrigation. Fever duration after mini VATS was 2.8 ± 1.8 d (0–5 d). Catheter indwelling time was 10.3 ± 7.2 d (3–33 d). Inflammatory markers significantly improved (p < 0.05) within a week after mini VATS. Eighteen patients achieved pleural disinfection, and two patients had residual pathogens, one of whom later died of lung abscess. Space closure was successful in 14 patients. No patient underwent subsequent open drainage. Nineteen (95%) patients were discharged from the hospital. This treatment was successful in 18 (90%) patients, and one (5.6%) patient experienced recurrence. Conclusions: The ES irrigation facilitates the rapid disinfection and closure of the empyema space. PMID:27513624
St. Peter, Shawn D.; Tsao, Kuojen; Harrison, Christopher; Jackson, Mary Ann; Spilde, Troy L.; Keckler, Scott J.; Sharp, Susan W.; Andrews, Walter S.; Holcomb, George W.; Ostlie, Daniel J.
Purpose Management of empyema has been debated in the literature for decades. Although both primary video-assisted thoracoscopic surgery (VATS) and tube thoracostomy with pleural instillation of fibrinolytics have been shown to result in early resolution when compared to tube thoracostomy alone, there is a lack of comparative data between these modes of management. Therefore, we conducted a prospective, randomized trial comparing VATS to fibrinolytic therapy in children with empyema. Methods After Institutional Review Board approval, children defined as having empyema by either loculation on imaging or more than 10,000 white blood cells/μL were treated with VATS or fibrinolysis. Based on our retrospective data using length of postoperative hospitalization as the primary end point, a sample size of 36 patients was calculated for an α of .5 and a power of 0.8. Fibrinolysis consisted of inserting a 12F chest tube followed by infusion of 4 mg tissue plasminogen activator mixed with 40 mL of normal saline at the time of tube placement followed by 2 subsequent doses 24 hours apart. Results At diagnosis, there were no differences between groups in age, weight, degree of oxygen support, white blood cell count, or days of symptoms. The outcome data showed no difference in days of hospitalization after intervention, days of oxygen requirement, days until afebrile, or analgesic requirements. Video-assisted thoracoscopic surgery was associated with significantly higher charges. Three patients (16.6%) in the fibrinolysis group subsequently required VATS for definitive therapy. Two patients in the VATS group required ventilator support after therapy, one of whom required temporary dialysis. No patient in the fibrinolysis group clinically worsened after initiation of therapy. Conclusions There are no therapeutic or recovery advantages between VATS and fibrinolysis for the treatment of empyema; however, VATS resulted in significantly greater charges. Fibrinolysis may pose less
Gotoh, Tatsuya; Aoki, Tadashi; Yazawa, Masatomo
A 59-year-old man was diagnosed as Aspergillus empyema with fistula after left upper lobectomy and radiation therapy. His pyrexia was continued after conservative treatment with antifungal agents. Initially, fenestration and vacuum-assisted closure (VAC) therapy were performed. The Aspergillus terreusdisappeared and inflammatory reactions were normalized. Eight days after fenestration, pectoralis major muscle flap transposition was subsequently performed. His postoperative course was uneventful. No recurrent empyema was found 15 months after surgery.
Mirza, Omar; Varadarajan, Vinay; Youshani, Amir Saam; Willatt, David J
Infratentorial subdural empyema is a neurosurgical emergency that is associated with an alarmingly high morbidity and mortality if appropriate management is delayed. It is an important differential to consider when confronted with a patient with a reduced Glasgow Coma Scale, focal neurology and symptoms of raised intracranial pressure in the presence of a head and neck infection. It is also important that the primary team managing these patients is aware of the many pathogens that may be involved, including Escherichia coli. Early recognition, prompt diagnosis, timely involvement of the appropriate multidisciplinary teams, including neurosurgery, otorhinolaryngology, radiology and microbiology should be sought, and urgent intervention are imperative in avoiding a fatal outcome. This article presents a case of E coli-positive infratentorial subdural empyema secondary to mastoiditis due to underlying cholesteatoma, and a review of the pertinent literature. PMID:24777089
Hofmann, Hans-Stefan; Neu, Reiner; Potzger, Tobias; Schemm, Rudolf; Grosser, Christian; Szöke, Tamas; Sziklavari, Zsolt
Enthusiasm for minimally invasive thoracic surgery is increasing. Thoracoscopy plays a significant therapeutic role in the fibrinopurulent stage (stage II) of empyema, in which loculated fluid cannot often be adequately drained by chest tube alone. For some debilitated and septic patients, further procedures such as open-window thoracostomy (OWT) with daily wound care or vacuum-assisted closure (VAC) therapy are necessary. In the present article, we propose a new option of minimally invasive VAC therapy including a topical solution of the empyema without open-window thoracostomy (Mini-VAC-instill). Three patients who underwent surgery using this technique are also presented. The discussion is focused on the advantages and disadvantages of the approach.
Konno, Takuya; Yamada, Kei; Kasahara, Sou; Umeda, Yoshitaka; Oyake, Mutsuo; Fujita, Nobuya
A 69-year-old man developed motor aphasia and right hemiparesis with severe headache, during the treatment of cellulitis and sepsis due to cat bites. Brain CT showed a low density, crescent-shaped lesion in the left subdural space, which was hypointense on brain diffusion-weighted imaging (DWI). One week later, when his neurological symptoms had worsened, the signal of the subdural lesion had changed to hyperintense on DWI. The lesion was capsule-shaped when enhanced by Gadolinium. The signal changes on DWI of the lesion indicated the existing hematoma had changed to an empyema, or so-called infected subdural hematoma, due to a hematogenous bacterial infection. Pasteurella multocida, a resident microbe in the oral cavity of cats, could be the responsible pathogen in this case. The patient recovered completely after treatment with intravenous high dose antibiotics. This is an important case report describing the transformation from a chronic subdural hematoma into a subdural empyema by DWI.
Şahin, Sevim; Yazar, Uğur; Cansu, Ali; Kul, Sibel; Kaya, Selçuk; Özdoğan, Elif Bahat
Subdural empyema related to Streptococcus constellatus is extremely rare in an immunocompetent child, and also there is no reported case along with Staphylococcus lugdunensis infection. Although Streptococcus constellatus has been determined as a co-pathogen with anerobic bacteria in many infections, it has not been reported in combination with Staphylococcus lugdunensis. The authors describe a case of previously healthy 16-y-old child with unilateral subdural empyema due to these bacteria. Sinusitis was the only predisposing factor in the index case. The authors propose that some cases of culture-negative intracranial infections may be due to these infectious agents. Therefore, these agents should be considered as causes of intracranial infection in persistent complaints such as fever and headache after sinusitis in children. It is important to treat them with effective antibiotics and early surgical intervention for favorable outcome, because fatal cases were reported due to Streptococcus constellatus infections.
Matsutani, Noriyuki; Kawamura, Masafumi
We describe the successful management of empyema in patients who need fenestration, but whose general condition is compromised by a high count of multi-drug resistant bacteria, deteriorating health, or bronchial fistula. The procedure is performed at the bed side, under local anesthesia. After making an incision in the thoracic wall using electric cautery, fenestration is created by inserting a Lap-Protector so as to widen the intercostal space. Fenestration using a Lap-Protector, which does not require resection of the ribs, is comparable to that obtained using the conventional rib resection method. However, it causes significantly less pain at the incision site, and the gauze can be changed without pain because it is not in direct contact with the fenestration wound. Thus, fenestration using a Lap-Protector is a more convenient and effective technique than conventional fenestration with rib resection for poor risk patients with empyema.
Medeiros, Israel Lopes; Terra, Ricardo Mingarini; Choi, Esther Mihwa; Pego-Fernandes, Paulo Manuel; Jatene, Fabio Biscegli
OBJECTIVE: Serial C-reactive protein measurements have been used to diagnose and monitor the response to therapy in patients with pneumonia and other infectious diseases. Nonetheless, the role of C-reactive protein measurement after surgical treatment for pleural empyema is not well defined. The aim of this study is to describe the behavior of C-reactive protein levels after the surgical treatment of pleural empyema and to correlate this parameter with the patient's prognosis. METHODS: We retrospectively analyzed the records of patients with pleural empyema treated by either chest-tube drainage or surgery from January 2006 to December 2008. C-reactive protein levels were recorded preoperatively and 2 and 7 days postoperatively. The clinical outcome was binary: success or failure (mortality or the need for repeated pleural intervention). RESULTS: The study group comprised fifty-two patients. The median C-reactive protein values were as follows: 146 mg/L (pre-operative), 134 mg/L (post-operative day 2), and 116 mg/L (post-operative day 7). There was a trend toward a decrease in these values during the first week after surgery, but this difference was only statistically significant on day 7 after surgery. Over the first week after surgery, the C-reactive protein values decreased similarly in both groups (successful and failed treatment). No correlation between the preoperative C-reactive protein level and the clinical outcome was found. CONCLUSIONS: We observed that, in contrast to other medical conditions, C-reactive protein levels fall slowly during the first postoperative week in patients who have undergone surgical treatment for pleural empyema. No correlation between the perioperative C-reactive protein level and the clinical outcome was observed. PMID:22473405
Petel, Dara; Li, Patricia; Emil, Sherif
Randomized trials have shown no benefit to thoracoscopic decortication over pleural drainage with fibrinolytic installation for pediatric empyema. However, the optimal method of pleural drainage has not been defined. The present study compares outcomes of 8.5-Fr soft pigtail catheters (PC) placed via Seldinger technique with larger caliber, stiff chest tubes (12- to 24-Fr) placed via tube thoracostomy (TT). A retrospective review of all pediatric patients treated for empyema during a 5-year period (2006-2011) was conducted. Clinical, therapeutic, and outcomes data from patients treated by PC were compared with those treated by TT. Treatment failure, the primary outcome, was defined as need for an additional invasive thoracic procedure (second tube or catheter or thoracoscopic decortication). We treated 43 patients, 21 by PC and 22 by TT. Fibrinolytics were used in 71% of the PC and 64% of the TT groups. Baseline clinical parameters were not different between the 2 groups. Treatment failure was significantly higher in the PC group (43% vs 14%; P = .045). When the analysis was limited to patients who received fibrinolytics, the failure rate was greater in the PC group (40% vs 14%; P = .129), and duration of illness was shorter (18.3 ± 1.0 vs 25.6 ± 3.5 days; P = .048). Soft PCs are associated with higher failure rates but shorter total duration of illness in the treatment of pediatric empyema. The ideal method for draining pediatric empyema may be a small-caliber, stiff chest tube placed percutaneously. Copyright © 2013 Mosby, Inc. All rights reserved.
Blair, Paul; Moshgriz, Mahdi; Siegel, Marc
Mycobacterium fortuitum is a rapidly growing mycobacterium (RGM) that is an uncommon cause of healthcare-associated infections. The most common infections caused by M. fortuitum include skin, soft tissue, and catheter-related infections. Although occasionally cultured from sputum samples, M. fortuitum is a rare cause of pulmonary disease. We report a case of M. fortuitum empyema associated with an infected pleural catheter and review M. fortuitum pulmonary infections.
Prasad, Rajniti; Kumari, Chhaya; Das, B K; Nath, Gopal
Empyema in children causes significant morbidity and mortality. However, identification of organisms is a major concern. To detect bacterial pathogens in pus specimens of children with empyema by 16S rDNA nested polymerase chain reaction (PCR) and correlate it with culture and sensitivity. Sixty-six children admitted to the paediatric ward with a diagnosis of empyema were enrolled prospectively. Aspirated pus was subjected to cytochemical examination, culture and sensitivity, and nested PCR targeting 16S rDNA using a universal eubacterial primer. Mean (SD) age was 5·8 (1·8) years (range 1-13). Analysis of aspirated pus demonstrated total leucocyte count >1000×10(6)/L, elevated protein (≧20 g/L) and decreased glucose (≤2·2 mmol/L) in 80·3%, 98·5% and 100%, respectively. Gram-positive cocci were detected in 29 (43·9%) and Gram-negative bacilli in two patients. Nested PCR for the presence of bacterial pathogens was positive in 50·0%, compared with 36·3% for culture. 16S rDNA PCR improves rates of detection of bacteria in pleural fluid, and can detect bacterial species in a single assay as well as identifying unusual and unexpected causal agents.
Hos, N J; Bauer, C; Liebig, T; Plum, G; Seifert, H; Hampl, J
Mycoplasma hominis is a commensal of the genitourinary tract, which is infrequently associated with urogenital infections. Extra-urogenital infections due to M. hominis are rare. Here, we report an unusual case of M. hominis subdural empyema in a woman occurring shortly after delivery. The patient presented with symptoms suggestive of bacterial meningitis. Spinal imaging revealed a subdural empyema that required neurosurgical intervention. Cultures from intraoperatively obtained biopsies identified M. hominis as the causative pathogen. The patient was treated with oral moxifloxacin for 4 weeks resulting in the resolution of the spinal lesion. The subdural empyema was presumably caused by a contaminated epidural blood patch performed with the patient's own blood during an episode of transient M. hominis bacteremia after delivery. The blood patch was indicated for the treatment of cerebrospinal fluid leakage, which had occurred after epidural anesthesia. Our findings highlight the significance of transient M. hominis bacteremia after delivery and implicate that M. hominis should be considered as a causative agent of extra-genitourinary tract infections particularly during the postpartum period or after genitourinary manipulation.
Alfageme, I; Muñoz, F; Peña, N; Umbría, S
The etiology, microbiologic findings, and management of 82 episodes of empyema treated by our unit over a period of 6 years were analyzed. Average patient age was 54 years. Eighty-two percent had underlying disease such as alcoholism (29 percent), malignancy (23 percent), and diabetes mellitus (20 percent). Sixty (73 percent) had an empyema develop secondary to a bronchopulmonary infection. Other etiologies were as follows: infradiaphragmatic sepsis, five cases; iatrogenic, ten cases; and idiopathic, seven cases. Cultures were positive in 76 cases and negative in the remaining 6 (2 positive Gram stains, 1 positive under bacilloscopy, and 3 were sterile). Anaerobes were isolated from 25 and aerobes from 47 of the positive cultures. A single bacteria was isolated from 43 and multiple organisms (average: 2.63/case) grew on the remaining 33 positive cultures. Length of hospitalization averaged 37 days. Seven patients received antibiotics only, thoracentesis was performed on three, intercostal chest tube drainage was required in 72, and more aggressive surgery was performed on 12 patients (7 with fibrothorax and 5 with pneumonectomy). Streptokinase was instilled into the pleural space of eight patients with good results. Pleural drainage superinfection occurred at a rate of 8.5 percent. Nine patients died; the remaining recovered. Only three deaths came about as a direct result of the empyema.
Wilkosz, Sylwia; Edwards, Lindsey A.; Bielsa, Silvia; Hyams, Catherine; Taylor, Abigail; Davies, Robert J. O.; Laurent, Geoffrey J.; Chambers, Rachel C.; Lee, Y. C. Gary
Although empyema affects more than 65,000 people each year in the United States and in the United Kingdom, there are limited data on the pathogenesis of pleural infection. We investigated the pathogenesis of empyema using animal and cell culture models of Streptococcus pneumoniae infection. The pathological processes during the development of empyema associated with murine pneumonia due to S. pneumoniae (strain D39) were investigated. Lungs were examined using histology, and pleural fluid and blood bacterial colony-forming units, cytokine levels, and cellular infiltrate were determined over time. Bacterial migration across mesothelial monolayers was investigated using cell culture techniques, flow cytometry, and confocal microscopy. After intranasal inoculation with 107 S. pneumoniae D39 strain, mice developed pneumonia associated with rapid bacterial invasion of the pleural space; raised intrapleural IL-8, VEGF, MCP-1, and TNF-α levels; and caused significant intrapleural neutrophilia followed by the development of fibrinous pleural adhesions. Bacterial clearance from the pleural space was poor, and in vitro assays demonstrated that S. pneumoniae crossed mesothelial layers by translocation through cells rather than by a paracellular route. This study describes key events during the development of S. pneumoniae empyema using a novel murine model of pneumonia-associated empyema that closely mimics human disease. The model allows for future assessment of molecular mechanisms involved in the development of empyema and evaluation of potential new therapies. The data suggest that transmigration of bacteria through mesothelial cells could be important in empyema development. Furthermore, upon entry the pleural cavity offers a protected compartment for the bacteria. PMID:21885676
Langley, Joanne M; Kellner, James D; Solomon, Nataly; Robinson, Joan L; Le Saux, Nicole; McDonald, Jane; Ulloa-Gutierrez, Rolando; Tan, Ben; Allen, Upton; Dobson, Simon; Joudrey, Heather
Although the incidence of serious morbidity with childhood pneumonia has decreased over time, empyema as a complication of community-acquired pneumonia continues to be an important clinical problem. We reviewed the epidemiology and clinical management of empyema at 8 pediatric hospitals in a period before the widespread implementation of universal infant heptavalent pneumococcal vaccine programs in Canada. Health records for children<18 years admitted from 1/1/00-31/12/03 were searched for ICD-9 code 510 or ICD-10 code J869 (Empyema). Empyema was defined as at least one of: thoracentesis with microbial growth from pleural fluid, or no pleural fluid growth but compatible chemistry or cell count, or radiologist diagnosis, or diagnosis at surgery. Patients with empyemas secondary to chest trauma, thoracic surgery or esophageal rupture were excluded. Data was retrieved using a standard form with a data dictionary. 251 children met inclusion criteria; 51.4% were male. Most children were previously healthy and those
Khan, Muhammad Laiq-uz-Zaman; Abbassi, Mujeeb Rehman; Jawed, Muhammad; Shaikh, Ubedullah
To underline the status of male gender and gall bladder wall thickness as significant risk factors for acute cholecystitis complications. The retrospective study, with purposive sampling of the patients of acute cholecystits in age above 18 years, who were operated within 10 days of onset of symptoms, was conducted at the Department of Surgery, Dow University Hospital, Karachi, by reviewing the patients' medical record from March 2010 to August 2012. Correlation of incidence of acute cholecystitis complications (empyema and gangrene) to male gender and to the sonographic gall bladder wall thickness more than 4.5 mm was analysed using SPSS 16. Out of 62 patients, 8 (13%) patients had gangrene while 10 (16.12%) had empyema. Overall, there were 21 (33.87%) males in the study. Ten (47.6%) of the male patients developed empyema or gangrene of the gall bladder as a complication of acute cholecystitis. Of the 41 (66.12%) female patients, only 8 (19.5%) developed these complications. There were 22 (35.48%) cases of gall bladders with sonographic wall thickness more than 4.5 mm who were operated for acute cholecystitis. Of them, 16 (72.7%) had empyema or gangrene. Male gender and sonographic gall bladder wall thickness more than 4.5 mm were statistically significant risk factors for suspicion of complicated acute cholecystitis (empyema/gangrene) and by using these risk factors, we can prioritise patients for surgery in the emergency room.
Syrogiannopoulos, George A; Michoula, Aspasia N; Tsimitselis, Georgios; Vassiou, Katerina; Chryssanthopoulou, Denise C; Grivea, Ioanna N
Parapneumonic effusions in children are usually associated with pneumococcal infections. In Greece, the 7-valent pneumococcal conjugate vaccine was replaced by higher-valent pneumococcal conjugate vaccines (PCVs); 10-valent was introduced in May 2009 and 13-valent (PCV13) in June 2010. Since July 2010, PCV13 has been the most commonly used PCV. In a study conducted at the University General Hospital of Larissa, Central Greece, from January 2012 to January 2016, 85.7% of children born after the implementation of PCV13 and aged 24-59 months had received the complete series (3 + 1 immunization schedule) of PCV13. We studied all paediatric community-acquired pneumonia cases with empyema hospitalized at the University General Hospital of Larissa from January 2008 to January 2016. There were 30 cases of parapneumonic empyema. Among 27 empyema cases of known aetiology, 19 (70.4%) were due to Streptococcus pneumoniae (identifiable serotypes 3, 19A, 7F, and 9N/L). After September 2011, no more cases caused by serotypes 7F and 19A were observed, whereas serotype 3 emerged as the predominant pathogen of pneumococcal empyema (9 of 11 cases). Serotype 3 continued to cause empyema despite vaccination with PCV13 either fully with a 3 + 1 schedule (n = 3) or with one booster dose at the age of 21 months (n = 1). In Central Greece during the first five years of high coverage with PCV13, serotype 3 was the only PCV13 serotype that clearly persisted in children with empyema.
Lai, Shih-Wei; Lin, Cheng-Li; Liao, Kuan-Fu
We assessed the association between diabetes mellitus and the risk of pleural empyema in Taiwan.A population-based retrospective cohort study was conducted using the database of the Taiwan National Health Insurance Program. There were 28,802 subjects aged 20 to 84 years who were newly diagnosed with diabetes mellitus from 2000 to 2010 as the diabetes group and 114,916 randomly selected subjects without diabetes mellitus as the non-diabetes group. The diabetes group and the non-diabetes group were matched by sex, age, comorbidities, and the year of index date. The incidence of pleural empyema at the end of 2011 was estimated. A multivariable Cox proportional hazards regression model was used to estimate the hazard ratio (HR) and 95% confidence interval (95% CI) for pleural empyema associated with diabetes mellitus.The overall incidence of pleural empyema was 1.65-fold higher in the diabetes group than that in the non-diabetes group (1.58 vs 0.96 per 10,000 person-years, 95% CI 1.57-1.72). After adjusting for confounders, a multivariable Cox proportional hazards regression model revealed that the adjusted HR of pleural empyema was 1.71 in subjects with diabetes mellitus (95% CI 1.16-2.51), compared with those without diabetes mellitus. In further analysis, even in the absence of any comorbidity, the adjusted HR was 1.99 for subjects with diabetes mellitus alone (95% CI 1.18-3.38).Diabetic patients confer a 1.71-fold increased hazard of developing pleural empyema. Even in the absence of any comorbidity, the risk remains existent.
Terra, Ricardo Mingarini; Waisberg, Daniel Reis; de Almeida, José Luiz Jesus; Devido, Marcela Santana; Pêgo-Fernandes, Paulo Manuel; Jatene, Fabio Biscegli
OBJECTIVE: We aimed to evaluate whether the inclusion of videothoracoscopy in a pleural empyema treatment algorithm would change the clinical outcome of such patients. METHODS: This study performed quality-improvement research. We conducted a retrospective review of patients who underwent pleural decortication for pleural empyema at our institution from 2002 to 2008. With the old algorithm (January 2002 to September 2005), open decortication was the procedure of choice, and videothoracoscopy was only performed in certain sporadic mid-stage cases. With the new algorithm (October 2005 to December 2008), videothoracoscopy became the first-line treatment option, whereas open decortication was only performed in patients with a thick pleural peel (>2 cm) observed by chest scan. The patients were divided into an old algorithm (n = 93) and new algorithm (n = 113) group and compared. The main outcome variables assessed included treatment failure (pleural space reintervention or death up to 60 days after medical discharge) and the occurrence of complications. RESULTS: Videothoracoscopy and open decortication were performed in 13 and 80 patients from the old algorithm group and in 81 and 32 patients from the new algorithm group, respectively (p<0.01). The patients in the new algorithm group were older (41±1 vs. 46.3±16.7 years, p = 0.014) and had higher Charlson Comorbidity Index scores [0(0-3) vs. 2(0-4), p = 0.032]. The occurrence of treatment failure was similar in both groups (19.35% vs. 24.77%, p = 0.35), although the complication rate was lower in the new algorithm group (48.3% vs. 33.6%, p = 0.04). CONCLUSIONS: The wider use of videothoracoscopy in pleural empyema treatment was associated with fewer complications and unaltered rates of mortality and reoperation even though more severely ill patients were subjected to videothoracoscopic surgery. PMID:22760892
Okonta, Kelechi E.; Ocheli, Emmanuel O.; Gbeneol, Tombari J.
Background: Peripheral bronchopleural fistula (BPF) and empyema from necrotising infections of the lung and pleural is difficult to treat resulting in increased morbidity and mortality rates. The aim of this study was to show the effectiveness of the Latissimus Dorsi muscle (LDM) flap and patch closure techniques in the management of recalcitrant peripheral BPFs with the aid of thoracotomy. Materials and Methods: Five patients with BPF and empyema out of 26 patients who were initially treated for empyema thoracis by single or multiple chest tube insertions and/or ultrasound-guided drainage were prospectively identified and followed up for 2 years, postoperatively. The postoperative hospital stay, dyspnoea score, function of the ipsilateral upper limb and any deformity of chest wall were assessed at follow-up visits by asking relevant questions. Results: The mean age was 46.8 years (23-69 years) (4 males and 1 female). The cause of the BPF in 18 patients was Mycobacterium tuberculosis and 8 was pneumonia. The mean total months of the chest tube insertions was 1.5 months (range 2.5-6 months) prior to the thoracotomy and closure of fistula procedures performed on the 5 patients (with LDM flap in 4 patients and pleural patch in 1 patient). The complications recorded were: subcutaneous emphysema, residual pus and haemothorax in three patients. The mean postoperative hospital stay was 20.8 days (13-28 days);There was improved dyspnoea score to 1 or 2 in the 5 (19.2%) patients. There was no recurrence of BPF or residual pus in all the patients; no loss of function or deformity of the chest wall. Conclusion: The use of LDM Flap was effective in treating peripheral BFP without any adverse long-term outcome. PMID:25657487
Matzi, Veronika; Lindenmann, Joerg; Porubsky, Christian; Neuboeck, Nicole; Maier, Alfred; Smolle-Juettner, Freyja Maria
We report a 72-year-old man suffering from pleural empyema after pneumonectomy due to nonsmall cell lung cancer 20 years previously. Insufficiency of the bronchial stump was ruled out by bronchoscopy and bronchography. Thoracic computed tomographic scan of the thorax detected an abscess located in the subcutaneous tissue of the right ventrolateral chest wall originating from severe pyogenic osteomyelitis of the fifth and sixth ribs. Our surgical management included partial resection of the chest wall followed by insertion of the vacuum-assisted closure system into the thoracic cavity. The patient fully recovered and was discharged on postoperative day 32.
Ekeke, Chigozirim; Noble, Stephen
Intrapleural foreign bodies are rare and there are few reports on the occurrence and management of this uncommon clinical presentation. We report a case of a patient with a history of ingesting multiple foreign bodies, which resulted in multiple laparotomy procedures for extraction. The patient recently required surgical removal of innumerable ingested foreign bodies from the stomach and developed a left empyema post-operatively. Subsequent imaging studies revealed evidence of a foreign object in the left pleural space without evidence of an esophageal perforation or diaphragm injury. PMID:27621882
Tappe, Dennis; Melzer, Falk; Schmoock, Gernot; Elschner, Mandy; Lâm, Thiên-Trí; Abele-Horn, Marianne; Stetter, Christian
Brucellosis is a regionally emerging infectious disease in Mediterranean countries with an increasing number of human cases and high morbidity rates. Here, we describe a case of severe B. melitensis biotype 3 infection in an immigrant who had contact with ruminants during a short-term stay in Bosnia before he returned to Germany. The patient developed thoracic spondylodiscitis accompanied by a large epidural empyema and neurological deficits. The isolated strain was characterized and compared to other strains from the Mediterranean region by multiple locus variable number of tandem repeat analysis, showing minor differences between emerging strains from neighbouring geographical areas.
Fayeye, Oluwafikayo; Silva, Adikarige Haritha Dulanka; Chavda, Swarupsinh; Furtado, Navin Raoul
Chronic low back pain is extremely common with a life time prevalence estimated at greater than 70%. Facet joint arthrosis is thought to be the causative aetiological substrate in approximately 25% of chronic low back pain cases. Facet joint injection is a routine intervention in the armamentarium for both the diagnostic and therapeutic management of chronic low back pain. In fact, a study by Carrino et al. reported in excess of 94,000 facet joint injection procedures were carried out in the US in 1999. Although generally considered safe, the procedure is not entirely without risk. Complications including bleeding, infection, exacerbation of pain, dural puncture headache, and pneumothorax have been described. We report a rare case of a 47-year-old female patient who developed a left L4/5 facet septic arthrosis with an associated subdural empyema and meningitis following facet joint injection. This case is unique, as to the best of our knowledge no other case of subdural empyema following facet joint injection has been reported in the literature. Furthermore this case serves to highlight the potential serious adverse sequelae of a routine and apparently innocuous intervention. The need for medical practitioners to be alert to and respond rapidly to the infective complications of facet joint injection cannot be understated.
Long, Anna-May; Smith-Williams, Jonathan; Mayell, Sarah; Couriel, Jon; Jones, Matthew O; Losty, Paul D
Children with empyema are managed at our center using a protocol-driven clinical care pathway. Chemical fibrinolysis is deployed as first-line management for significant pleural disease. We therefore examined clinical outcome(s) to benchmark standards of care while analyzing disease severity with introduction of the pneumococcal conjugate vaccine. Medical case-records of children managed at a UK pediatric center were surveyed from Jan 2006 to Dec 2012. Binary logistic regression was utilized to study failure of fibrinolytic therapy. The effects of age, comorbidity, number of days of intravenous antibiotics prior to drainage and whether initial imaging showed evidence of necrotizing disease were also studied. A total of 239 children were treated [age range 4months-19years; median 4years]. A decreasing number of patients presenting year-on-year since 2006 with complicated pleural infections was observed. The majority of children were successfully managed without surgery using antibiotics alone (27%) or a fine-bore chest-drain and urokinase (71%). Only 2% of cases required primary thoracotomy. 14.7% cases failed fibrinolysis and required a second intervention. The only factor predictive of failure and need for surgery was suspicion of necrotizing disease on initial imaging (P=0.002, OR 8.69). Pediatric patients with pleural empyema have good outcomes when clinical care is led by a multidisciplinary team and protocol driven care pathway. Using a 'less is best' approach few children require surgery. Copyright © 2016 Elsevier Inc. All rights reserved.
Yuba, Tatsuya; Hatsuse, Mayumi; Kodama, Mai; Uda, Sayaka; Yoshimura, Akihiro; Kurisu, Naoko
A 79-year-old man with a history of tuberculosis was found to have chronic empyema in the right lung and was diagnosed with malignant diffuse large-cell lymphoma (Ann Arbor stage IIE). After completion of one course of rituximab plus cyclophosphamide, pirarubicin, vincristine, and prednisolone (R-CHOP) chemotherapy, the patient developed lung abscess and sepsis caused by Streptococcus intermedius. This condition was treated with antimicrobial agents, and chemotherapy was resumed. After the second course, the chemotherapy regimen was continued without prednisolone, and after administration of the third course, a chest wall mass was found in the right lung. An acid-fast bacillus smear test of the abscess aspirate was positive, and Mycobacterium tuberculosis was detected in a polymerase chain reaction assay, leading to a diagnosis of perithoracic tuberculosis. Chemotherapy for the lymphoma was discontinued, and treatment with four oral antitubercular agents was started. This treatment led to remission of perithoracic tuberculosis. In Japan, tuberculous scar and chronic empyema are relatively common findings, and relapse of tuberculosis should always be considered for patients with these findings during chemotherapy and immunosuppressive therapy.
Stamatis, G; Goebel, R; Konietzko, N; Greschuchna, D
To demonstrate the indication for surgery, the preoperative and postoperative course, and to assess the influence of thoracoplasty on respiratory physiology, the data of patients subjected to thoracoplasty during the past 30 years at our hospital were evaluated. Final assessment was performed separately for patients with and without preceding pulmonary resection. In 21 cases there was an unspecific empyema of the pleura and in 6 cases a specific one; in 14 cases there was also a concomitant bronchopleural fistula. After a washing-out period of 92 days (24-283) and after surgery had been unsuccessful in 9 patients, standard thoracoplasty was performed, complemented by a "jalousie" ("Venetian blind") plasty after Heller. Postoperative lethality was 11.1%. 5 patients developed pleuro-cutaneous fistulas that healed by local treatment; in one patient, a small residual cavity remained that required an additional plasty for correction. In 94% of the patients who had been operated upon, scoliosis occurred convex to the thoracoplasty; this was more marked in patients in whom lung resection had been performed than in patients without resection. Restrictive ventilatory disorders were seen in the lung function of 55% of the patients, whereas mixed restrictive-obstructive disorders occurred in 45%. Ergospirometry resulted under load besides in an increased respiratory minute volume (AMV), in a proportionate dead space of the AMV which was significantly higher than preoperatively. Despite the considerable functional and aesthetic consequences resulting therefrom, thoracoplasty still has its justification in refractory pleura empyemas as an ultimate means of cleaning up.
Introduction To date intracranial complication caused by tooth extractions are extremely rare. In particular parietal subdural empyema of odontogenic origin has not been described. A literature review is presented here to emphasize the extreme rarity of this clinical entity. Case presentation An 18-year-old Caucasian man with a history of dental extraction developed dysarthria, lethargy, purulent rhinorrhea, and fever. A computed tomography scan demonstrated extensive sinusitis involving maxillary sinus, anterior ethmoid and frontal sinus on the left side and a subdural fluid collection in the temporal-parietal site on the same side. He underwent vancomycin, metronidazole and meropenem therapy, and subsequently left maxillary antrostomy, and frontal and maxillary sinuses toilette by an open approach. The last clinical control done after 3 months showed a regression of all symptoms. Conclusions The occurrence of subdural empyema is an uncommon but possible sequela of a complicated tooth extraction. A multidisciplinary approach involving otolaryngologist, neurosurgeons, clinical microbiologist, and neuroradiologist is essential. Antibiotic therapy with surgical approach is the gold standard treatment. PMID:25146384
Hagos, Girmay; Esayas, Reiye; G/Selassie, Kibrom
Chronic empyema is a serious problem and is often difficult to manage. Its incidence has dropped worldwide, but continues to pose health problems in low and middle income countries. This study has been conducted to assess the outcome of open thoracic window in patients with neglected chronic thoracic empyemain Ethiopian patients. A six-year (June 2008 to October 2014) retrospective study was conducted on thirty five patients (ten females and twenty five males, age ranging from 30-70 years). Open window thoracostomy was performed on these patients for chronic empyema with residual lung tissue and with or without bronchopleural fistula who failed to respond to the conventional methods of treatment. The etiology was primary empyema in 16 patients, post-traumatic in 12 patients, and post-thoracotomy in seven patients. Spontaneous closure was achieved in 12 patients; simple closure was done on 18 patients; and closure with muscle flap in five patients. In all patients, the cavity cleared from secretions in two to three weeks and the residual space narrowed in seven to nine months. All patients gained weight following the surgery. Our result has revealed that open thoracic window is still an alternative method for the treatment of chronic empyema when the conventional method of treatment fails.
Umezawa, Hiroki; Miyamoto, Shimpei; Fujiki, Masahide; Higashino, Takuya; Oshima, Azusa; Tsuboi, Masahiro
Background: Postoperative bronchopleural fistula (BPF) and empyema are not uncommon after lung cancer surgery. Some patients require reconstructive surgery to achieve wound healing. In this report, we describe a novel method of reconstructive surgery for BPF and empyema. Methods: From 1996 through 2014, we performed reconstructive surgery for the treatment of BPF and empyema in 13 cases. BPF or a pulmonary fistula was present in 11 patients at the time of reconstruction. Of these, a free fascial patch graft combined with a free soft tissue flap was used to close the fistula in 6 cases. In the other 5 cases, primary fistula closure or direct coverage of the fistula with a transferred flap was performed. Medical records were retrospectively reviewed, and postoperative results were compared for these methods. Results: All the flaps were transferred successfully except in 1 case. Although postoperative air leakage was observed in 5 cases, most of these healed with conservative management. Of 11 fistulas, 8 were successfully controlled. Although differences were not statistically significant, a higher success rate of fistula closure was obtained in patients with a fascial patch graft (100% vs 40%). As a result, 9 patients could be discharged from the hospital, but 4 died during their hospital stay. Conclusion: Although the incidence of in-hospital mortality was high, fistula closure with a fascial patch graft combined with free flap transfer was effective for the treatment of BPF and empyema, compared with other procedures. PMID:28203500
Hardavella, Georgia; Papakonstantinou, Nikolaos A; Karampinis, Ioannis; Papavasileiou, Gerasimos; Ajab, Shereen; Shafaat, Mohammed; Malagaris, Stavros; Anastasiou, Nikolaos
The aim of this study was to evaluate the safety and efficacy of medical thoracoscopy through a single port [single-port medical thoracoscopy (S-MT)] for the treatment of empyema thoracis in its early stages. We performed a retrospective analysis reviewing the medical records of 84 patients referred for empyema and treated by medical thoracoscopy at our Thoracic Departments from January 2001 until November 2014. S-MT was performed under local anesthesia with neuroleptoanalgesia and spontaneous breathing using a single 1-cm incision for debridement and lavage of the pleural cavity. A total of 84 patients underwent S-MT for pleural empyema stage I (9 patients, 10.7%) or II (75 patients, 89.3%). Median age was 61.8 years (range, 18 to 84 y). Male to female ratio was 3.76. Surgery was performed 5 to 26 days after the onset of symptoms. Macroscopically complete debridement of the pleural cavity was achieved in 71 patients (84.5% of cases). The rest 15.5% of cases required video-assisted thoracoscopic surgery or open decortication due to trapped-lung syndrome. Median operation time was 45 minutes (range, 30 to 94 min). No intraoperative complications occurred. In-hospital mortality was zero, whereas in-hospital morbidity rate was 16.7%. Median hospital stay was 7.8 days (range, 3 to 18 days). Recurrence rate was 4.8% as 4 patients experienced a relapse of empyema. It seems that S-MT is a minimally invasive, safe and effective procedure for the treatment of pleural empyema with very good results in early stages of the disease and reduced time of hospital stay.
Achi, V H; Brou Ahui, J C; Anon, J C; Kouassi, A B; Bi Djè, H; Horo, K; N'dhatz, M S; Koffi, N; Aka Danguy, E
To identify the main bacteria that cause thoracic empyema of HIV-infected patients. Retrospective study analyzing the etiology of thoracic empyema in patients admitted to the pneumology clinic of the university hospital center in Abidjan from January 1998 to December 2010. We included all patients with bacteriologically confirmed thoracic empyema and had serological test for HIV. We compared the different pathogens based on HIV status. There were 42 patients of thoracic empyema composed of 24 (63.3%) HIV-infected patients [15 (62.5%) males and nine (37.5%) women] and 18 (36.7%) HIV-negative patients [13 (72.22%) men and five (27.78%) women]. The average age of HIV-infected patients was 41.2 years and 44.8 years for HIV-negative patients. HIV status was known only for 4.76% patients at admission, and most of them had a severe stage of immune suppression, (the average T CD4 cell count was 96/mm(3)). Pleurisy was monomicrobial in 83.33% HIV-infected patients and 94.4% HIV-negative patients. It was polymicrobial in 16.67% immunocompromised patients and 5.56% HIV-negative patient. Gram-negative bacteria were isolated from 58.33% HIV-infected patients. Streptococcus Pneumoniae was observed in 61.11% HIV-negative patients. Gram-negative bacteria are the main causes of thoracic empyema in patients HIV-infected. Copyright © 2013. Published by Elsevier Masson SAS.
Cabello-Serrano, Almudena; Monsalve-Iglesias, Fernando; Roman-Ramos, Maria; Garcia-Medina, Blas
Complication of dental infections might be various and heterogeneous. The most common complications are represented by maxilar celulitis, canine space celulitis, infratemporal space celulitis, temporal celulitis and bacteremia. Among rarest complications we found: sepsis, bacterial endocarditis, mediastinitis, intracranial complications, osteomyelitis, etc. Although dental infections are often considered trivial entities, sometimes they can reach an impressive gravity. In this regard, the present study describes a case of dental infection complicated by meningitis, subdural empiema and cerebral vasculitis. Furthermore, we observed other neurological complications, like thalamic ischemic infarction, during the disease evolution. Noteworthy, these entities were not presented when the patient was admitted to hospital. Therefore, the main aim of this report is to highlight the serious consequences that an infection of dental origin could cause. Key words:Meningitis, subdural empyema, odontogenic infections. PMID:27703619
Ariza-Prota, Miguel Angel; Pando-Sandoval, Ana; García-Clemente, Marta; Fernández, Ramón; Casan, Pere
Citrobacter species, belonging to the family Enterobacteriaceae, are environmental organisms commonly found in soil, water, and the intestinal tracts of animals and humans. Citrobacter koseri is known to be an uncommon but serious cause of both sporadic and epidemic septicemia and meningitis in neonates and young infants. Most cases reported have occurred in immunocompromised hosts. The infections caused by Citrobacter are difficult to treat with usual broad spectrum antibiotics owing to rapid generation of mutants and have been associated with high death rates in the past. We believe this is the first case described in the literature of a community-acquired pneumonia and empyema caused by Citrobacter koseri in an immunocompetent adult patient.
Cardoso, Maria Regina Alves; Nascimento-Carvalho, Cristiana Maria Costa; Ferrero, Fernando; Berezin, Eitan Naaman; Ruvinsky, Raul; Sant'Anna, Clemax Couto; Brandileone, Maria Cristina de Cunto; March, Maria de Fátima Bazhuni Pombo; Maggi, Ruben; Feris-Iglesias, Jesus; Benguigui, Yehuda; Camargos, Paulo Augusto Moreira
We compared bacteremic pneumococcal pneumonia (BPP) and pneumococcal empyema (PE), in terms of clinical, radiological, and laboratory findings, in under-fives. A cross-sectional nested cohort study, involving under-fives (102 with PE and 128 with BPP), was conducted at 12 centers in Argentina, Brazil, and the Dominican Republic. Among those with PE, mean age was higher; disease duration was longer; and tachypnea, dyspnea, and high leukocyte counts were more common. Among those with BPP, fever and lethargy were more common. It seems that children with PE can be distinguished from those with BPP on the basis of clinical and laboratory findings. Because both conditions are associated with high rates of morbidity and mortality, prompt diagnosis is crucial.
Kovács, Ottó; Szántó, Zoltán; Krasznai, Géza
Authors introduce the case of a 64-year-old male patient with fulminant isolated necrotizing fasciitis of the chest wall, complicating empyema thoracis of unknown origin. The patient's co-morbidities were hypertension, ischaemic heart disease, atrial fibrillation with oral anticoagulation. The real etiology was revealed post mortem, due to the rapid progression. The autopsy demonstrated that the fasciitis was caused by a small blunt thoracic trauma (haematoma), not emerged from patient's history and was not visible during physical examination. Authors review diagnostic pitfalls, leading to delayed recognition in addition to this very case. After quick diagnosis surgical debridement, targeted wide spectrum antibiotics and maximal intensive care are the basic pillars of the management of necrotizing fasciitis.
Cariati, Paolo; Cabello-Serrano, Almudena; Monsalve-Iglesias, Fernando; Roman-Ramos, Maria; Garcia-Medina, Blas
Complication of dental infections might be various and heterogeneous. The most common complications are represented by maxilar celulitis, canine space celulitis, infratemporal space celulitis, temporal celulitis and bacteremia. Among rarest complications we found: sepsis, bacterial endocarditis, mediastinitis, intracranial complications, osteomyelitis, etc. Although dental infections are often considered trivial entities, sometimes they can reach an impressive gravity. In this regard, the present study describes a case of dental infection complicated by meningitis, subdural empiema and cerebral vasculitis. Furthermore, we observed other neurological complications, like thalamic ischemic infarction, during the disease evolution. Noteworthy, these entities were not presented when the patient was admitted to hospital. Therefore, the main aim of this report is to highlight the serious consequences that an infection of dental origin could cause. Key words:Meningitis, subdural empyema, odontogenic infections.
Ruzicić, Radica Dragojlović; Jakovljević, Vladimir; Zivković, Vladimir; Vujić, Sinisa; Varagić, Pavle; Nikodijević, Predrag
Spine tuberculosis is caused by Micobacterium tuberculosis. It is localized in the vertebral body or intervertebral disc. Its diagnosis is often delayed because of nonspecific symptoms and neglected presence of tuberculosis, which leads to serious complications. This paper presents a case of tuberculous spondylitis, which was complicated with the fracture of vertebra, paraparesis of lower extremities and pleural empyema. The treatment with antituberculous drugs started after the fracture of 10th and 11th thoracic vertebras. The therapy brought some improvement but paraparesis of lower extremities remained. In the further course of disease, inflammatory process affected the pleura. Antibiotic and antitubercular therapy with puncture of pleura were not very effective. Operation was performed on December 20th 2011: Thoracotomia lat. dex. Decorticatio pulmonum lat.dex. Seven months after surgery, the patient was without symptoms. Tuberculous spondylitis occurs relatively frequently in clinical practice. Early diagnosis and adequate therapy of this disease can prevent the occurrence of its serious complications.
Cardoso, Maria Regina Alves; Nascimento-Carvalho, Cristiana Maria Costa; Ferrero, Fernando; Berezin, Eitan Naaman; Ruvinsky, Raul; Sant'Anna, Clemax Couto; Brandileone, Maria Cristina de Cunto; March, Maria de Fátima Bazhuni Pombo; Maggi, Ruben; Feris-Iglesias, Jesus; Benguigui, Yehuda; Camargos, Paulo Augusto Moreira
We compared bacteremic pneumococcal pneumonia (BPP) and pneumococcal empyema (PE), in terms of clinical, radiological, and laboratory findings, in under-fives. A cross-sectional nested cohort study, involving under-fives (102 with PE and 128 with BPP), was conducted at 12 centers in Argentina, Brazil, and the Dominican Republic. Among those with PE, mean age was higher; disease duration was longer; and tachypnea, dyspnea, and high leukocyte counts were more common. Among those with BPP, fever and lethargy were more common. It seems that children with PE can be distinguished from those with BPP on the basis of clinical and laboratory findings. Because both conditions are associated with high rates of morbidity and mortality, prompt diagnosis is crucial. PMID:24626272
Ariza-Prota, Miguel Angel; Pando-Sandoval, Ana; García-Clemente, Marta; Fernández, Ramón; Casan, Pere
Citrobacter species, belonging to the family Enterobacteriaceae, are environmental organisms commonly found in soil, water, and the intestinal tracts of animals and humans. Citrobacter koseri is known to be an uncommon but serious cause of both sporadic and epidemic septicemia and meningitis in neonates and young infants. Most cases reported have occurred in immunocompromised hosts. The infections caused by Citrobacter are difficult to treat with usual broad spectrum antibiotics owing to rapid generation of mutants and have been associated with high death rates in the past. We believe this is the first case described in the literature of a community-acquired pneumonia and empyema caused by Citrobacter koseri in an immunocompetent adult patient. PMID:26634165
Lakranbi, M; Rabiou, S; Belliraj, L; Issoufou, I; Ammor, F Z; Ghalimi, J; Ouadnouni, Y; Smahi, M
The occurrence of empyema after pneumonectomy or in suites with chronic pleural pocket is a dreaded complication. The management is long and difficult. The authors report their experience before this complication including infection control by an emptying of the pleural pocket percutaneous drainage or thoracostomy which will be complemented by a thoracomyoplasty the aim to erase the pleural pocket. This is a retrospective study conducted between 2009 and 2015 concerning the records of 9 patients treated for empyema or in the aftermath of a lung resection or as part of a chronic pleural pocket and calcific. We had identified all 9 male patients aged 30 to 67 years. This was pyothorax complicating pneumonectomy in 4 patients and 1 pyothorax after a left upper lobectomy in 1 case. For the other 4 patients, there was a post-tuberculous pleural pocket, calcified chronic and whose attempts to decortication seemed impossible. We observed 3 cases of bronchopleural fistula. All patients had received evacuation of the contents of the pleural drainage bag is either thoracostomy laying the bed of a possible filling thoracomyoplasty. The evolution of pleural cavities after thoracostomy was favorable on septic map leading to a retraction of the pleural cavity and its spontaneous closure in 1 patient. In 6 patients, filling the cavity with thoracomyoplasty was necessary. The evolution immediate postoperative was favorable in all patients and no deaths were noted in connection with this technique. Pyothorax on pneumonectomy cavity and chronic pleural calcified pockets are serious complications whose management is long and delicate. The thoracomyoplastie is a real alternative to the filling of the cavity in fragile patients with significant operational risk. The results are satisfactory in the hands of a broken team this technique. Copyright Â© 2016 Elsevier Masson SAS. All rights reserved.
Botianu, Petre Vlah-Horea; Botianu, Alexandru Mihail; Bacarea, Vladimir Constantin
The role of muscle flaps and thoracomyoplasty in the treatment of postoperative empyema is controversial. The major difficulty is given by the sectioning of the muscular masses during the previous thoracotomy/thoracotomies, resulting in a limitation of the volume and mobility of the available neighborhood flaps. Between January 1, 2004, and January 1, 2012, we used muscle flaps and thoracomyoplasty as a re-redo procedure in seven patients having a history of at least two major procedures performed through thoracotomy (without considering tube thoracostomy and open thoracic window). In all the cases, the indication for thoracomyoplasty was the presence of an empyema which could not be controlled by the previous procedures. The principle of our procedure was to perform a complete obliteration of the cavity, closure reinforcement of the bronchial fistulae using muscle flaps (in four cases), drainage, and primary closure of the new operative wound. We encountered no mortality, one bronchopneumonia requiring prolonged antibiotic treatment, and one intermuscular seroma; there was no need for prolonged mechanical ventilation or major inotropic support. In all the patients, we achieved complete obliteration of the cavity and per primam wound healing, with postoperative hospitalizations ranging between 30 and 51 days. At late follow-up (1-8 years), we encountered no recurrence and no major functional sequelae. Thoracomyoplasty may be a definitive solution in cases with recurrent postoperative complications. A careful analysis of the local anatomy allows the use of muscle flaps even after more procedures involving opening of the chest. Georg Thieme Verlag KG Stuttgart · New York.
Jacob-Kokura, Susan; Chan, Claire Y; Kaplan, Lewis
To describe the first reported case of bacteremia and empyema caused by Shewanella algae and summarize the existing literature on Shewanella human infection. A 25-year-old healthy male was shot through the chest into the abdomen and fled into an adjacent body of seawater. He underwent surgical repair of his injuries, including pleural decortication. Leukocytosis, bandemia, and copious yellow bronchorrhea led to cultures; piperacillin/tazobactam and vancomycin were started for broad-spectrum empiric management based on the local intensive care unit antibiogram. Blood and pleural fluid cultures revealed S algae. Sputum cultures grew methicillin-sensitive Staphylococcus aureus and Haemophilus influenzae. He was successfully managed with an empiric and then tailored antibiotic regimen. Shewanella algae is a rare Gram-negative bacillus that has infrequently been reported to cause infection. It is found predominantly in men. Shewanella algae infections span bacteremia to necrotizing soft tissue infection and are associated with injury and seawater exposure. Shewanella is susceptible to the majority of third- and fourth-generation cephalosporins, aminoglycosides, chloramphenicol, erythromycin, aztreonam, and fluoroquinolones, but are less predictably susceptible to tetracycline and trimethoprim/sulfamethoxazole and carbapenem agents. Shewanella infection is associated with medical comorbidities, in particular, renal failure and cardiovascular disease. To our knowledge, this is the first case report of bacteremia and empyema caused by S algae. Such a case involving a young healthy individual should encourage health care providers to be aware of the potential infections caused by unusual pathogens, and to employ appropriate empiric antibiotic therapy based on reported sensitivity profiles. Based on available susceptibilities, we recommend using a third or fourth-generation cephalosporin as first-line pharmacologic management with regimen de-escalation based on culture
Tsujimoto, Naoki; Saraya, Takeshi; Light, Richard W.; Tsukahara, Yayoi; Koide, Takashi; Kurai, Daisuke; Ishii, Haruyuki; Kimura, Hirokazu; Goto, Hajime; Takizawa, Hajime
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
Mao, Rui; Ying, Peng-Qing; Xie, Dong; Dai, Chen-Yang; Zha, Jun-Yan; Chen, Tao; Jiang, Ge-Ning; Fei, Ke
Background Bronchopleural fistula (BPF) is an infrequent but life-threatening complication after lung surgery. Tentative closure of the fistula and irrigation have been the conventional treatments, but are also surgically challenging and associated with a considerable failure rate. This study reports on a conservative practice of this difficult issue, in aim to examine its outcomes. Method All enrolled cases were handled consecutively from September 2006 to June 2015. The empyema was first properly drained till disseminated pneumonia controlled. After conducting lavage, tube drainage was gradually transited to postural drainage. During the follow-up, information on tube removal, fistula healing, and survival were recorded. Results Thirteen cases were enrolled, including 9 rights and 4 lefts. The primary diseases were lung cancer , lung abscess , organizing pneumonia , and aspergillosis . Early fistula (≤30 days postoperatively) occurred in 8 cases and late fistula (>30 days postoperatively) in 5 cases. Two patients underwent debridement to ascertain complete drainage. Chest tubes retained from 7 to 114 days (mean 40.54±30.49 days) before removal. At follow-up, we observed gradually narrowing-down of all residual cavities, and symptoms of fistula and empyema eventually disappeared in all patients. No complication or death occurred during the follow-up. Conclusions Conservative management by a combination of tube and postural drainage provides an effective and safe treatment for empyema-complicated post-lobectomy BPFs. PMID:27499946
Sütçü, Murat; Aktürk, Hacer; Karagözlü, Fatih; Somer, Ayper; Gürler, Nezahat; Salman, Nuran
Background: Clinical vaccine failure is the occurence of the specific vaccine-preventable disease in an appropriately and fully vaccinated person after enough time has elapsed for protection against the antigens of the vaccine to develop. Fully immunized cases with pneumoccal vaccine may sometimes develop a complicated pneumonia with empyema caused by a vaccine serotype. Case Report: A 2 year-old male patient was admitted with the complaints of fever. On the basis of findings and laboratory results, the patient was diagnosed as having empyema. He was successfully treated with parenteral antibiotics and chest tube drainage. The pleural fluid culture and hemoculture of the patient yielded penicillin-susceptible pneumococci and the isolate was identified as serotype 9V. The patient had been vaccinated with a 13-valent pneumococcal conjugate vaccine according to the Turkish national immunization schedule at 2, 4, 6 and 12 months of age. His medical history and basic immunological profile were inconsistent with a primary immunodeficiency. Conclusion: The failure of the PCV13 vaccine may results in a complicated pneumonia with empyema. It is important to investigate serotypes of pneumococci in these cases to determine other possible vaccine failures due to PCV13 and to study the underlying mechanisms. PMID:28251028
Manjila, Sunil; Singh, Gagandeep; Ndubuizu, Obinna; Jones, Zoe; Hsu, Daniel P; Cohen, Alan R
The authors demonstrate the use of an endovascular plug in securing a carotid artery pseudoaneurysm in an emergent setting requiring craniotomy for a concurrent subdural empyema. They describe the case of a 14-year-old boy with sinusitis and bifrontal subdural empyema who underwent transsphenoidal exploration at an outside hospital. An injury to the right cavernous segment of the ICA caused torrential epistaxis. Bleeding was successfully controlled by inflating a Foley balloon catheter within the sphenoid sinus, and the patient was transferred to the authors' institution. Emergent angiography showed a dissection of the right cavernous carotid artery, with a large pseudoaneurysm projecting into the sphenoid sinus at the site of arterial injury. The right internal carotid artery was obliterated using pushable coils distally and an endovascular plug proximally. The endovascular plug enabled the authors to successfully exclude the pseudoaneurysm from the circulation. The patient subsequently underwent an emergent bifrontal craniotomy for evacuation of a left frontotemporal subdural empyema and exenteration of both frontal sinuses. He made a complete neurological recovery. Endovascular large-vessel sacrifice, obviating the need for numerous coils and antiplatelet therapy, has a role in the setting of selected acute neurosurgical emergencies necessitating craniotomy. The endovascular plug is a useful adjunct in such circumstances as the device can be deployed rapidly, safely, and effectively.
Köksal, Vaner; Özgür, Abdulkadir; Terzi, Suat
Subtentorial empyema is a rare intracranial complication of chronic otitis media. Moreover, if not correctly treated, it is a life-threatening infection. Epidural and subdural empyemas on subtentorial space have different effects. This difference is not mentioned in literature. If the distinction can be made, surgical treatment method will be different, and the desired surgical treatment may be less minimal invasive. A 26-year-old male patient was found to have developed epidural empyema in the subtentorial space. We performed a burr-hole evacuation in this case because there was low cerebellar edema, Also, the general condition of the patient was good, the empyema was a convex image on the lower surface of tentorium on magnetic resonance images, and when the dura mater base is reached during mastoidectomy for chronic otitis media, we were observed to drain a purulent material through the epidural space. After 10 days from surgery increased posterior fossa edema caused hydrocephalus. Therefore, ventriculoperitoneal shunt insertion was performed. The patient fully recovered and was discharged after 6 weeks. Complete correction in the posterior fossa was observed by postoperative magnetic resonance imaging. Burr-hole evacuation from inside of the mastoidectomy cavity for subtentorial epidural empyema is an effective and minimal invasive surgical treatment. PMID:27057210
Ampofo, Krow; Herbener, Amy; Blaschke, Anne J.; Heyrend, Caroline; Poritz, Mark; Korgenski, Kent; Rolfs, Robert; Jain, Seema; Carvalho, Maria da Glória; Pimenta, Fabiana C.; Daly, Judy; Mason, Edward O.; Byington, Carrie L.; Pavia, Andrew T.
Background During previous influenza pandemics, many deaths were associated with secondary bacterial infection. In April 2009, a previously unknown 2009 influenza A virus (2009 H1N1) emerged, causing a global influenza pandemic. We examined the relationship between circulating 2009 H1N1 and the occurrence of secondary bacterial parapneumonic empyema in children. Methods Children hospitalized with parapneumonic empyema from August 2004 to July 2009, including a period when the 2009 H1N1 circulated in Utah, were identified using International Classification of Diseases, Ninth Revision codes. We compared the average number of children diagnosed with influenza A and the number of admissions for empyema per month for the previous 4 seasons to rates of empyema during the 2009 H1N1 outbreak. We identified causative bacteria using culture and polymerase chain reaction (PCR). Results We observed an increase in hospitalization of children with pneumonia complicated by empyema during a severe outbreak of 2009 H1N1 during the spring and summer of 2009, compared with historical data for the previous 4 seasons. Streptococcus pneumoniae and Streptococcus pyogenes were the predominant bacteria identified. Conclusions Similar to previous pandemics, secondary bacterial infection with S. pneumoniae and S. pyogenes were associated with the 2009 H1N1 outbreak. There is an urgent need to better understand bacterial complications of pandemic influenza. In the interim, influenza vaccines, antiviral agents, and pneumococcal vaccines should be used to prevent cases of secondary bacterial pneumonia whenever possible. PMID:20407400
Galmès, Johanna; Li, Yongjun; Rajoharison, Alain; Ren, Lili; Dollet, Sandra; Richard, Nathalie; Vernet, Guy; Javouhey, Etienne; Wang, Jianwei; Telles, Jean-Noël; Paranhos-Baccalà, Gláucia
An unexplained increase in the incidence of parapneumonic empyema (PPE) in pneumonia cases has been reported in recent years. The present study investigated the genetic and biological specifications of new isolates of torque teno mini virus (TTMV) detected in pleural effusion samples from children hospitalised for severe pneumonia with PPE. A pathogen discovery protocol was applied in undiagnosed pleural effusion samples and led to the identification of three new isolates of TTMV (TTMV-LY). Isolated TTMV-LY genomes were transfected into A549 and human embryonic kidney 293T cells and viral replication was assessed by quantitative real-time PCR and full-length genome amplification. A549 cells were further infected with released TTMV-LY virions and the induced-innate immune response was measured by multiplex immunoassays. Genetic analyses of the three TTMV-LY genomes revealed a classic genomic organisation but a weak identity (<64%) with known sequences. We demonstrated the in vitro replication of TTMV-LY in alveolar epithelial cells and the effective release of infectious viral particles. We also showed a selective production of inflammatory mediators in response to TTMV infection. This study reports the description of replicative TTMV-LY isolated from parapneumonic effusions of children hospitalised with PPE, suggesting a potential role of the virus in the pathogenesis of pneumonia. PMID:23060626
Introduction The trigemino-cardiac reflex is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hypermotility during stimulation of any of the sensory branches of the trigeminal nerve. Clinically, trigemino-cardiac reflex has been reported to occur during neurosurgical skull-base surgery. Apart from the few clinical reports, the physiological function of this brainstem reflex has not yet been fully explored. Little is known regarding any predisposing factors related to the intraoperative occurrence of this reflex. Case presentation We report the case of a 70-year-old Caucasian man who demonstrated a clearly expressed form of trigemino-cardiac reflex with severe bradycardia requiring intervention that was recorded during surgical removal of a large subdural empyema. Conclusion To the best of our knowledge, this is the first report of an intracranial infection leading to perioperative trigemino-cardiac reflex. We therefore add a new predisposing factor for trigemino-cardiac reflex to the existing literature. Possible mechanisms are discussed in the light of the relevant literature. PMID:21118536
Kornberger, A; Walter, V; Khalil, M; Therapidis, P; Assmus, B; Moritz, A; Beiras-Fernandez, A; Stock, U A
Device-related infections in recipients of left ventricular assist devices (LVAD) have been recognized as a major source of morbidity and mortality. They require a high level of diagnostic effort as part of the overall burden resulting from infectious complications in LVAD recipients. We present a multi-allergic patient who was treated for persistent sterile intrathoracic abscess formation and pericardial empyema following minimally invasive LVAD implantation including use of a sheet of e-polytetrafluoroethylene (ePTFE) membrane to restore pericardial integrity. Sterile abscess formation and pericardial empyema recurred after surgical removal until the ePTFE membrane was removed, suggesting that in disposed patients, ePTFE may be related to sterile abscess formation or sterile empyema.
Noguchi, Shingo; Yatera, Kazuhiro; Kawanami, Toshinori; Yamasaki, Kei; Fukuda, Kazumasa; Naito, Keisuke; Akata, Kentarou; Nagata, Shuya; Ishimoto, Hiroshi; Taniguchi, Hatsumi; Mukae, Hiroshi
The bacterial species in the Streptococcus anginosus group (S. constellatus, S. anginosus, S. intermedius) are important causative pathogens of bacterial pneumonia, pulmonary abscesses and empyema. However, the bacteria in this group are primarily oral resident bacteria and unable to grow significantly on ordinary aerobic culture media. We experienced a case of pneumonia and empyema caused by Streptococcus intermedius detected using a 16S rRNA gene sequencing analysis of bronchoalveolar lavage fluid and pleural effusion, but not sputum. Even when applying the molecular method, sputum samples are occasionally unsuitable for identifying the causative pathogens of lower respiratory tract infections.
Ahmed, Sultan; Azam, Hammad; Basheer, Imran
Objective: To confirm that either Fibrinolytic therapy or open decortication which of the two is an effective First line treatment of pleural empyema. Methods: This prospective comparative study was conducted in the department of surgery Sheikh Zayed Medical College and Hospital, Rahim Yaar Khan. Seventy eight (78) patients were included in this study. There were two groups of patients; Group I (n=35) patients treated with fibrinolytic therapy, Group II (n=43) patients treated with open decortication. Data was entered and analyzed in SPSS v16. Student’s t-test was used for comparison of quantitative variables. Chi-square and Fisher’s Exact test were used for comparison of qualitative variables. P-value ≤ 0.05 was taken as significant difference. Results: There was no significant difference in base baseline characteristics of patients of Group I and II. Incidence of comorbidities was also same between the groups. Most of the patients in Group I and II were in empyema stage III. Fluid cultures was positive in 33 (94.3%) patients in group I and 39 (90.7%) patients in group II. 30 (85.7%) was successfully treated using fibrinolytic therapy but this therapy failed in five (14.3%) patients, two of these patients expired within the hospital. There was only one (2.3%) treatment failure in open decortication Group that patient expired within the hospital (p-value 0.04). Overall duration of hospitalization was significantly high in fibrinolytic group, this was 17.6± 1.95 days versus 12.09± 2.18 days in open decortication group (p-value<0.0001). There was no significant difference regarding operative mortality within the two groups. Conclusion: Open Drainage is associated with better outcomes as compared to fibrinolytic therapy when used as a First line treatment of empyema. PMID:27182233
Yabuki, Hiroshi; Tabata, Toshiharu; Sugawara, Takafumi; Fukaya, Ken; Fujimura, Shigefumi
A case is 48-year-old man who had a history of Blalock-Taussig shunt and the radical operation for Fallot's tetralogy, had been performed cavernostomy and fenestration operation for aspergilloma of left upper lobe in the previous hospital due to control blood spitting. Although the contents of the abscess cavity were removed, the opened cavity was again infected by methicillin-resistant Staphylococcus aureus (MRSA) and he was referred to our hospital. The plombage of free omental flap with vascular anastomosis was performed. He has been well without any symptoms or recurrence of empyema for 6 years after surgery.
Mier, José M; Cortés-Julián, Gildardo; Berrios-Mejía, Juan; Víctor-Valdivia, Zotés
Prolonged air leak after pleural decortication is one of the most frequent complications. The aim of this study is to compare the effects of prolonged air leak between the digital chest drainage (DCD) system and the classic drainage system in patients with empyema class IIB or III (American Thoracic Society classification) in pleural decortication patients. A total of 37 patients were enrolled in a prospective randomized control trial over one year, consisting of 2blinded groups, comparing prolonged air leak as a main outcome, the number of days until removal of chest drain, length of hospital stay and complications as secondary outcomes. The percentage of prolonged air leak was 11% in the DCD group and 5% in the classic group (P=0.581); the mean number of days of air leak was 2.5±1.8 and 2.4±2.2, respectively (P=0.966). The mean number of days until chest tube removal was 4.5±1.8 and 5.1±2.5 (P=0.41), the length of hospital stay was 7.8±3.7 and 8.9±4.0 (P=0.441) and the complication percentages were 4 (22%) and 7 (36%), respectively (P=0.227). In this study, no significant difference was observed when the DCD was compared with the classic system. This was the first randomized clinical trial for this indication; thus, future complementing studies are warranted. Copyright © 2016 Academia Mexicana de Cirugía A.C. All rights reserved.
Komissarov, Andrey A; Florova, Galina; Azghani, Ali O; Buchanan, Ann; Boren, Jake; Allen, Timothy; Rahman, Najib M; Koenig, Kathleen; Chamiso, Mignote; Karandashova, Sophia; Henry, James; Idell, Steven
The incidence of empyema (EMP) is increasing worldwide; EMP generally occurs with pleural loculation and impaired drainage is often treated with intrapleural fibrinolytic therapy (IPFT) or surgery. A number of IPFT options are used clinically with empiric dosing and variable outcomes in adults. To evaluate mechanisms governing intrapleural fibrinolysis and disease outcomes, models of Pasteurella multocida and Streptococcus pneumoniae were generated in rabbits and the animals were treated with either human tissue (tPA) plasminogen activator or prourokinase (scuPA). Rabbit EMP was characterized by the development of pleural adhesions detectable by chest ultrasonography and fibrinous coating of the pleura. Similar to human EMP, rabbits with EMP accumulated sizable, 20- to 40-ml fibrinopurulent pleural effusions associated with extensive intrapleural organization, significantly increased pleural thickness, suppression of fibrinolytic and plasminogen-activating activities, and accumulation of high levels of plasminogen activator inhibitor 1, plasminogen, and extracellular DNA. IPFT with tPA (0.145 mg/kg) or scuPA (0.5 mg/kg) was ineffective in rabbit EMP (n = 9 and 3 for P. multocida and S. pneumoniae, respectively); 2 mg/kg tPA or scuPA IPFT (n = 5) effectively cleared S. pneumoniae-induced EMP collections in 24 h with no bleeding observed. Although intrapleural fibrinolytic activity for up to 40 min after IPFT was similar for effective and ineffective doses of fibrinolysin, it was lower for tPA than for scuPA treatments. These results demonstrate similarities between rabbit and human EMP, the importance of pleural fluid PAI-1 activity, and levels of plasminogen in the regulation of intrapleural fibrinolysis and illustrate the dose dependency of IPFT outcomes in EMP. Copyright © 2016 the American Physiological Society.
Florova, Galina; Azghani, Ali O.; Buchanan, Ann; Boren, Jake; Allen, Timothy; Rahman, Najib M.; Koenig, Kathleen; Chamiso, Mignote; Karandashova, Sophia; Henry, James; Idell, Steven
The incidence of empyema (EMP) is increasing worldwide; EMP generally occurs with pleural loculation and impaired drainage is often treated with intrapleural fibrinolytic therapy (IPFT) or surgery. A number of IPFT options are used clinically with empiric dosing and variable outcomes in adults. To evaluate mechanisms governing intrapleural fibrinolysis and disease outcomes, models of Pasteurella multocida and Streptococcus pneumoniae were generated in rabbits and the animals were treated with either human tissue (tPA) plasminogen activator or prourokinase (scuPA). Rabbit EMP was characterized by the development of pleural adhesions detectable by chest ultrasonography and fibrinous coating of the pleura. Similar to human EMP, rabbits with EMP accumulated sizable, 20- to 40-ml fibrinopurulent pleural effusions associated with extensive intrapleural organization, significantly increased pleural thickness, suppression of fibrinolytic and plasminogen-activating activities, and accumulation of high levels of plasminogen activator inhibitor 1, plasminogen, and extracellular DNA. IPFT with tPA (0.145 mg/kg) or scuPA (0.5 mg/kg) was ineffective in rabbit EMP (n = 9 and 3 for P. multocida and S. pneumoniae, respectively); 2 mg/kg tPA or scuPA IPFT (n = 5) effectively cleared S. pneumoniae-induced EMP collections in 24 h with no bleeding observed. Although intrapleural fibrinolytic activity for up to 40 min after IPFT was similar for effective and ineffective doses of fibrinolysin, it was lower for tPA than for scuPA treatments. These results demonstrate similarities between rabbit and human EMP, the importance of pleural fluid PAI-1 activity, and levels of plasminogen in the regulation of intrapleural fibrinolysis and illustrate the dose dependency of IPFT outcomes in EMP. PMID:27343192
Alemán, Carmen; Porcel, José M; Alegre, José; Ruiz, Eva; Bielsa, Silvia; Andreu, Jordi; Deu, Maria; Suñé, Pilar; Martínez-Sogués, Mireia; López, Iker; Pallisa, Esther; Schoenenberger, Joan Antoni; Bruno Montoro, J; de Sevilla, Tomás Fernández
Pleurofibrinolysis has been reported to be potentially beneficial in the management of complicated parapneumonic effusions (CPPE) and empyemas in the adult population. Prospective, controlled, randomized, and double-blind study, to evaluate intrapleural alteplase 10 mg (initially 20 mg was considered but bleeding events forced dose reduction) versus 100,000 UI urokinase every 24 h for a maximum of 6 days in patients with CPPE or empyemas. The primary aim was to evaluate the success rate of each fibrinolytic agent at 3 and 6 days. Success of therapy was defined as the presence of both clinical and radiological improvement, making additional fibrinolytic doses unnecessary, and eventually leading to resolution. Secondary outcomes included the safety profile of intrapleural fibrinolytics, referral for surgery, length of hospital stay, and mortality. A total of 99 patients were included, of whom 51 received alteplase and 48 urokinase. Success rates for urokinase and alteplase at 3 and 6 days were not significantly different, but when only the subgroup of CPPE was considered, urokinase resulted in a high proportion of cures. There were no differences in mortality or surgical need (overall, 3 %). Five (28 %) patients receiving 20 mg of alteplase and 4 (12 %) receiving 10 mg presented serious bleeding events. If intrapleural fibrinolytics are intended to be used, urokinase may be more effective than alteplase in patients with non-purulent CPPE and have a lower rate of adverse events.
Sakai, Tetsuya; Taniyama, Daisuke; Takahashi, Saeko; Nakamura, Morio; Takahashi, Takashi
Group A Streptococcus (GAS, Streptococcus pyogenes) causes invasive infections including streptococcal toxic shock syndrome (STSS) and local infections. To our knowledge, this is the first report of a case of an invasive GAS infection with pneumonia and pleural empyema (PE) followed by STSS (disseminated intravascular coagulation [DIC] and acute renal insufficiency) in a healthy male adult. He received combined supportive therapies of PE drainage, anti-DIC agent, hemodialysis, and antimicrobials and eventually made a clinical recovery. GAS isolated from PE was found to have emm1/speA genes, suggestive of a pathogenic strain. Clinicians should be aware of the possibility of this disease entity (pneumonia, PE, and STSS) in healthy male adults as well as children and adult women.
Dunphy, Louise; Shetty, Prashanth; Kavidasan, Ajitkumar; Rice, Alexandra
A 33-year-old man, born in India but resident in the UK for 5 years, presented to the emergency department with a 4-week history of a dry cough and right-sided pleuritic chest pain. He reported systemic features, including fever and unintentional weight loss. His medical history included vitamin D deficiency. He had travelled to India 10 months previously and denied any exposure to tuberculosis (TB). He was an ex-smoker with a 20 pack history. Respiratory examination confirmed decreased air entry of the right lower lobe and stony dullness on percussion. His C reactive protein was 178 mg/L. A chest radiograph identified a moderate-sized right-sided pleural effusion and destruction of the lateral aspect of the right fifth rib, strongly suggestive of underlying malignancy. Further investigation with a CT of the thorax identified a focal lytic lesion in the right fifth rib, at its lateral aspect, with expansion of the rib observed. Ultrasound-guided pleural aspiration confirmed an exudative pleural effusion. Gram stain revealed no organisms or polymorphs. Four days post admission, the patient was transferred to the regional thoracic surgery unit and underwent video-assisted thoracic surgery, bronchoscopy and drainage of his empyema. His Mantoux tuberculin skin test and his TB Elispot were negative, suggesting that TB infection was unlikely. Culture confirmed no growth after 48 h incubation. Histology of his pleural biopsy identified multiple non-confluent necrotising granulomatous inflammation with very occasional acid-alcohol-fast bacilli-like organisms, highly suspicious for mycobacterial infection. The isolate, Mycobacterium tuberculosis, was identified by Accuprobe and HAIN tests, respectively. MPT64 erythrocyte sedimentation rate (ESR) results from the fifth rib were positive for M. tuberculosis. This case report discusses the aetiology, clinical presentation and pathophysiology of both empyema necessitans and tubercular osteomyelitis of the rib. 2016 BMJ
Sohnle, P G; Hahn, B L
Abscess fluid supernatants have zinc-reversible microbial growth-inhibitory activity that is mediated by calprotectin, a zinc-binding protein. Because it inhibits microbial growth, this activity might interfere with killing by antibiotics that require their target organisms to be proliferating. In the present study, we cultured bacteria in human empyema fluid and used zinc to overcome the growth-inhibitory effect of calprotectin. We then compared the effect of zinc on killing by the beta-lactams ampicillin and cefazolin with that of the fluoroquinolone trovafloxacin, since the latter may be better able to kill nonproliferating organisms. In empyema fluid diluted 1:5 in normal saline, addition of zinc (30 microM) increased growth of two strains of Staphyloccocus aureus and two strains of Escherichia coli but did not affect the MICs or MBCs of the three antibiotics in Mueller-Hinton broth. For one strain of S. aureus, no effect of zinc was found on killing by either ampicillin or cefazolin. However, with the other strain of S. aureus and both strains of E. coli, significant enhancement of killing by both drugs was observed with zinc addition. On the other hand, no effect on the killing of any of the organisms was observed for trovafloxacin when zinc was added. These results suggest that the zinc-reversible growth-inhibitory activity of abscess fluid may interfere with the microbicidal activity of antibiotics requiring proliferating target organisms, although antibiotics better able to kill nonproliferating organisms may be less affected by this phenomenon.
Stewart, Zachary E; Shaker, Mohammed; Baxter, J David
Urological problems are common in spina bifida and are often treated with urinary diversions. Spina bifida and ileal conduits put patients at increased risk for ascending urinary tract infections. Here we present a novel case of a Citrobacter koseri urinary tract infection complicated by a perinephric abscess with pleural extension. To our knowledge, no case of an ascending C. koseri UTI progressing to peri-nephric abscess and empyema by direct extension exists in the literature.
Tsoucalas, Gregory; Sgantzos, Markos
Hippocrates was the first physician to describe in accuracy pleural effusion and pneumonia. To treat empyema thoracis he had introduced a combined method of tracheal intubation with a simultaneously thoracotomy. The surgical incision was used for the pus to be progressively drainaged. If the patient was too weak to eat, he had suggested for nutritional mixtures to be administered through an oral-gastric tube. Thus Hippocrates composed in his operating theatre, an icon similar to modern surgical operations.
Cobanoglu, Ufuk; Sayir, Fuat; Bilici, Salim; Melek, Mehmet
Today, in spite of the developments in imaging methods and antibiotherapy, childhood pleural empyema is a prominent cause of morbidity and mortality. In recent years, it has been shown that there has been an increase in the frequency of pleural empyema in children, and antibiotic resistance in microorganisms causing pleural empyema has made treatment difficult. Despite the many studies investigating thoracoscopic debridement and fibrinolytic treatment separately in the management of this disease, there is are not enough studies comparing these two treatments. The aim of this study was to prospectively compare the efficacy of two different treatment methods in stage II and III empyema cases and to present a perspective for treatment options. We excluded from the study cases with: i) thoracoscopic intervention and fibrinolytic agent were contraindicated; ii) immunosuppression or additional infection focus; iii) concomitant diseases, those with bronchopleural fistula diagnosed radiologically, and Stage I cases. This gave a total of 54 cases: 23 (42.6%) in stage II, and 31 (57.4%) cases in stage III. These patients were randomized into two groups of 27 cases each for debridement or fibrinolytic agent application by video-assisted thoracoscopic decortication (VATS). The continuity of symptoms after the operation, duration of thoracic tube in situ, and the length of hospital stay in the VATS group were of significantly shorter duration than in the streptokinase applications (P=0.0001). In 19 of 27 cases (70.37%) in which fibrinolytic treatment was applied and in 21 cases of 27 (77.77%) in which VATS was applied, the lung was fully expanded and the procedure was considered successful. There was no significant difference with respect to success rates between the two groups (P=0.533). The complication rate in our cases was 12.96% and no mortality was observed. Similar success rates in thoracoscopic drainage and enzymatic debridement, and the low cost of enzymatic drainage
Long, Richard; Barrie, James; Peloquin, Charles A
Chronic tuberculous empyema (CTE) is a rare and unusual, low grade and protracted, infection of the pleural space resulting in marked thickening, even calcification of the visceral and parietal pleura. Historically its management has been extraordinarily challenging. Differential penetration of anti-TB drugs into the pleural space has resulted in acquired drug resistance and surgery to remove the empyema or close a complicating bronchopleural fistula (BPF) has been technically difficult or unacceptably hazardous. On the basis of limited experience, the combination of tube thoracostomy or catheter drainage and high-end dosing of anti-TB drugs has been recommended as an initial approach to these lesions. Herein we report the first well documented case of closure of a BPF and cure of a CTE using this approach. The chances of a favorable outcome are improved, we suggest, by using therapeutic drug monitoring (TDM) to guide high-end drug dosing. An 84 year old male immigrant to Canada from Croatia was diagnosed with a CTE after he developed a BPF. The diagnosis was made 62 years after what was, in retrospect, an episode of tuberculous pleurisy. He was treated with computed tomography-guided catheter drainage and TDM-guided high-end dosed anti-TB drugs (serum and pleural fluid drug concentrations) over a 10 month period. Sustained closure of the BPF and mycobacteriologic cure of the CTE was achieved. Drug concentrations in the present case and all other reported cases are summarized and interpreted. When serum concentrations of the anti-TB drugs isoniazid, pyrazinamide and ethambutol at the high end of the normal range are achieved, pleural fluid concentrations at the low end of the normal range may be anticipated in CTE. Though highly protein bound drugs such as rifampin and moxifloxacin appear to penetrate CTEs less well, their free concentrations in the pleural space may be proportionately higher on account of lower protein concentrations. Interventional radiology and
Chaini, Eleftheria; Chainis, Nikolaos D.; Ioannidis, Anastasios; Magana, Maria; Nikolaou, Chryssoula; Papaparaskevas, Joseph; Liakata, Melina-Vassiliki; Katopodis, Panagiotis; Papastavrou, Leonidas; Tegos, George P.; Chatzipanagiotou, Stylianos
Lactobacilli are human commensals found in the gastrointestinal and genitourinary tract. Although generally conceived as non-pathogenic microorganisms, the existence of several reports implicating them in certain severe pathological entities renders this species as opportunistic pathogens. The case of a 58-year-old woman with mixed Lactobacillus infection is described. The patient was admitted in an outpatient clinic with community acquired pneumonia, and on the third day of hospitalization she presented rapid pneumonia deterioration. Subsequent imaging techniques revealed increased pleural empyema in alignment with the general deterioration of her clinical condition. Pleural fluid culture revealed the presence of Lactobacillus delbrueckii and Lactobacillus gasseri and the infection was successfully treated with clindamycin. Five months after hospital discharge and an overall good condition, the patient developed signs of dysphagia and upon re-admission an inoperable esophageal carcinoma was diagnosed. The patient succumbed to the cancer 11 months later. Herein, we report for the first time a mixed respiratory infection due to lactobacilli, possibly associated with a formerly unveiled esophageal malignancy. PMID:27734016
Marajh, Kanitha; Hattingh, Olga; Mlisana, Koleka P.
Introduction: Nutritionally variant streptococci (NVS) are an infrequent cause of human infection with Granulicatella elegans being the least encountered species in clinical specimens. The most common infection caused by NVS is infective endocarditis. Case Presentation: We report an unusual case of thoracic empyema due to G. elegans in a patient with pulmonary tuberculosis (TB) and human immunodeficiency virus infection. The patient responded favourably to drainage and penicillin. Conclusion: This case illustrates that even though TB is responsible for the majority of pleural effusions in this setting, other rare opportunistic bacteria may cause infection in susceptible patients. Therefore, microbiological investigations should be performed in all patients presenting with pleural effusion. PMID:28348783
Picazo, Juan; Ruiz-Contreras, Jesus; Casado-Flores, Juan; Negreira, Sagrario; Del Castillo, Fernando; Hernández-Sampelayo, Teresa; Bueno, Mercedes; Calvo, Cristina; Ríos, Esther; Méndez, Cristina
In October 2006, the heptavalent pneumococcal conjugate vaccine was included in the Madrid vaccination calendar, warranting serotype (St) surveillances in pneumococcal pediatric parapneumonic empyema (PPE). A prospective 2-year (May 2007-April 2009) laboratory-confirmed PPE surveillance was performed in 22 hospitals. All isolates (for serotyping) and culture-negative pleural fluids were sent to the reference laboratory for polymerase chain reaction (PCR) analysis. We identified 138 PPEs. Pneumococcal etiology was confirmed in 100 cases: 38 by culture, 62 by PCR. Mean age was 44.64 ± 26.64 months; 51.0% were male. Similar pneumococcal PPE distribution was found by age: 21% to 28% in <24, ≥24-<36, ≥36-<60, and ≥60 months. PPE-associated Sts were St 1 (38%), St 5 (15%), St 19A (11%), St 7F (9%), St 3 (8%), and others (19%). St 1 was the most common in >36 months, with similar rates to St 19A in <24 months (≈30%). In ≥24-≤36 months, St 3 (21.7%), St 1 and St 5 (17.4% each) were the most frequent. No differences in demographic data, vaccination status, length of hospitalization, and outcome were found between culture-negative (PCR positive) and culture-positive PPE patients, with significantly higher percentages of St 1 and St 5 in culture-positive PPEs. Total rates of St 1 (38%), St 5 (15%), and St 7F (9%) would have been over-represented considering only positive-culture PPEs (n = 38), by increasing to 52.6% (St 1), 23.7% (St 5), and 10.5% (St 7F). The 13-valent pneumococcal conjugate vaccine would cover 84.0% of Sts causing PPEs. PCR is essential for determining the specific etiology of PPE.
Hioki, Akira; Miyamoto, Kei; Inoue, Toshiyuki; Hosoe, Hideo; Shinoda, Jun; Iwama, Toru; Shimizu, Katsuji
Halo orthosis is used for cervical spine fixation after spinal surgery or injury. Although superficial infection at pin sites occurs frequently, intracranial development of infection, including brain abscesses, is very rare. We experienced subdural empyema due to methicillin-resistant Staphylococcus aureus (MRSA) caused by intracranial penetration of halo pins. A 38-year-old woman with a 4-year history of rheumatoid arthritis experienced severe myelopathy due to atlanto-axial dislocation and vertical subluxation. Reduction and immobilization using a halo vest resulted in neurologic improvement; she later underwent occipital bone to C2 fusion using posterior instrumentation. Three months after halo orthosis fixation, she complained of a headache, experienced a generalized tonic-clonic seizure, and became unconscious for 10 min. Computed tomography revealed pneumoencephalus, and Gd-enhanced magnetic resonance imaging revealed edema, enhancement of the overlying dura in the left partial lobe, and subdural and subarachnoidal empyema. Following removal of the halo vest, there was a purulent discharge from the left-posterior pin site. Culture of the discharge was positive for MRSA. The patient was treated with intravenous vancomycin for 2 weeks, followed by cefozopran hydrochloride for 4 weeks. Her symptoms improved, and additional surgery was not required. At latest follow-up, 10 years after the seizure, she is neurologically stable without any recurrence of the infection.
Munguía-Canales, Daniel Alejandro; Vargas-Mendoza, Gary Kosai; Alvarez-Bestoff, Gustavo; Calderón-Abbo, Moisés Cutiel
The patient is a 21-year-old female, diagnosed with cryptogenic cirrhosis at the age of 9. She presented with left post-pneumonic empyema that did not remit with conventional medical management and evolved with fistulization to the skin in the 7th intercostal space in the left subscapular region. We performed an open thoracic window procedure, and on the 6th day the patient was sent home with a portable vacuum-assisted closure device, with changes of the material every 4 days until the cavity was completed obliterated (92 days). Imaging tests showed full expansion of the lung, and chest wall reconstruction was performed with titanium rods. The high mortality of empyema in patients with liver disease requires both implementing and searching for new adjuvant therapies, like the use of vacuum-assisted closure systems and reconstruction with titanium rods. Controlled studies with a wide range of cases are needed for proper evaluation. Copyright © 2012 SEPAR. Published by Elsevier Espana. All rights reserved.
Aziz, Abdulhameed; Healey, Jeffrey M; Qureshi, Faisal; Kane, Timothy D; Kurland, Geoffrey; Green, Michael; Hackam, David J
Controversy exists regarding the optimal management strategy for children having empyema or parapneumonic effusion as a complication of pneumonia. We hypothesized that video-assisted thoracoscopic surgery (VATS)-assisted drainage of pleural fluid and debridement of the pleural space is superior to a chest tube alone in the management of these patients. We further identified predictive factors-namely, presentation, radiographic findings, antibiotic usage, and pleural fluid features-that could predict the need for VATS rather than primary chest tube drainage. Forty-nine pediatric patients with pneumonia complicated by parapneumonic effusion or empyema treated at the Children's Hospital of Pittsburgh (1997-2003) were divided into three groups according to the therapy instituted: Primary chest tube, chest tube followed by VATS, or primary VATS. The groups were analyzed in terms of demographics and outcome, as judged by pleural fluid analysis and hospital resource utilization. Demographic and outcome data were compared among groups using one-way analysis of variance and the Student t-test. All groups were similar with respect to demographics and initial antibiotic usage. Patients undergoing primary VATS had a higher initial temperature, whereas radiographic findings of mediastinal shift and air bronchograms were more likely to be found in patients who underwent primary chest tube placement. Patients undergoing primary VATS demonstrated a significantly shorter total stay and lower hospital charges than the other groups. Forty percent of children started on chest tube therapy failed even with subsequent VATS, necessitating a significantly longer hospital course (18 +/- 3 vs. 11 +/- 0.8 days; p < 0.05) and higher hospital charges ($50,000 +/- 7,000 vs. $29,000 +/- 1000) than those having primary VATS. Patients treated by primary VATS had a shorter stay and lower hospital charges than patients treated by chest tube and antibiotic therapy alone. There were no demographic
Parelkar, Sandesh V.; Patil, Shalil H.; Sanghvi, Beejal V.; Gupta, Rahul Kumar; Mhaskar, Satej S.; Shah, Rujuta S.; Tiwari, Pooja; Pawar, Arjun A.
Background/Purpose: The aim of our study is to determine efficacy, safety, and feasibility of video-assisted thoracoscopic surgery (VATS) in childhood empyema with a technique of only two ports and open instruments at a tertiary care center in India. Methods: This is a retrospective study of patients below 18 years, with empyema presenting to the Department of Pediatric Surgery of a Tertiary Care Referral Hospital in India, over a period of 9 years who underwent VATS decortication. Only two ports with open surgical instruments were used. The patients were assessed on the basis of mean duration of preoperative symptoms, duration of surgery, average blood loss, postoperative pain relief, complications, and need for redo surgery. Results: A total of 97 patients underwent primary VATS decortications without inserting an intercostal drainage (ICD) tube and 70 patients as a secondary procedure after ICD tube was inserted. Mean duration of symptoms was 11 days. The average blood loss during surgery was estimated to be 170 cc. The mean duration of surgery was 90 min. The most common postoperative complication was air leak seen in 19.16% of patients. Minor leaks usually settled by 24 h. In eight patients, a negative suction had to be applied to the ICD tube for persistent air leak. The average length of postoperative stay was 4 days. Two patients required a repeat open decortication procedure due to nonresolution of symptoms and poor lung expansion after VATS. Patients had minimal pain and excellent cosmetic outcome after VATS. Conclusion: Two-port VATS decortication procedure is as feasible and effective as three-port procedure for decortication with better cosmetic result and pain relief. PMID:28694571
Parelkar, Sandesh V; Patil, Shalil H; Sanghvi, Beejal V; Gupta, Rahul Kumar; Mhaskar, Satej S; Shah, Rujuta S; Tiwari, Pooja; Pawar, Arjun A
The aim of our study is to determine efficacy, safety, and feasibility of video-assisted thoracoscopic surgery (VATS) in childhood empyema with a technique of only two ports and open instruments at a tertiary care center in India. This is a retrospective study of patients below 18 years, with empyema presenting to the Department of Pediatric Surgery of a Tertiary Care Referral Hospital in India, over a period of 9 years who underwent VATS decortication. Only two ports with open surgical instruments were used. The patients were assessed on the basis of mean duration of preoperative symptoms, duration of surgery, average blood loss, postoperative pain relief, complications, and need for redo surgery. A total of 97 patients underwent primary VATS decortications without inserting an intercostal drainage (ICD) tube and 70 patients as a secondary procedure after ICD tube was inserted. Mean duration of symptoms was 11 days. The average blood loss during surgery was estimated to be 170 cc. The mean duration of surgery was 90 min. The most common postoperative complication was air leak seen in 19.16% of patients. Minor leaks usually settled by 24 h. In eight patients, a negative suction had to be applied to the ICD tube for persistent air leak. The average length of postoperative stay was 4 days. Two patients required a repeat open decortication procedure due to nonresolution of symptoms and poor lung expansion after VATS. Patients had minimal pain and excellent cosmetic outcome after VATS. Two-port VATS decortication procedure is as feasible and effective as three-port procedure for decortication with better cosmetic result and pain relief.
Sherman, M M; Subramanian, V; Berger, R L
Over a ten year period, 102 patients with thoracic empyemata were treated at Boston City Hospital. Only three patients died from the pleural infection while twenty-six succumbed to the associated diseases. Priniciples of management include: (1) thoracentesis; (2) antibiotics; (3) closed-tube thoracostomy; (4) sinogram; (5) open drainage; (6) empyemectomy and decortication in selected patients; and (7) bronchoscopy and barium swallow when the etiology is uncertain.
Capsular serotypes and antimicrobial susceptibilities of Streptococcus pneumoniae causing invasive pneumococcal disease from 2009-2012 with an emphasis on serotype 19A in bacteraemic pneumonia and empyema and β-lactam resistance.
Lee, Meng-Rui; Chen, Chung-Ming; Chuang, Tzu-Yi; Huang, Yu-Tsung; Hsueh, Po-Ren
Capsular serotypes and antimicrobial susceptibilities of Streptococcus pneumoniae isolates that cause invasive pneumococcal disease (IPD) were studied and the role of serotype 19A in the development of bacteraemic pneumonia and empyema was investigated. Subjects comprised 98 patients (56 adults and 42 children) who were treated for IPD at a university-affiliated tertiary referral centre in Taiwan during 2009-2012. Serotypes of the isolates were identified using the latex agglutination method. In vitro susceptibilities of the isolates to 13 antimicrobial agents were determined using the broth microdilution method and were interpreted as recommended by the Clinical and Laboratory Standards Institute. During the study period, bacteraemic pneumonia was the most common type of infection (43/98; 43.9%), followed by primary bacteraemia (30/98; 30.6%). Serotype 19A was the most common serotype (23/98; 23.5%) in all patients. Fourteen (70.0%) of 20 children (47.6% of all children) with serotype 19A infection had pneumonia with empyema, whilst eight patients had concomitant bacteraemia. 7-valent pneumococcal conjugated vaccine (PCV-7), PCV-10, PCV-13 and 23-valent pneumococcal polysaccharide vaccine (PPV-23) had coverage rates of 37.8%, 38.8%, 79.6% and 77.6%, respectively. A substantial increase in the proportion of serotype 15A (6.1%) and 6A (8.2%) was found. In addition, there was a significant reduction in rates of susceptibility of serotype 19A isolates to penicillin, cefotaxime and ceftriaxone but not to azithromycin or any quinolone tested compared with those of non-19A isolates. The prevalence of serotypes 19A, 15A and 6A in patients with IPD increased markedly during the period, especially in children with bacteraemic pneumonia and empyema.
Yuen, Kwok-Yung; Woo, Patrick C. Y.; Teng, Jade L. L.; Leung, Kit-Wah; Wong, Michelle K. M.; Lau, Susanna K. P.
A bacterium was isolated from the blood and empyema of a cirrhotic patient. The cells were facultatively anaerobic, nonsporulating, gram-negative, seagull shaped or spiral rods. The bacterium grows on sheep blood agar as nonhemolytic, gray colonies 1 mm in diameter after 24 h of incubation at 37°C in ambient air. Growth also occurs on MacConkey agar and at 25 and 42°C but not at 4, 44, and 50°C. The bacterium can grow in 1 or 2% but not 3, 4, or 5% NaCl. No enhancement of growth is observed with 5% CO2. The organism is aflagellated and nonmotile at both 25 and 37°C. It is oxidase, catalase, urease, and arginine dihydrolase positive, and it reduces nitrate. It does not ferment, oxidize, or assimilate any sugar tested. 16S rRNA gene sequencing showed that there are 91 base differences (6.2%), 112 base differences (7.7%), and 116 base differences (8.2%) between the bacterium and Microvirgula aerodenitrificans, Vogesella indigofera, and Chromobacterium species, respectively. The G+C content (mean and standard deviation) is 68.0% ± 2.43%, and the genomic size is about 3 Mb. Based on phylogenetic affiliation, the bacterium belongs to the Neisseriaceae family of the β-subclass of Proteobacteria. For these reasons, a new genus and species, Laribacter hongkongensis gen. nov., sp. nov., is proposed, for which HKU1 is the type strain. Further studies should be performed to ascertain the potential of this bacterium to become an emerging pathogen. PMID:11724825
Halberstam, M; Isenberg, H D; Hilton, E
Legionella micdadei is the second most common species implicated in the occurrence of Legionella pneumonia (D. J. Bremer, Semin. Respir. Infect. 4:190-205, 1987). Although there has been a reported lung abscess caused by dual infection (L. micdadei and L. pneumophila), there are no known cases of L. micdadei as the only causative organism. We report a case of a patient with a lung abscess from which L. micdadei was the sole organism isolated. PMID:1537927
Pawley, Barbara; Smith, Melissa; Nickels, David
This is the 18th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/?page=CCIP_TOC .
Walden, Jeffrey Howard; Hess, Bryan; Rigby, Michael
A 7-year-old girl with an unremarkable medical history presented to a local paediatric emergency department with a 7-day history of fever, sore throat and vomiting, and a 1-day history of rash. She was admitted to the hospital, with presumed Kawasaki disease. A few hours after admission, the patient had sudden onset of two witnessed tonic-clonic seizures and subsequent decreased mental status. She was transferred to the paediatric intensive care unit and started on broad-spectrum antibiotics. On hospital day 2, cerebral spinal fluid cultures and blood cultures grew Streptococcus pyogenes, and repeat physical examination was consistent with acute streptococcal pharyngitis. On hospital day 3, the patient developed left-sided hemiparesis and had another witnessed seizure. A CT scan was obtained and revealed a subdural abscess. She was transferred to a tertiary care centre and underwent craniotomy with evacuation of her subdural abscess. Surgical cultures eventually grew S. pyogenes.
Lopez-Escamilla, Eduardo; Sanchez-Aguillon, Fabiola; Alatorre-Fernandez, Cynthia Pamela; Aguilar-Zapata, Daniel; Arroyo-Escalante, Sara; Arellano, Teresa; Moncada-Barron, David; Romero-Valdovinos, Mirza; Martinez-Hernandez, Fernando; Rodriguez-Zulueta, Patricia
Two unusual occurrences of pleural trichomonosis due to a new Tetratrichomonas species previously reported but not named were confirmed. In one patient, Trichomonas tenax and a Tetratrichomonas species were also detected in the oral cavity by molecular methods. We suggest that this new Tetratrichomonas species be named Tetratrichomonas empyemagena. PMID:23784131
Khan, Sadia; Sistla, Sujatha; Dhodapkar, Rahul; Parija, Subhash Chandra
Delftia acidovorans (earlier known as Comamonas acidovorans) is an aerobic, non-fermentative, Gram negative rod, classified in the Pseudomonas rRNA homology Group III. Reports of isolation of the organism from serious infections like central venous catheter associated bacteremia, corneal ulcers, otitis media exist. The microbiologists can identify this organism based on an orange indole reaction. This reaction demonstrates the organism's ability to produce anthranilic acid from tryptophan on addition of Kovac's reagent; which gives the media its characteristic “pumpkin orange” colour. Here we report the isolation of this organism from the Endotracheal tube aspirate of a 4 year old child. With the increasing use of invasive devices, it has become important to recognize these non fermentative gram negative bacilli as emerging source of infection even in immunocompetent individuals. PMID:23569872
Page, C; Lehmann, P; Jeanjean, P; Strunski, V; Legars, D
The purpose of this study was to evaluate the diagnosis criteria, the bacteriology and the evolution after adapted treatment of intracranial abscess of ENT origin. It was a retrospective study from 1985 to 2003 concerning 22 patients who had brain abscesses secondary to an ENT infection. The infectious origin was sinusoid in 32% of cases, otologic in 32% of cases, pharyngeal or dental in 27% of cases and cutaneous in 9% of cases. The clinical symptoms were: fever in 55% of cases, headache in 73% of cases (Intra cranial hypertension syndrome in 23% of cases), epilepsy in 32% of cases and various other neurologic symptoms. Bacteria were identified in 82% of cases. In 50% of cases multibacterial associations were found. All the patients had bi antibiotherapy associated to surgical excision of the abscess (16 cases) or single (or more) punction (stereotaxic guided or not) of the abscess. 3 patients (14%) died and 50% are alive and well. The diagnosis of cerebral abscess is often difficult. The "classical" intracranial hypertension associated to high fever is usually incomplete and sometimes absent. There is no predominant bacteria involved and multibacterial infections are frequent. Despite abscesses are serious and potentially lethal, an early diagnosis, a medical (antibiotics) and surgical treatment (punction and/or surgical excision) may completely be cured in more than 50% of cases.
Gaster, Richard S; Berger, Aaron J; Ahmadi-Kashani, Mastaneh; Shrager, Joseph B; Lee, Gordon K
We report a case of a 72-year-old man who presented with a persistent pleural effusion and painful abscess in the right lower chest wall 6 months following a laparoscopic cholecystectomy. The patient subsequently developed a chronic cutaneous chest wall fistula requiring a large resection and complex closure. The complication was likely secondary to intraoperative spillage of gallstones. While previous reports describe gallstone spillage in the abdominal cavity as benign, this case illustrates that stones left in the abdominal cavity can potentially lead to significant morbidity. Therefore, stones should be diligently removed from the abdominal cavity when spillage occurs. In addition, it is important that operative notes reflect the occurrence of stone spillage so stones may be suspected when a patient presents with an abdominal or thoracic infection following a cholecystectomy.
Ramos, Ricard; Rodríguez, Laura; Saumench, Josep; Iborra, Elena; Cairols, Marc Antoni; Dorca, Jordi
Massive and/or recurrent hemoptysis is a clear indication for surgical treatment of pleuropulmonary aspergilloma, despite the incidence of postoperative morbidity and mortality. Thoracoplasty has been widely used for 20 years and is still indicated in these cases, following lobectomy, even though the procedure is not free of complications. We report the case of a patient who required thoracoplasty to treat a pleuropulmonary aspergilloma invading the chest wall. Subsequent placement of an aortic stent-graft was required due to tearing of the left subclavian artery.
Chakravarthy, Murali; Jawali, Vivek
In patients with bilateral bullous disease and empyema in one lung, controlled ventilation may be hazardous and result in severe hypoxia. A 50-year-old man with bullous disease and thoracic empyema on the left side was operated on under general anesthesia with spontaneous respiration using differential lung ventilation.
Zahn, Matt; Hesson, Michael; Morton, Ronald; Wheat, L Joseph
Pneumonia with pleuritis is a rare presentation of histoplasmosis infection. We present a 12-year old previously healthy boy in whom histoplasmosis presented with pleuritis, confirmed by detection of antigen in empyema fluid.
... More Information Related Topics COPD Cough Cystic Fibrosis Pleurisy and Other Pleural Disorders Ventilator/Ventilator Support Send ... to remove the pus. Pleural effusions, empyema, and pleurisy. These painful or even potentially fatal complications can ...
Various hydrocarbons ... Empyema Many of the most dangerous effects of hydrocarbon (such as diesel oil) poisoning are due to ... PA: Elsevier Saunders; 2016:chap 75. Lee DC. Hydrocarbons. In: Marx JA, Hockberger RS, Walls RM, et ...
... Destruction of parts of the lungs Emphysema Meningitis Osteomyelitis (bone infection) When to Contact a Medical Professional ... More Brain abscess Dental care - adult Empyema Meningitis Osteomyelitis Pleural effusion Tooth abscess Review Date 3/13/ ...
Gee, I; Wood, G
Case reports of transdiaphragmatic fistulas connecting subphrenic collections and empyemas are uncommon. We report the rare complication of a fistulous connection between a subphrenic collection and the bronchial tree. PMID:10770829
Sanz, N; Aguado, P; de Agustín, J C; Matute, J M; Molina, E; Ollero, J C; Morató, P
The incidence of empyema thoracis in children seems to be increasing. The objective [corrected] of this study is to propose a rational initial treatment of parapneumonic effusions in order to reduce hospital stay and late-stage empyema complications. Medical records of 33 children presenting parapneumonic effusions who required any surgical therapy between 1997 and 2002 were reviewed. They were grouped as (I) successful management with chest tube, (II) successful management with intrapleural instillation of urokinase and (III) successful surgical treatment: (IIIa) thoracoscopy or (IIIb) thoracotomy. Early sonographic evaluation of parapneumonic effusions is usefull to evaluate the severity of disease and the need for surgical intervention. Thoracoscopic-assisted surgery is an effective treatment for pediatric early-stage empyema. Thoracotomy is indicated for most children with established empyema.
Shrestha, Pranabh; Safdar, Syed Aatif; Jawad, Sami Abdul; Shaaban, Hamid; Dieguez, Javier; Elberaqdar, Enas; Rai, Srijana; Adelman, Marc
Context: There are no established guidelines for the proper treatment of patients with bronchopleural fistulas (BPFs). Apart from attempts to close the fistula, emphasis of treatment and management is placed on preventive measures, early administration of antibiotics, drainage of the empyema and aggressive nutritional and rehabilitative support. Case Report: A 53-year-old male presented with nausea, vomiting, and dry cough with eventual respiratory failure. He was found to have an empyema of the left hemithorax which was managed with thoracostomy drainage and antibiotics. However, he had persistent air leak through the chest tube due to a BPF. Bronchoscopy failed to localize the involved segment. Application of fibrin glue through the chest tube succeeded in completely sealing the leak. Conclusion: To our knowledge, this is the first case report in which fibrin glue was successfully used intrapleurally to close a BPF related to an empyema. PMID:25317397
Wallace, J; Tharion, J
Bush thoracotomy is still practised in the South Western Highlands of Papua New Guinea, by traditional bush doctors. These bush thoracotomies are performed with the aim of letting out the 'bad blood' that is believed to have collected in the body cavities following injuries. During a 3 year period between 1989 and 1992, 183 patients with complications of bush thoracotomy were treated at the Sopas Hospital in the Highlands of Papua New Guinea. Of these patients, 55 had chest wall infections only, without any pleural involvement. Of the patients with empyemas, 14 were treated by decortication of the empyema with one death and all remaining patients were treated by drainage procedures with one death. We recommend early treatment by adequate drainage of the empyema and, where feasible, early decortication. Continuing education to eradicate the procedure, and provision of adequate surgical facilities for management of complications, should be the long-term aim for this continuing problem.
Villegas-Carlos, Felipe; Vázquez-Martínez, Aarón Moisés; Pinedo-Onofre, Javier Alfonso; Guevara-Torres, Lorenzo; Belmares-Taboada, Jaime Arístides; Sánchez-Aguilar, Martín
Thoracic trauma accounts for 25% of deaths due to trauma. Chest trauma patients generally present to the emergency room with pneumo- or hemothorax. According to the majority of the studies, management of closed thoracostomy for trauma includes the use of antimicrobial drugs to prevent infectious complications, but this has not been proven to be beneficial. We undertook this study to evaluate antimicrobial use in thoracic trauma patients with closed thoracostomy and its impact on the development of infectious complications. We carried out a prospective, randomized, double blind, comparative study. Patients with isolated chest trauma requiring closed thoracostomy were divided into two groups. Group A received cefalotin, and group B received placebo. Ages ranged from 15-65 years. Results were analyzed with chi(2) and Fisher exact test. One hundred twenty six patients were included in this study. There were 63 patients in each group with similar demographic characteristics. The mean length of hospital stay with the tube was 6.56 days, but the average stay was 11 days for patients who developed empyema. Eight patients developed empyema, three patients with empyema belonged to group A patients and five patients with empyema belonged to group B. For empyema management, five cases were resolved by chest drainage, two cases required thoracoscopic cleaning and drainage and one patient was resolved with thoracotomy and pleural decortication. Bivariate analysis comparing antimicrobial use vs. empyema and length of drainage vs. antimicrobials did not show a statistically significant difference. The present study did not demonstrate that antimicrobial use was beneficial in the prevention of pleural infections in the management of chest trauma patients requiring closed thoracostomy.
Shrestha, Merica; Shah, Anita; Lettieri, Christopher
Pleuropulmonary amebiasis is an uncommon complication of Entamoeba histolytica infection. It typically occurs in endemic regions including Central and South America, Africa and the Indian subcontinent. The case of a previously healthy US Army male stationed in Liberia with an acute onset of fevers, abdominal pain and bloody diarrhea is presented. He developed a productive cough with pleuritic chest pain and imaging revealed multiple liver abscesses, with rupture through the diaphragm causing a large right pleural empyema. A positive Entamoeba histolytica serum antibody and pleural fluid antigen confirmed the diagnosis. Surgical drainage of the pleural empyema and medical treatment with antiparasitics were necessary for symptom and disease resolution.
Odontogenic facial abscesses associated with periapical infections and osteomyelitis of the jaw represent an important part of the acquired and progressive dental disease syndrome in pet rabbits. Complications such as retromasseteric and retrobulbar abscesses, extensive osteomyelitis of the mandible, and empyemas of the skull are possible sequelae. Standard and advanced diagnostic imaging should be pursued to make a detailed and proper diagnosis, and plan the most effective surgical treatment. This article reviews the surgical anatomy, the pathophysiology, and the classification of abscesses and empyemas of the mandible, the maxilla, and the skull. It also discusses surgical techniques for facial abscesses.
Siegel, Marc O.; Fedorko, Daniel P.; Drake, Steven K.; Calhoun, Leslie B.; Holland, Steven M.
Legionella feeleii has rarely been reported as causing pneumonia in patients with hematologic malignancies. We present a case of Legionella feeleii serotype 2 pneumonia with empyema in a man with chronic lymphocytic leukemia and describe the methods of identifying this organism using both standard methods and newer diagnostic techniques. PMID:20357216
Siegel, Marc O; Fedorko, Daniel P; Drake, Steven K; Calhoun, Leslie B; Holland, Steven M
Legionella feeleii has rarely been reported as causing pneumonia in patients with hematologic malignancies. We present a case of Legionella feeleii serotype 2 pneumonia with empyema in a man with chronic lymphocytic leukemia and describe the methods of identifying this organism using both standard methods and newer diagnostic techniques.
Pediatric Problems, Infant Feeding Pulmonary Problems Pharmacy Radiology Rheumatologic Problems Sexually Transmitted Diseases Surgical Procedures...ecchymosis elicit emphysema empyema epiphysis epistaxis erythema exacerbate fasciitis fibromyalgia fibrous filariasis foramen funduscope giardiasis gonorrhea...perineal peritoneum peroneal persistent petechia (singular); petechiae (plural) phlegm plantar pleurisy pneumococcus pneumonic pore preventive
Medical Readiness Initiative. The initiative offers tuition-free online education about chemical, biological, radiological /nuclear, and explosive...red. diphtheria dysentery ecchymosis elicit emphysema empyema epiphysis epistaxis erythema exacerbate fasciitis fibromyalgia fibrous filariasis...paroxysmal pathognomonic penicillin perineal peritoneum peroneal persistent petechia (singular); petechiae (plural) phlegm plantar pleurisy pneumococcus
Woo, Patrick C. Y.; Tse, Herman; Wong, Samson S. Y.; Tse, Cindy W. S.; Fung, Ami M. Y.; Tam, Dorothy M. W.; Lau, Susanna K. P.; Yuen, Kwok-yung
We report the first two cases of life-threatening invasive Helcococcus kunzii infection, with primary bacteremia and empyema thoracis, respectively. Gram smears of both H. kunzii isolates showed a mixture of gram-positive and gram-negative cocci. The isolate from the first patient, resistant to erythromycin and clindamycin, possessed an ermA gene. PMID:16333132
Woo, Patrick C Y; Tse, Herman; Wong, Samson S Y; Tse, Cindy W S; Fung, Ami M Y; Tam, Dorothy M W; Lau, Susanna K P; Yuen, Kwok-yung
We report the first two cases of life-threatening invasive Helcococcus kunzii infection, with primary bacteremia and empyema thoracis, respectively. Gram smears of both H. kunzii isolates showed a mixture of gram-positive and gram-negative cocci. The isolate from the first patient, resistant to erythromycin and clindamycin, possessed an ermA gene.
Lymphocele 18 Failed limb salvage due to extensive soft tissue necrosis Wound infection at subsequent BKA site 19 Thrombosis of vein graft Sacral decubitus ... ulcer Empyema Heparin-induced thrombocytopenia 20 Initial graft thrombosis BKA, below knee amputation. The Journal of TRAUMA Injury, Infection, and
Wakui, Daisuke; Nagashima, Goro; Takada, Tatsuro; Ueda, Toshihiro; Itoh, Hidemichi; Tanaka, Yuichiro; Hashimoto, Takuo
A 34-year-old man presented with a case of subdural empyema and cerebral abscess that developed 12 years after initial neurosurgical intervention for a traffic accident in 1998. Under a diagnosis of acute subdural hematoma and cerebral contusion, several neurosurgical procedures were performed at another hospital, including hematoma removal by craniotomy, external decompression, duraplasty, and cranioplasty. The patient experienced an epileptic seizure, and was referred to our hospital in March 2010. Magnetic resonance imaging revealed a cerebral abscess extending to the subdural space just under the previous surgical field. Surgical intervention was refused and antimicrobial treatment was initiated, but proved ineffective. Surgical removal of artificial dura and cranium with subdural empyema, and resection of a cerebral abscess were performed on May 12, 2010. No organism was recovered from the surgical samples. Meropenem and vancomycin were selected as perioperative antimicrobial agents. No recurrence of infection has been observed. Postneurosurgical subdural empyema and cerebral abscess are recently emerging problems. Infections of neurosurgical sites containing implanted materials occur in 6% of cases, usually within several months of the surgery. Subdural empyema and cerebral abscess developing 12 years after neurosurgical interventions are extremely rare. The long-term clinical course suggests less pathogenic organisms as a cause of infection, and further investigations to develop appropriate antimicrobial selection and adequate duration of antimicrobial administration for these cases are needed.
Abolhoda, Amir; Bui, Trung D.; Milliken, Jeffrey C.; Wirth, Garrett A.
Bronchopleural fistula and empyema are serious complications after thoracic surgical procedures, and their prevention is paramount. Herein, we review our experience with routine prophylactic use of the pedicled ipsilateral latissimus dorsi muscle flap. From January 2004 through February 2006, 10 surgically high-risk patients underwent intrathoracic transposition of this muscle flap for reinforcement of bronchial-stump closure or obliteration of empyema cavities. Seven of the patients were chronically immunosuppressed, 5 were severely malnourished (median preoperative serum albumin level, 2.4 g/dL), and 5 had severe underlying obstructive pulmonary disease (median forced expiratory volume in 1 second, 44% of predicted level). Three upper lobectomies and 1 completion pneumonectomy were performed in order to treat massive hemoptysis that was secondary to complex aspergilloma. One patient underwent left pneumonectomy due to ruptured-cavitary primary lung lymphoma. One upper lobectomy was performed because of necrotizing, localized Mycobacterium avium-intracellulare infection. One patient underwent right upper lobectomy and main-stem bronchoplasty for carcinoma after chemoradiation therapy. In 3 patients, the pedicled latissimus dorsi muscle was used to obliterate chronic empyema cavities and to buttress the closure of underlying bronchopleural fistulas. No operative deaths or recurrent empyemas resulted. Two patients retained peri-flap air that required no surgical intervention. We conclude that the use of transposed pedicled latissimus dorsi muscle flap effectively and reliably prevents clinically overt bronchopleural fistula and recurrent empyema. We advocate its routine use in first-time and selected reoperative thoracotomies in patients who are undergoing high-risk lung resection or reparative procedures. PMID:19693302
Rovina, Nikoletta; Dima, Efrossini; Psallidas, Ioannis; Moschos, Charalampos; Kollintza, Androniki; Kalomenidis, Ioannis
The aim of this study was to investigate the pleural and systemic expression of interleukin-18 (IL-18) in patients with pleural effusions (PEs), and the effects of the cytokine in mouse pleural space. One hundred and sixty patients, 23 with pleural effusions (PEs) due to heart failure, 60 malignant, 25 parapneumonic/empyemas, 15 tuberculous and 37 with exudates of miscellaneous etiologies were included in the study. Pleural fluid (PF) and serum IL-18 content was determined using ELISA. IL-18 was injected intrapleurally in mice and pleural inflammation was assessed using pleural lavage. The highest PF IL-18 levels were observed in parapneumonic PEs and the lowest PF IL-18 levels in patients with exudates of miscellaneous aetiologies and transudates. PF IL-18 levels were significantly higher in patients with empyemas compared to those with uncomplicated (p=0.009) or complicated (p=0.028) parapneumonic effusions, while serum levels did not differ significantly among the three groups. Pleural IL-18 content was higher than that of blood only in patients with empyemas. In patients with pleural exudates of all etiologies and in those with parapneumonic PEs/empyema, PF IL-18 levels were correlated with markers of acute pleural inflammation such as the percentage of PF neutrophils, PF LDH and PF/serum LDH ratio, low PF glucose and PF/serum glucose ratio and low PF pH. In mice, intrapleural IL-18 caused neutrophil-predominant pleural inflammation. In conclusion, IL-18 is linked to the intensity of neutrophilic pleural inflammation in patients with PEs, it is up-regulated in the pleural space of patients with empyema and it stimulates the accumulation of neutrophils in mouse pleura. Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.
Leahy, Timothy Ronan; Cohen, Eyal; Allen, Upton D
A three-year-old boy presented with community-acquired pneumonia complicated by empyema. Streptococcus pyogenes (group A streptococcus) was identified on culture of the pleural fluid. The patient improved with antibiotic therapy and drainage of the empyema. During his convalescence, the patient developed persistent fever, lethargy and anorexia. His inflammatory markers were elevated, and repeat cultures were negative. Although the patient had none of the classical mucocutaneous features of Kawasaki disease, an echocardiogram was performed, which revealed coronary artery dilation. The patient was diagnosed with incomplete Kawasaki disease and treated with intravenous immunoglobulin and high-dose acetylsalicylic acid. The fever subsided within 48 h. To the authors' knowledge, the present report is the first report of Kawasaki disease associated with complicated S pyogenes pneumonia. It emphasizes the importance of considering incomplete Kawasaki disease among children with persistent fever, the role of echocardiography in diagnosis, and the potential link between Kawasaki disease and superantigen-producing organisms such as S pyogenes.
Diefenbeck, M; Abitzsch, D; Hofmann, G O
Acute septic arthritis is a surgical emergency because rapid septic destruction of articular cartilage can lead to impairment or even loss of joint function. Diagnosis consists of patient history, clinical examination, laboratory results, (sonography- guided) joint aspiration and radiography. Emergency therapy is based on arthroscopic or open joint debridement and lavage combined with systemic antibiotic therapy. No data are available for the recommendation of local antibiotics but antiseptic solutions are not recommended because of cartilage damage. New trends in diagnostics are positron emission tomography/computed tomography (PET/CT), urine sticks for analysis of joint fluid and molecular pathology. Chronic joint empyema is more diagnostically demanding and is difficult to treat. In cases of necrotic and infected articular cartilage, joint resection has to be performed for quiescence of infection. Options following successful treatment of empyema are arthroplasty, arthrodesis or permanent resection.
Govindarajah, Narendranath; Hameed, Waseem; Middleton, Simon; Booth, Michael
This is a case of a 75-year-old man being admitted to the on-call surgical department with acute abdominal pain. On arrival he was clinically dehydrated and shocked with localised pain over McBurney's point and examination findings were suggestive of appendiceal or other colonic pathology. Full blood testing revealed a white cell count of 38×109/L and a C reactive protein (CRP) of 278 mg/L. A CT scan revealed a gallbladder empyema that extended into the right iliac fossa. This case highlights the potential for a hyperdistended gallbladder empyema to present as acute right iliac fossa pain with blood tests suggestive of complicated disease. Further analysis confirmed Actinomyces infection as the underlying aetiology prior to a laparoscopic subtotal cholecystectomy. This case serves to remind clinicians of this as a rare potential cause of atypical gallbladder pathology. PMID:24872493
The primary care in terms of emergency for pneumothorax is chest drainage in almost cases. The following cases of pneumothorax and the complications need something of surgery and treatments. Pneumothorax with subcutaneous emphysema often needs small skin incisions around the drainage tube. Tension pneumothorax often needs urgent chest drainage. Pneumothorax with intractable air leakage often needs interventional treatments like endobroncheal occlusion (EBO) or thoracographic fibrin glue sealing method (TGF) as well as urgent thoracoscopic surgery. Pneumothorax with acute empyema also often needs urgent thoracoscopic surgery within 2 weeks if chest drainage or drug therapy are unsuccessful. It will probably become chronic empyema of thorax after then. Pneumothorax with bleeding needs urgent thoracoscopic surgery in case of continuous bleeding over 200 ml/2 hours. In any cases of emergency for pneumothorax, respiratory physicians should collaborate with respiratory surgeons at the 1st stage because it is important to timely judge conversion of surgical treatments from medical treatments.
Laperuta, Paolo; Napolitano, Filomena; Vatrella, Alessandro; Di Crescenzo, Rosa Maria; Cortese, Antonio; Di Crescenzo, Vincenzo
Broncho-pleural fistula (BPF), is a dramatic complication that may occur after lung resection. The treatment is challenging due to its high rate of morbidity and mortality. Herein, a case of BPF associated with empyema, occurred in an elderly patient who had undergone to left pneumonectomy for non-small cell lung cancer (NSCLC), is reported. After various treatments including chest drainage and endoscopic procedures, BPF was successfully closed by open-window thoracotomy associated with vacuum assisted closure (V.A.C.) device therapy. The authors conclude that V.A.C. is a convenient and safe measure in the management of empyema with BPF. Moreover, in similar clinical contexts, V.A.C. may be the only option available that may assure the survival of the patient and the avoiding any later-phases of residual cavity. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Mora de Sambricio, A; Garrido Stratenwerth, E
Pleural effusion is a possible complication of the thoraco-abdominal approach to the spine. It is more commonly a reactive effusion, but it also may be caused by hemothorax, empyema or, less commonly, a chylothorax. The case of a chylothorax is reported as a late onset complication of a double anterior and posterior instrumented fusion of the lumbar spine. Its management and clinical outcome, and a review of the literature is presented.
interferes with vigorous physical exertion. k. Empyema (510), including residual pleural effusion (511.9) or unhealed sinuses of chest wall (510). l...than one lobe (P32.4). o. Pleurisy with effusion (511.9), within the previous 2 years if known or unknown origin. p. Pneumothorax (512) during the year...Obstacles and Opportunities p. Photosensitivity (692.72), any primary sun-sensitive condition, such as polymorphous light eruption or solar urticaria
advances in surgical technique.4 Haemorrhage and sepsis have remained the main causes of mortality throughout twentieth century warfare.1,6 In the...World War I, chest injuries were 6% of all combat wounds,1 with a mortality of 24– 27%2; haemorrhage and empyema were the leading causes of death...such as endotracheal intubation , mechanical ventilation, the use of antimicrobial agents and improved pulmonary toilet techniques removing retained
This review describes the microbiology, and medical management of orbital and intracranial complications of sinusitis in children. The most common complications are orbital cellulitis, subperiosteal abscess, orbital abscess, brain abscess, subdural empyema and meningitis. The predominate organisms recovered from these infection are anaerobic, aerobic, and microaerophilic bacteria of oral flora origin. Establishing the microbiology by obtaining appropriate cultures for both aerobic and anaerobic bacteria are essential for proper antimicrobial selection. Early recognition and appropriate surgical and medical therapy are essential to ensure recovery.
Gahlot, Satindra; Nasreen, Najmunnisa; Johnson, Judith A.; Sahn, Steven A.; Mohammed, Kamal A.
Methicillin Resistant Staphylococcus aureus (MRSA) cause pneumonia and empyema thoraces. TLR9 activation provides protection against bacterial infections and Heme oxygenase-1 (HO-1) is known to enhance host innate immunity against bacterial infections. However, it is still unclear whether HO-1 regulates TLR-9 expression in the pleura and modulates the host innate defenses during MRSA empyema. In order to determine if HO-1 regulates host innate immune functions via modulating TLR expression, in MRSA empyema, HO-1+/+ and HO-1-/- mouse pleural mesothelial cells (PMCs) were infected with MRSA (1:10, MOI) in the presence or absence of Cobalt Protoporphyrin (CoPP) and Zinc Protoporphyrin (ZnPP) or CORM-2 (a Carbon monoxide donor) and the expression of mTLR9 and mBD14 was assessed by RT-PCR. In vivo, HO-1+/+ and HO-1-/- mice were inoculated with MRSA (5x106 CFU) intra-pleurally and host bacterial load was measured by CFU, and TLR9 expression in the pleura was determined by histochemical-immunostaining. We noticed MRSA inducing differential expression of TLR9 in HO-1+/+ and HO-1 -/- PMCs. In MRSA infected HO-1+/+ PMCs, TLR1, TLR4, and TLR9 expression was several fold higher than MRSA infected HO-1-/- PMCs. Particularly TLR9 expression was very low in MRSA infected HO-1-/- PMCs both in vivo and in vitro. Bacterial clearance was significantly higher in HO-1+/+ PMCs than compared to HO-1-/- PMCs in vitro, and blocking TLR9 activation diminished MRSA clearance significantly. In addition, HO-1-/- mice were unable to clear the MRSA bacterial load in vivo. MRSA induced TLR9 and mBD14 expression was significantly high in HO-1+/+ PMCs and it was dependent on HO-1 activity. Our findings suggest that HO-1 by modulating TLR9 expression in PMCs promotes pleural innate immunity in MRSA empyema. PMID:28052108
Doan, Thien; Revere, Elizabeth
Pasteurella is one of the zoonotic pathogens that can cause variety of serious infections in animals and humans such as bacteremia, septic shock, endocarditis, meningitis, prosthetic and native valve infections, osteomyelitis, skin and soft tissue infections, abscesses, and even pneumonia with empyema. However, there have been few reports of upper respiratory involvements like tonsillitis and epiglottitis in humans. We present a case of recurrent Pasteurella glossitis after a cat scratch which has not been reported in humans. PMID:27840749
Lindstrand, Ann; Bennet, Rutger; Galanis, Ilias; Blennow, Margareta; Ask, Lina Schollin; Dennison, Sofia Hultman; Rinder, Malin Ryd; Eriksson, Margareta; Henriques-Normark, Birgitta; Ortqvist, Ake; Alfvén, Tobias
Streptococcus pneumoniae is a major cause of pneumonia and sinusitis. Pneumonia kills >1 million children annually, and sinusitis is a potentially serious pediatric disease that increases the risk of orbital and intracranial complications. Although pneumococcal conjugate vaccine (PCV) is effective against invasive pneumococcal disease, its effectiveness against pneumonia is less consistent, and its effect on sinusitis is not known. We compared hospitalization rates due to sinusitis, pneumonia, and empyema before and after sequential introduction of PCV7 and PCV13. All children 0 to <18 years old hospitalized for sinusitis, pneumonia, or empyema in Stockholm County, Sweden, from 2003 to 2012 were included in a population-based study of hospital registry data on hospitalizations due to sinusitis, pneumonia, or empyema. Trend analysis, incidence rates, and rate ratios (RRs) were calculated comparing July 2003 to June 2007 with July 2008 to June 2012, excluding the year of PCV7 introduction. Hospitalizations for sinusitis decreased significantly in children aged 0 to <2 years, from 70 to 24 cases per 100 000 population (RR = 0.34, P < .001). Hospitalizations for pneumonia decreased significantly in children aged 0 to <2 years, from 450 to 366 per 100 000 population (RR = 0.81, P < .001) and in those aged 2 to <5 years from 250 to 212 per 100 000 population (RR = 0.85, P = .002). Hospitalization for empyema increased nonsignificantly. Trend analyses showed increasing hospitalization for pneumonia in children 0 to <2 years before intervention and confirmed a decrease in hospitalizations for sinusitis and pneumonia in children aged 0 to <5 years after intervention. PCV7 and PCV13 vaccination led to a 66% lower risk of hospitalization for sinusitis and 19% lower risk of hospitalization for pneumonia in children aged 0 to <2 years, in a comparison of 4 years before and 4 years after vaccine introduction. Copyright © 2014 by the American Academy of Pediatrics.
Niknam, Negin; Doan, Thien; Revere, Elizabeth
Pasteurella is one of the zoonotic pathogens that can cause variety of serious infections in animals and humans such as bacteremia, septic shock, endocarditis, meningitis, prosthetic and native valve infections, osteomyelitis, skin and soft tissue infections, abscesses, and even pneumonia with empyema. However, there have been few reports of upper respiratory involvements like tonsillitis and epiglottitis in humans. We present a case of recurrent Pasteurella glossitis after a cat scratch which has not been reported in humans.
The use of pleural and lung ultrasound is being performed increasingly by respiratory and critical care clinicians around the world. This article describes how to create cheap and reliable lung and pleural phantoms for teaching. The phantoms described replicate the appearance of normal ventilating lung, pneumothorax (including the contact or lung point), pulmonary oedema, pleural effusion and empyema. The pleural effusion phantom can be used to teach procedural ultrasound (pleurocentesis). PMID:28191142
Porcel, J M
In this narrative review we describe the main aetiologies, clinical characteristics and treatment for patients with benign pleural effusion that characteristically persists over time: chylothorax and cholesterol effusions, nonexpansible lung, rheumatoid pleural effusion, tuberculous empyema, benign asbestos pleural effusion and yellow nail syndrome. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.
We investigated the causes of death of late sequelae of pulmonary tuberculosis. Chronic respiratory failure is one of the most frequent cause of death in the patients of late sequelae of pulmonary tuberculosis. We compared the long term prognosis of chronic respiratory failure in case of emphysema and pulmonary tuberculosis. In the patients with chronic respiratory failure by pulmonary emphysema, the prognosis was poor in those with pulmonary hypertension. But in case of late sequelae of pulmonary tuberculosis, prognosis was not affected by presence or absence of pulmonary hypertension. The determinants of prognosis of late sequelae of pulmonary tuberculosis are the indication of home oxygen therapy, malnutrition, and hypoxemia. Fungal infection, especially aspergilloma, is a common secondary infection of late sequelae of pulmonary tuberculosis. We investigated forty-two cases of aspergilloma as late sequelae of pulmonary tuberculosis, and of those 15 patients died. The causes of death were pneumonia and respiratory failure. Measurement of galactomannan antigen of aspergillus in serum using ELISA or PCR, it was apparent that the outcome was poor in the patients positive for antigen. It suggested that the prognosis of the patients with aspergilloma related with some degree of invasion of Aspergillus in parenchyma. It was reported that neoplasm is closely related to chronic tuberculous empyema. Lymphoma is most frequently complicated with chronic tuberculous empyema, and squamous cell carcinoma, adenocarcinoma, sarcoma and carcinoid were reported as complication of chronic empyema. We reported the case of angiosarcoma, originated from chronic empyema in left thoracic cavity formed after being treated for tuberculosis with artificial pneumothorax. Recently, the number of patients with late sequelae of pulmonary tuberculosis have been decreased, but some severe cases of patients of pulmonary tuberculosis will suffer from late sequelae of pulmonary tuberculosis, and
Daly, B D
Pneumonectomy is performed for a number of benign and malignant conditions. It is most commonly performed for lung cancer. Adjuvant and neoadjuvant protocols have increased the number of these operations being performed and the long-term results are improving. Pneumonectomy may also be performed for metastases to lung and for mesothelioma with encouraging results. Some bronchial adenomas require pneumonectomy. Treatment of resistant mycobacteria or the complications of tuberculosis frequently require pneumonectomy. Late bronchopleural fistulae, esophagopleural fistulae, and empyema may occur.
Solak, Ilhami; Cankayali, Ilkin; Aksu, Hasim; Moral, Ali Resat
Thinners, including aromatic hydrocarbons such as toluene, xylene, and N-hexane, are widely used in industry for the production of plastics, varnish, paint, and glue. Use of these toxic agents frequently leads to chronic intoxication caused by abuse or misuse of solvents, which are usually taken in through inhalation. Thinners may have neurotoxic, myotoxic, hepatotoxic, nephrotoxic, and cardiotoxic systemic effects. The patient described in this report attempted to commit suicide by injecting 10 cc thinner into the left hemithorax. Acute chemical empyema developed at the left hemithorax. No bacterial growth was noted in empyema liquid and blood samples. Empyema was treated with tube thoracostomy, and full remission was observed after 33 d. No systemic toxic signs were noted, other than a low level of hepatotoxicity. Although pleural effusion, atelectasis, and pleural thickening were observed at the acute phase on computed tomography (CT) of the thorax, only pleural thickening persisted on CT of the thorax after 1 y. Investigators could not find a documented case of parenteral use of thinners in the medical literature.
Moore, Forrest O; Duane, Therese M; Hu, Charles K C; Fox, Adam D; McQuay, Nathaniel; Lieber, Michael L; Como, John J; Haut, Elliott R; Kerwin, Andrew J; Guillamondegui, Oscar D; Burns, J Bracken
Antibiotic use in injured patients requiring tube thoracostomy (TT) to reduce the incidence of empyema and pneumonia remains a controversial practice. In 1998, the Eastern Association for the Surgery of Trauma (EAST) developed and published practice management guidelines for the use of presumptive antibiotics in TT for patients who sustained a traumatic hemopneumothorax. The Practice Management Guidelines Committee of EAST has updated the 1998 guidelines to reflect current literature and practice. A systematic literature review was performed to include prospective and retrospective studies from 1997 to 2011, excluding those studies published in the previous guideline. Case reports, letters to the editor, and review articles were excluded. Ten acute care surgeons and one statistician/epidemiologist reviewed the articles under consideration, and the EAST primer was used to grade the evidence. Of the 98 articles identified, seven were selected as meeting criteria for review. Two questions regarding presumptive antibiotic use in TT for traumatic hemopneumothorax were addressed: (1) Do presumptive antibiotics reduce the incidence of empyema or pneumonia? And if true, (2) What is the optimal duration of antibiotic prophylaxis? Routine presumptive antibiotic use to reduce the incidence of empyema and pneumonia in TT for traumatic hemopneumothorax is controversial; however, there is insufficient published evidence to support any recommendation either for or against this practice.
Hata, Yoshinobu; Otsuka, Hajime; Makino, Takashi; Koezuka, Satoshi; Sugino, Keishi; Shiraga, Nobuyuki; Tochigi, Naobumi; Shibuya, Kazutoshi; Homma, Sakae; Iyoda, Akira
Surgery for chronic pulmonary aspergillosis is often technically risky. The choice of immediate thoracoplasty or muscle flap plombage to prevent postoperative space problems remains controversial. This study focused on the use of muscle flaps to prevent postoperative complications. During an 8-year period (2004 to 2012), all patients surgically treated for chronic pulmonary aspergillosis were enrolled in this retrospective study. Concomitant intrathoracic transposition of the latissimus dorsi muscle flap has been performed since 2011. The clinical records of these patients were reviewed retrospectively. From 2004 to 2012, 16 patients were treated for chronic pulmonary aspergillosis. Fifteen patients received lobectomies and one had a partial resection. A preventive latissimus dorsi muscle flap was used in 6 patients (37 %). No postoperative deaths occurred. Prolonged air leaks appeared in 2 patients without muscle flaps, resulting in empyema in both. None of the patients with preventive muscle flaps suffered prolonged air leaks and subsequent empyema. In the outpatient clinic, late onset air leaks developed in 2 patients, one of whom had a lobectomy with muscle flap while the other had a lobectomy without muscle flap. Residual pleural space persisted in these two patients and Aspergillus infection later recurred. Concomitant latissimus dorsi muscle flaps may be effective for the prevention of prolonged air leaks and subsequent empyema. Late onset air leaks are problematic.
Mikić, Dragan; Djordjević, Zoran; Sekulović, Leposava; Kojić, Miroslav; Tomanović, Branka
Rhodococcus (R) equi is an opportunistic, uncommon human pathogen that causes mainly infection in immunocompromised hosts. The disease is usually presented as subacute pneumonia that is mostly cavitary and sometimes bacteremic. We reported the extremly rare case of a 43-year-old woman with Hodgkin lymphoma, who developed R equi pulmonary infection after recieving multiple courses of chemotherapy. Secondary, the patient developed bacteremia, leading to sepsis and dissemination of R equi infection in many extrapulmonary sites. At addmission the patient was febrile, tachypnoic, tachycardic, hypotensive, with fa cial edema, splenomegaly, positive meningeal signs, left hemiparesis and paraparesis. Laboratory data included erythrocyte sedimentation rate (ESR) > 140 mm/h, C-reactive protein (CRP) 143.0 mg/L, red blood cells (RBC) 2.14 x 10(12)/L, whyite blood cells (WBC) 2.8 x 10(9)/L, lactate dehydrogenase (LDH) 706 U/L, serum albumin 26 g/L, sodium 127 mmol/L and potassium 2.7 mmol/L. Blood culture and culture of sputum and empyema were positive for R equi. Imaging studies demonstrated a large right cavitary pneumonia and abscess, empyema, pericarditis, mediastinal and intra-abdominal lymphadenopathy, brain and psoas abscesses, osteomyelitis and spondylodiscitis. The patient recovered completely after a 12-month treatment with combinations of parenteral and oral antibiotics (meropenem, vancomycin, teicoplanin, ciprofloxacin, rifampicin, macrolides etc), including drainage of abscesses and empyema. Eight years after completition of the treatment the patient was without recurrence of R equi infection and lymphoma. Since the eradication od R equi is very difficult, it is very important to make the diagnosis and initiate appropriate antibiotic therapy as soon as possible.
Papaioannou, Andriana I; Kostikas, Konstantinos; Tsopa, Paschalina; Kiropoulos, Theodoros; Tsilioni, Irene; Oikonomidi, Smaragda; Gerogianni, Irene; Gourgoulianis, Konstantinos I
Many patients with pneumonia develop pleural effusions. Pleural fluid vascular endothelial growth factor (VEGF) levels are known to be elevated in complicated parapneumonic effusion and seem to play a major role in the fibrotic process in the pleura. To test whether VEGF levels in pleural effusions of infectious origin correlate with the residual pleural thickening. VEGF levels were measured in the pleural fluid of 45 patients with pleural effusion of infectious origin. Patients were reassessed 3 months after hospital discharge and residual pleural thickening (RPT) was recorded using a simple chest radiograph. Pleural fluid VEGF was higher in empyemas compared to simple parapneumonic and complicated parapneumonic effusions. RPT was higher in patients with empyemas compared to simple parapneumonic effusions. Patients with RPT >2 mm had higher pleural fluid LDH and pleural fluid to serum LDH ratio, lower glucose and pH and higher VEGF levels. However, patients with RPT ≥10 mm differed only in pleural fluid VEGF levels. Pleural fluid VEGF levels correlated to RPT and to pleural fluid pH. VEGF presented moderate performance for the prediction of RPT 3 months after hospital discharge. Its performance was comparable to that of pleural fluid glucose and pH for the development of a radiologically significant RPT >2 mm, whereas it was the only statistically significant predictor of a clinically significant RPT ≥10 mm. VEGF levels are elevated in complicated parapneumonic effusions and empyemas compared to simple parapneumonic effusions and are a significant predictor for the development of clinically significant RPT. Copyright © 2009 S. Karger AG, Basel.
Reyes, K G; Mason, D P; Murthy, S C; Su, J W; Rice, T W
In modern day thoracic surgical practice, better understanding of the pathophysiology of intrathoracic infections, improved antibiotic therapy and advancements in thoracic surgical techniques have decreased the use of procedures such as open window thoracostomy (OWT). Despite this, there are occasions where OWT cannot be avoided, and it is of interest where its current utility lies. To determine the current efficacy of OWT, we reviewed our recent experience with a focus on the indications, timing of surgery, effectiveness in clearing infection, patient survival, and timing of closure. After Institutional Review Board approval, charts of 78 patients were reviewed. Dates reviewed were from 1/1/1998 to 1/1/2008. Patients were predominantly male (66 %) with a median age 58 years. Median time from initial diagnosis to OWT was 70 days (range 1 to 720 days). Primary indication for surgery was empyema in 75 (96 %), and most patients had previous thoracic surgery. The most frequent causes of empyema were post-pneumonectomy (n = 25), post-pneumonic (n = 14), and post-lobectomy (n = 9). Bronchopleural fistulae were present in 29 (37 %) cases. Lung cancer was diagnosed in 34 (45 %) patients, and 24 underwent perioperative radiation therapy. Patient survival at 1 month, 6 months, 1 year and 5 years was 94 %, 82 %, 74 % and 60 %, respectively, with an in-hospital mortality of 6.4 %. Infection was controlled in nearly all patients (n = 72). Fifteen (19 %) patients underwent surgical closure for OWT; in 2 (2.6 %), OWT closed spontaneously. Currently, open window thoracostomy is used to treat complex empyema incurred from pulmonary resection, cancer and/or infection in patients that cannot be managed by more conservative strategies. Overall mortality and morbidity rates are acceptable in this debilitated patient group.
Savage, Stephanie A; Cibulas, George A; Ward, Tyler A; Davis, Corinne A; Croce, Martin A; Zarzaur, Ben L
Although tube thoracostomy is a common procedure after thoracic trauma, incomplete evacuation of fluid places the patient at risk for retained hemothorax. As little as 300 to 500 cm of blood may result in the need for an additional thoracostomy tube or, in more severe cases, lung entrapment and empyema. We hypothesized that suction evacuation of the thoracic cavity before tube placement would decrease the incidence of late complications. Patients requiring tube thoracostomy within 96 hours of admission were prospectively identified and underwent suction evacuation of the pleural space (SEPS) before tube placement. These patients were compared to historical controls without suction evacuation. Demographics, admission vital signs, laboratory values, details of chest tube placement, and outcomes were collected on all patients. Multivariable logistic regression was used to compare outcomes between groups. A total of 199 patients were identified, consisting of 100 retrospective controls and 99 SEPS patients. There were no differences in age, sex, admission injury severity score or chest abbreviated injury score, admission laboratory values or vital signs, or hospital length of stay. Mean (SD) volume of hemothorax in SEPS patients was 220 (297) cm; with only 48% having a volume greater than 100 cm at the time of tube placement. Three patients developed empyema, and 19 demonstrated retained blood; there was no difference between SEPS and control patients. Suction evacuation of the pleural space was significantly protective against recurrent pneumothorax after chest tube removal (odds ratio, 0.332; 95% confidence interval, 0.148-0.745). Preemptive suction evacuation of the thoracic cavity did not have a significant impact on subsequent development of retained hemothorax or empyema. Suction evacuation of the pleural space significantly decreased incidence of recurrent pneumothorax after thoracostomy removal. Although the mechanism is unclear, such a benefit may make this
Hsieh, Yu-Chia; Chi, Hsin; Chang, Kuang-Yi; Lai, Shen-Hao; Mu, Jung-Jung; Wong, Kin-Sun; Liu, Ching-Chuan; Huang, Yi-Chuan; Lin, Hsiao-Chuan; Chang, Luan-Yin; Huang, Yhu-Chering; Huang, Li-Min
The incidence of necrotizing pneumococcal pneumonia has increased during the past 2 decades. We hypothesized that increased pneumococcal load or augmented inflammatory cytokine production might lead to destructive pneumococcal lung disease. This study enrolled prospectively 0- to 18-year-old children with a diagnosis of community-acquired pneumonia with pleural effusion admitted to 6 medical centers from March 2010 to April 2012. Children were diagnosed with pneumococcal empyema if the pleural fluid tested positive for quantitative pneumococcal (lytA) detection by real-time polymerase chain reaction. Pneumococcal empyema cases were further divided into 4 groups according to necrosis severity: (0) nonnecrosis, (1) mild necrosis, (2) cavitation and (3) bronchopleural fistula. Nasopharyngeal and pleural pneumococcal load, as well as levels of proinflammatory cytokines (TNF-α, IL-1β, IL-6, IL-8), Th1-(IL-2, IFN-γ), Th2-(IL-4, IL-10) and Th17-cytokines (IL-17), in the pleural fluid was measured. Serotypes 19A and 3 accounted for 69.4% and 12.5%, respectively, of 72 cases of pneumococcal empyema. Pleural pneumococcal load was significantly higher in serotypes 19A and 3 infection than in the other strains causing infection (P = 0.006). There was a correlation between nasopharyngeal and pleural pneumococcal load (ρ = 0.35; P = 0.05). In multivariate ordinal logistic regression analysis, pleural pneumococcal load (adjusted odds ratio: 1.79; 95% confidence interval: 1.03-3.06) and IL-8 (adjusted odds ratio: 2.64; 95% confidence interval: 1.21-5.75) were independent factors associated with the severity of lung necrosis. Evolution of Streptococcus pneumoniae toward increased fitness in their interaction with host and exaggerated IL-8 expression may be responsible for the increase of necrotizing pneumococcal pneumonia.
Jiang, Li-bin; Zhu, Yi-hao; Yao, Yu-feng; Xu, Jun; Wang, Zhen
To improve understanding of the clinical features, diagnosis and treatment of pyopneumothorax caused by Salmonella choleraesuis. One case of pyopneumothorax caused by Salmonella choleraesuis diagnosed and treated in our hospital in 2010 was reported and the related literatures were reviewed. As of May 2011, the literature review was carried out with "Salmonella choleraesuis" and "thoracic empyema" as the search terms in Wanfang Med Online and Pubmed Database. A 43-year-old Chinese woman presenting with fever and chest pain for 4 days was admitted to our hospital. A CT scan of the chest revealed a massive shadow with mixed density in the right hemithorax, from the top of thorax to diaphragmatic surface, and there was air inside or surrounding the mass irregularly but without an air-fluid level. Blood culture and bronchial secretion culture by bronchoscope both showed some serotypes of Salmonella strains. At first intravenous antibiotic therapy (piperacillin-tazobactam, ceftazidime, and then imipenem-cilastatin) was ineffective. Open chest surgery was performed, and chest tube placed. Salmonella choleraesuis was isolated from the drained pleural fluid. Chest tube drainage remained in place for more than 6 weeks, and with prolonged antibiotic therapy, which contributed to a good outcome. Literature review found no related reports in Wanfang Med Online, while 3 literatures were found in Pubmed, including 2 of case report and 1 of retrospective study. Among 973 patients with empyema thoracis in the retrospective study, 12 of these patients, including 9 men and 3 women, were infected with Salmonella species. The median age was 49 years, and 10 patients were immunocompromised, including malignancy, liver cirrhosis, and diabetes mellitus. Seven patients were infected with Salmonella choleraesuis, and 4 (57%) of them died. Pyopneumothorax or thoracic empyema is a rare complication of Salmonella choleraesuis infection. Higher rates of death were noted in this disease
Bang, Jin Hyuk
Gas-containing (emphysematous) infections of the abdomen, pelvis, and extremities are well-known disease entities, which can potentially be life-threatening. They require aggressive medical and often surgical treatment. In the neurosurgical field, some cases of gas-containing brain abscess and subdural empyema have been reported. Sometimes they progress rapidly and even can cause fatal outcome. However, gas-containing spinal epidural abscess has been rarely reported and clinical course is unknown. We report on a case of rapidly progressive gas-containing lumbar spinal epidural abscess due to Enterococcus faecalis in a 72-year-old male patient with diabetes mellitus. PMID:26512268
Bang, Jin Hyuk; Cho, Keun-Tae
Gas-containing (emphysematous) infections of the abdomen, pelvis, and extremities are well-known disease entities, which can potentially be life-threatening. They require aggressive medical and often surgical treatment. In the neurosurgical field, some cases of gas-containing brain abscess and subdural empyema have been reported. Sometimes they progress rapidly and even can cause fatal outcome. However, gas-containing spinal epidural abscess has been rarely reported and clinical course is unknown. We report on a case of rapidly progressive gas-containing lumbar spinal epidural abscess due to Enterococcus faecalis in a 72-year-old male patient with diabetes mellitus.
Postoperative complications can pose a significant obstacle in the ongoing management of surgical patients. However, it is pertinent to remember that postoperative events are not always complications of the preceding operation. We present the case of a patient with calculous cholecystitis and gallbladder empyema who underwent laparoscopic cholecystectomy. Postoperatively, he continued to have right upper quadrant pain associated with abnormal liver function tests. Ultimately, the cause of his postoperative symptoms was rather prosaic and ran counter to Occam’s razor, the relevance of which is discussed below. PMID:27310811
Duzhiy, I D; Grehsko, I Ya; Kravets, O V; Oleshchenko, G P; Glazunova, N I
In coincidence of chronic phthisic pleuritis in a rigid stage with pulmonary tuberculosis operative intervention is indicated of a pleuropulmonectomy type, what is a complex situation for performance and preservation of the patient's functional state. Pleuropulmonectomy in some patients is complicated by empyema and pathological processes in bronchi. Possibilities of operative interventions application, alternative to pleuropulmonectomy, were studied. Of 48 patients, to whom pleuropulmonectomy is indicated in accordance to data of clinic-roentgenological investigations, in 7--simultant operative treatment were conducted with positive results.
Yildirim, Inci; Shea, Kimberly M; Pelton, Stephen I
Universal immunization of infants and toddlers with pneumococcal conjugate vaccines over the last 15 years has dramatically altered the landscape of pneumococcal disease. Decreases in invasive pneumococcal disease, all-cause pneumonia, empyema, mastoiditis, acute otitis media, and complicated otitis media have been reported from multiple countries in which universal immunization has been implemented. Children with comorbid conditions have higher rates of pneumococcal disease and increased case fatality rates compared with otherwise healthy children, and protection for the most vulnerable pediatric patients will require new strategies to address the underlying host susceptibility and the expanded spectrum of serotypes observed.
Daniels, Albert C.; Childress, Max E.
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. ImagesFigure 3Figure 4Figure 5 PMID:13374556
Abolhoda, Amir; Wirth, Garrett A; Bui, Trung D; Milliken, Jeffrey C
Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of a number of complex intrathoracic pathologies such as bronchopleural fistulas and residual infected pleural spaces. We present a simple step-wise technique for preservation and harvesting of the most common muscle flap employed by thoracic surgeons, namely latissimus dorsi, just prior to performing a standard posterolateral thoracotomy. Since 2004, we have successfully utilized pedicled latissimus muscle as our preferred prophylactic flap against development of postoperative bronchopleural fistulas or recurrent empyemas. This technique should be part of every thoracic surgeon's surgical armamentarium.
Mungo, Benedetto; Barbetta, Arianna; Lidor, Anne O; Stem, Miloslawa; Molena, Daniela
We describe the case of a patient successfully reconstructed with laparoscopic retrosternal gastric pull-up after esophagectomy for unresectable posterior mediastinal inflammatory myofibroblastic tumor, eroding into the esophagus and compressing the airways. A partial esophagectomy with esophagostomy was performed for treatment of esophageal pleural fistula and empyema, while the airways were managed with the placement of an endobronchial stent. Gastrointestinal reconstruction was performed using a laparoscopic approach to create a retrosternal tunnel for gastric conduit pull-up and cervical anastomosis. The patient was discharged uneventfully after 6 d, and has done very well at home with normal diet.
Pleural infection is a common and increasing clinical problem in thoracic medicine, resulting in significant morbidity and mortality. In recent years there has been a marked increase in interests and publications relating to evolving interventions and management options for pleural infection and empyema. Recently published research data as well as guidelines have suggested better approaches of radiological assessment, updated management algorithms for pleural infection, intrapleural adjunct therapies and re-examined the roles of biomarkers, pleural drainage techniques, and the role of surgery. This review highlights some of the recent advances and recommendations relevant to clinical care of pleural infection. PMID:22833824
A patient with post-pneumonia empyema complicated by type-2 respiratory failure required mechanical ventilation as part of his therapy. A pneumothorax was noted on his chest radiograph. This was treated with an intercostal chest drain (ICD). Unfortunately, he was still hypoxic, his subcutaneous emphysema was worsening and the ICD was bubbling. A computed tomography (CT) scan of chest demonstrated that the ICD has penetrated the right upper lobe parenchyma. A new ICD was inserted and the previous one was removed. Although both hypoxia and subcutaneous emphysema improved, the patient chronically remained on mechanical ventilation. PMID:21447174
Abramzon, O M; Bukharin, O V; Kurlaev, P P
Results of treatment of patients with acute pulmonary abscess, acute empyema of the pleura and pyopneumothorax were analyzed. The local treatment of the main group of patients consisting of 50 persons included oxitocin in combination with antiseptics and antibiotics which facilitated maximal reduction of the persistent potential of the pathogenic agent, its rapid elimination from the purulent focus and allowed to get better results using conservative therapy. The obtained clinical effect confirmed the experimental data on pronounced inhibition of persistent properties of the bacterial pathogens with the complexes "antibiotic-oxitocin".
Ebisawa, Kei; Yamada, Norihiro; Okada, Shinji; Suzuki, Yasuko; Satoh, Asami; Kobayashi, Makoto; Morikawa, Naoto
Pulmonary infection after a tsunami is often polymicrobial and tends to form chronic pyogenic lung disease, necrotizing pneumonia, and empyemas. We report a combined pulmonary infection of Legionella and multiple antibiotic-resistant Escherichia coli in a previously well 75-year-old woman following immersion in tsunami waters 1 km inland from the Pacific coastline following the Tohoku Region Pacific Coast Earthquake of 2011. She needed drainage several times and the long-term use of multiple antibiotics according to the type of bacteria found and antibiotic susceptibility. We should be mindful of infections caused by multiple pathogens in the environment in Japan as a consequence of a tsunami disaster.
Moore, Michael V; Little, Paul; Hay, Alastair D; Fox, Robin; Prevost, A Toby; Juszczyk, Dorota; Charlton, Judith; Ashworth, Mark
Objective To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs). Design Cohort study. Setting 610 UK general practices from the UK Clinical Practice Research Datalink. Participants Registered patients with 45.5 million person years of follow-up from 2005 to 2014. Exposures Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients. Main outcome measures Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice. Results From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade
Because of difficulties in antemortem diagnosis of systemic aspergillosis, a radioimmunoassay to an Aspergillus fumigatus carbohydrate was developed and evaluated in patients with mycotic or bacterial infections. Antigenemia was detected in sera obtained antemortem from four of seven patients with systemic aspergillosis and in pleural fluid from an Aspergillus empyema but not in control sera or pleural fluid from 43 patients or 27 normal donors. When characterized with reference to onset of disease, antigenemia was an early sign of infection. This study shows the usefulness of the Aspergillus antigen radioimmunoassay for early, specific immunodiagnosis of systemic aspergillosis.
Bali, Rishi Kumar; Sharma, Parveen; Gaba, Shivani; Kaur, Avneet; Ghanghas, Priya
Life-threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. Complications include airway obstruction, mediastinitis, necrotizing fascitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre's syndrome, cerebral abscess, orbital abscess, and osteomyelitis. The incidence of these "space infections" has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur. This study reviews complications of odontogenic infections. The search done was based on PubMed and Google Scholar, and an extensive published work search was undertaken. Advanced MEDLINE search was performed using the terms "odontogenic infections," "complications," and "risk factors."
Morrison, V A; Wagner, K F
A patient with antecedent coccidioidal pulmonary cavitary disease who developed an empyema due to Kingella kingae prompted our analysis of the literature regarding this unusual bacterial pathogen. Formerly classified among other genera and considered a nonpathogen, K. kingae has been increasingly recognized as a cause of human infection. While the most commonly diagnosed infections due to this organism are endocarditis and septic arthritis, there have also been isolated reports of bacteremia, diskitis, abscesses, meningitis, and oropharyngeal infections. The treatment of choice is penicillin, to which K. kingae strains are uniformly susceptible. Recognition of the potential pathogenicity of this microorganism in appropriate clinical settings will probably result in more prompt and specific therapy.
Swischuk, L.E.; Hayden, K.; Richardson, J.
Eight newborn infants with opaque right lungs were examined. Clinically, the main problem associated with the opaque right lung is mild respiratory distress, and radiographyically, the findings consist of (a) a totally opaque right lung, (b) a semiopaque right lung, or (c) an opaque right upper lobe only. These findings are usually interpreted as representing pneumonia, empyema, or hydrochlothorax, but the fact that they clear within 24 to 48 hours indicates that none of these diseases is the cause. It is thought that neonatal opaque right lung results from the transient retention of normal fetal fluid in the right lung.
Craig, E; Al-Mahmoud, R; Batty, R; Raghavan, A; Mordekar, S R; Chan, J; Connolly, D J A
Objective: To assess the incidence and complications of pre-septal (pre-SC) and post-septal (post-SC) cellulitis over 10 years. Pre-SC and post-SC are also known as periorbital and orbital cellulitis, respectively. Methods: Retrospective analysis of CT scans. Data included the presence of pre-SC and post-SC, paranasal sinus disease (PNS) and complications. Results: Among 125 patients scanned for these suspected diagnoses, 67 had both pre-SC and post-SC, 37 had pre-SC and 4 had post-SC; there were 17 normal scans. 110 patients had PNS. 68/71 (96%) patients with post-SC had PNS. Post-SC complications included orbital and/or subperiosteal abscess (50/71: 30 medial orbital, 10 superomedial, 3 lateral, 2 anteromedial, 2 inferomedial, 1 superior, 1 anterosuperior and 1 not specified), cavernous sinus thrombosis (CST) (1), superior ophthalmic vein (SOV) thrombosis (4) and subdural frontal empyema (2); 1 patient had SOV and CST and subdural empyema. Conclusion: 71/125 (57%) patients had post-SC. 50/125 (40%) patients imaged for pre-SC/post-SC had orbital abscess; 44/50 (88%) of these involved the medial orbit. Patients can develop solely superior or inferior abscesses that are difficult to identify by axial imaging alone, hence coronal reformatted imaging is essential. 5/125 (4%) patients developed major complications (SOV/CST/empyema), hence imaging review of the head and cavernous sinus region is essential. A diagnosis of post-SC on CT should alert the radiologist because this diagnosis can be associated with an increased incidence (5/71, 7%) of complications. Advances in knowledge: We recommend that all patients with a suspected diagnosis of post-SC should undergo CT scan (post-contrast orbits and post-contrast head, with multiplanar reformats and a careful review of the SOV and the cavernous sinus). Particular attention should be paid to exclude intracranial complications including subdural empyema and cerebral abscess. As soon as a diagnosis of post-SC is made, in
Randhawa, H S; Pal, M
Cryptococcus neoformans was cultured from 13 (3%) of 469 clinical specimens examined from the respiratory tract of patients with bronchopulmonary diseases. These isolations came from 5 (2%) of 207 patients; 11 isolates were from sputum and 1 each were from bronchoscopic aspirate and empyema pus. The fungus was not cultured from the oropharyngeal washings of 101 apparently healthy volunteers. Of the 5 patients, 3 had pulmonary tuberculosis, including one with pyopneumothorax and 2 with allergic bronchopulmonary aspergillosis as the underlying disease. In the tuberculosis patient with pyopneumothorax and C. neoformans in empyema pus, the fungus was presumably a tissue invader, whereas its role could not be unequivocally ascertained in the remaining 4 patients from whom it was isolated from sputum or bronchial aspirate on at least two consecutive occasions. The question of C. neoformans being a transient resident, commensal, or incitant of benign minimal lesions in the tracheobronchial tree is discussed. A comprehensive laboratory and clinical follow-up is warranted in patients from whose sputum or bronchial aspirate C. neoformans may be cultured even though definitive signs of cryptococcosis may be lacking. PMID:319109
Sutton, Jonathan; Ahmed, Waqar
Oesophageal anastomotic leak and fistula are major and life-threatening complications of oesophagectomy with resultant increased mortality. Non-operative approach of such cases should be the initial strategy. Re-operative surgery and/or stent insertion are considered if conservative measures failed. Although oesophageal stenting is a safe option for the leaks, stent migration and failure to completely cover large anastomotic leaks are the main complications and pitfalls of the procedure. These can be overcome by using multiple or larger stents. We describe a case of a 73-year-old man who underwent a laparoscopic oesophagectomy for an oesophageal adenocarcinoma. The procedure was complicated by a large gastro-pleural fistula and anastomotic leak, resulting into a chronic empyema. The initial conservative treatment and a conventional oesophageal stent insertion failed to heal the fistula and to resolve the empyema. Re-operative surgery was ruled out because of the patient’s poor general health and high surgical risk. Due to the changed oesophago-gastric anatomy and a potential risk of migration of the additional conventional stent, a mega stent was deployed with successful closure of the oesophageal leak. Post-stenting contrast studies and an out-patient follow up review of the case confirmed no further anastomotic leakage. PMID:28078131
Plaksin, S A; Petrov, M E
A frequency of postoperative complications varied from 1-2% after endoscopic thoracal operations to 4-12% after open operations using thoracotomic access. There isn't any common approach to indications and terms of the recurrent endoscopic intervention. An analysis of postoperative complications was made after 2795 thoracothomies and 3632 videothoracoscopies required the recurrent operation in 139 patients (2.2%). The rethoracoscopies were performed on 62 patients (44.6%), thoracoscopies were carried out after thoracotomies in 40 cases (28.8%) and rethoracotomies were in 37 cases (26.6%). The more frequent indication to recurrent operation was bleeding (26.6%), pleural empyema (20.9%), fragmented pleuritis (11.5%). It was shown that thoracoscopy was an alternative to rethoracotomy as the rethoracoscopy in case of nonmassive intrapleural bleeding, clotted hemothorax, postoperative fragmented pleuritis, non-sanitized empyema region, the presence of sequestrums in this area, limited postoperative pleuritis, chylothorax, bronchopleural fistula of the size of 1-2 mm, leakage of the lung, a foreign body in pleural cavity. The lethality consisted of 35.1% after rethoracotomies and it was 12.7% after recurrent endoscopic operations.
Guihaire, Julien; Flecher, Erwan; de Latour, Bertrand; Verhoye, Jean-Philippe
OBJECTIVES Video-thoracoscopic surgery (VTS) has been accepted as a safe and credible technique since 1990. Lung injury is one of the main perioperative complications. Few data are available about cardiac trauma and VTS-related false aneurysm of the left ventricular (LV) wall has not yet been reported. METHODS A 62-year old woman presented with a left thoracic empyema. Video-thoracoscopy was attempted for bacterial sampling and surgical drain of the pleura. A rapid conversion to open thoracotomy was necessary to control massive bleeding after the first thoracic port intrusion. An apical systolic murmur was found 2 weeks later during a systematic clinical examination. The patient was asymptomatic and had no personal history of cardiac disease. RESULTS Colour Doppler imaging showed two spurious aneurysms on the LV wall without any haemopericardium. Pericardial enhancement around the left ventricle was observed on the chest computerized tomography scan with the injection of contrast. After the careful excision of the two false aneurysms, a surgical repair was strengthened with a suture under a cardiopulmonary bypass. The postoperative course was uneventful and the patient was safe at 3 years. CONCLUSIONS This is the first report of LV traumatic false aneurysms secondary to an attempt of a video-thoracoscopic procedure. This is a rare but life-threatening complication because of the risk of spontaneous rupture. Left persistent thoracic empyemas associated with the ipsilateral mediastinum deviation carry a high risk of myocardial damage related to the trocar port intrusion.
Cicero-Sabido, Raúl; Páramo-Arroyo, Rafael F; Navarro-Reynoso, Francisco Pascual; Pimentel-Ugarte, Lorenzo
Pleural effusion is a common clinical entity. Proper diagnosis and management are important for successful treatment. We undertook this study to evaluate immediate results of the procedures used in a group of cases with pleural effusion. Of 2589 patients at first consultation, 787 were hospitalized and 156 had pleural effusion. Diagnostic and therapeutic procedures used were evaluated. With thoracentesis and evacuation of liquid, 23 nonneoplastic cases had resolution. Chest tube drainage with water seal was performed in 133 patients. This procedure suppressed the effusion in 109 patients, but in 24 patients another approach was necessary. In this group there were 35 neoplastic and 96 nonmalignant cases, the latter 36 were provoked by iatrogenic management. Twenty two cases of pneumothorax considered as gaseous effusion and 10 cases of chronic empyema sequelae of pleural effusions were also studied. Proportion comparison demonstrated significant differences between neoplastic and nonneoplastic effusions (p =0.001) and in cases managed with minimally invasive procedures and chest tube drainage (p =0.001). The performance of pleurodesis and thoracoscopy is discussed. In chronic cases, indications of open window thoracostomy and myoplasty are elucidated. In pleural effusion, opportune diagnosis and proper management are essential. Drainage tube can solve the majority of cases. Pneumothorax must be treated in the same way. In chronic empyema, open window thoracostomy and myoplasty are indicated. Careless patient management and poor treatment lead to iatrogenic complications.
Lad, Lalitkumar V; Samsudin, Ahmad Toha; Kannan, Kunji; Makki, Jaafar Sadeq; Mohamed, Moharzudi
This study was carried out to ascertain the aetiology of exudative pleural effusions when other diagnostic investigations such as pleural fluid and sputum examination for cytology and acid fast bacilli fail to yield a definitive diagnosis and to differentiate between tuberculosis and malignancy in cases suspicious of malignancy. Pleuroscopic biopsies were obtained in 219 cases by Chest Physicians in the endoscopy suite using flexi-rigid fiber-optic pleuroscopes. Histological sections were stained with H&E and microscopic examination performed. Ziehl-Nielsen stain for acid fast bacilli was performed in all suspected tuberculosis cases and immunohistochemistry for Thyroid transcription factor 1 and other markers were carried out for all cases suspicious of malignancy. Adequate biopsy material for interpretation was obtained in 210 (95.9%) of 219 cases. Histopathology revealed 79 (37.6%) cases were tuberculosis, 64 (30.5%) were malignant (primary from lung and other sites), 62 (29.5%) were non-specific inflammation and 5 (2.4%) were empyema. A definitive diagnosis of tuberculosis, malignancy and empyema was obtained in 70.5% of cases. Tuberculosis was encountered in a younger age-group than malignancy. Mean age for tuberculosis patient was 49 years while for malignant patients was 63 years. The majority (79.6%) of malignances encountered were metastatic lung adenocarcinoma.
Çullu, Neşat; Kalemci, Serdar; Karakaş, Ömer; Eser, İrfan; Yalçin, Funda; Boyacı, Fatıma Nurefşan; Karakaş, Ekrem
We aimed to evaluate the efficacy of multidetector computed tomography (CT) imaging in diagnosis of pleural exudates and transudates using attenuation values. This retrospective study included 106 patients who were diagnosed with pleural effusion between January 2010 and June 2012. After the patients underwent chest CT, thoracentesis was performed in the first week. The attenuation values of the pleural effusions were measured in all patients. According to Light's criteria, 30 of 106 patients with pleural effusions had transudates, and the remaining patients had exudates. The Hounsfield unit (HU) value of the exudates (median, 12.5; range, 4-33) was significantly higher than that of the transudates (median, 5; range, 2-15) (P = 0.001). Additionally, when evaluated by disease subgroups, congestive heart failure and empyema were predictable in terms of median HU values of the pleural effusions with high and moderate sensitivity and specificity values (84.6% and 81.2%, respectively; 76.9% and 66.7%, respectively). Compared with other patients, the empyema patients had significantly more loculation and pleural thickening. CT attenuation values may be useful in differentiating exudates from transudates. Although there is an overlap in most effusions, exudate can be considered when the CT attenuation values are >15 HU. Because of overlapping HU values, close correlation with clinical findings is essential. Additional signs, such as fluid loculation and pleural thickness, should be considered and may provide further information for the differentiation.
Çullu, Neşat; Kalemci, Serdar; Karakaş, Ömer; Eser, İrfan; Yalçın, Funda; Boyacı, Fatıma Nurefşan; Karakaş, Ekrem
PURPOSE We aimed to evaluate the efficacy of multidetector computed tomography (CT) imaging in diagnosis of pleural exudates and transudates using attenuation values. MATERIALS AND METHODS This retrospective study included 106 patients who were diagnosed with pleural effusion between January 2010 and June 2012. After the patients underwent chest CT, thoracentesis was performed in the first week. The attenuation values of the pleural effusions were measured in all patients. RESULTS According to Light’s criteria, 30 of 106 patients with pleural effusions had transudates, and the remaining patients had exudates. The Hounsfield unit (HU) value of the exudates (median, 12.5; range, 4–33) was significantly higher than that of the transudates (median, 5; range, 2–15) (P = 0.001). Additionally, when evaluated by disease subgroups, congestive heart failure and empyema were predictable in terms of median HU values of the pleural effusions with high and moderate sensitivity and specificity values (84.6% and 81.2%, respectively; 76.9% and 66.7%, respectively). Compared with other patients, the empyema patients had significantly more loculation and pleural thickening. CONCLUSION CT attenuation values may be useful in differentiating exu-dates from transudates. Although there is an overlap in most effusions, exudate can be considered when the CT attenuation values are >15 HU. Because of overlapping HU values, close correlation with clinical findings is essential. Additional signs, such as fluid loculation and pleural thickness, should be considered and may provide further information for the differentiation. PMID:24100060
Mitsuhashi, Satomi; Kryukov, Kirill; Nakagawa, So; Takeuchi, Junko S; Shiraishi, Yoshiki; Asano, Koichiro; Imanishi, Tadashi
We developed a portable system for 16S rDNA analyses consisting of a nanopore technology-based sequencer, the MinION, and laptop computers, and assessed its potential ability to determine bacterial compositions rapidly. We tested our protocols using a mock bacterial community that contained equimolar 16S rDNA and a pleural effusion from a patient with empyema, for time effectiveness and accuracy. MinION sequencing targeting 16S rDNA detected all 20 of the bacterial species present in the mock bacterial community. Time course analysis indicated that the sequence data obtained during the first 5 minutes of sequencing (1,379 bacterial reads) were enough to detect all 20 bacteria in the mock sample and to determine species composition, consistent with results of those obtained from 4 hours of sequencing (24,202 reads). Additionally, using a clinical sample extracted from the empyema patient's pleural effusion, we could identify major bacterial pathogens in that effusion using our rapid sequencing and analysis protocol. All results are comparable to conventional 16S rDNA sequencing results using an IonPGM sequencer. Our results suggest that rapid sequencing and bacterial composition determination are possible within 2 hours after obtaining a DNA sample.
Wells, Bryan J; Roberts, Derek J; Grondin, Sean; Navsaria, Pradeep H; Kirkpatrick, Andrew W; Dunham, Michael B; Ball, Chad G
Historical data suggests that many traumatic hemothoraces (HTX) can be managed expectantly without tube thoracostomy (TT) drainage. The purpose of this study was to identify predictors of TT, including whether the quantity of pleural blood predicted tube placement, and to evaluate outcomes associated with TT versus expected management (EM) of traumatic HTXs. A retrospective cohort study of all trauma patients with HTXs and an Injury Severity Score (ISS) ≥12 managed at a level I trauma centre between April 1, 2005 and December 31, 2012 was completed. Mixed-effects models with a subject-specific random intercept were used to identify independent risk factors for TT. Logistic and log-linear regression were used to compute odds ratios (ORs) for mortality and empyema and percent increases in length of hospital and intensive care unit stay between patients managed with TT versus EM, respectively. A total of 635 patients with 749 HTXs were included in the study. Overall, 491 (66%) HTXs were drained while 258 (34%) were managed expectantly. Independent predictors of TT placement included concomitant ipsilateral flail chest [OR 3.03; 95% confidence interval (CI) 1.04-8.80; p=0.04] or pneumothorax (OR 6.19; 95% CI 1.79-21.5; p<0.01) and the size of the HTX (OR per 10cc increase 1.12; 95% CI 1.04-1.21; p<0.01). Although the adjusted odds of mortality were not significantly different between groups (OR 3.99; 95% CI 0.87-18.30; p=0.08), TT was associated with a 47.14% (95% CI, 25.57-69.71%; p<0.01) adjusted increase in hospital length of stay. Empyemas (n=29) only occurred among TT patients. Expectant management of traumatic HTX was associated with a shorter length of hospital stay, no empyemas, and no increase in mortality. Although EM of smaller HTXs may be safe, these findings must be confirmed by a large multi-centre cohort study and randomized controlled trials before they are used to guide practice. Copyright © 2015 Elsevier Ltd. All rights reserved.
Simonsen, Lone; Taylor, Robert J; Schuck-Paim, Cynthia; Lustig, Roger; Haber, Michael; Klugman, Keith P
In March 2010, 13-valent pneumococcal conjugate vaccine (PCV13) replaced the seven-valent vaccine in the USA. We assessed the effect of PCV13 use on pneumococcus-related admissions to hospital 2 years after the vaccine was introduced, when coverage in children younger than age 5 years had reached 54%. We used data from a private inpatient discharge record database. We extracted age-specific data for admissions to hospital per month (July 1-June 30) for all-cause pneumonia, invasive pneumococcal disease, non-invasive pneumococcal pneumonia, and empyema (all coded by International Classification of Diseases 9) for 2005-12. We also extracted data for urinary tract infection and hospital admission for any reason as control outcomes. We assessed incidences of hospital admission before and after the introduction of PCV13 and used a negative binomial multiple regression model to estimate how much of the change in hospital admissions could be attributed to the vaccine. Our model results showed that PCV13 was associated with significant reductions in hospital admissions for all-cause pneumonia for some children (21% [95% CI 14-28] in children aged <2 years, 17% [7-27] in those aged 2-4 years) and for empyema (50% [95% CI 22-68] for children age <2 years, 46% [21-64] for 2-4 years, and 37% [13-54] for 5-17 years). All-cause pneumonia was significantly reduced in adults aged 18-39 years (12% (6-17) but not for other adult age groups. The vaccine also reduced admissions for invasive pneumococcal pneumonia and non-invasive pneumococcal or lobar pneumonia in children and adults, indicating herd protection, although the reduction was only significant in some age groups. Only 2 years into the US programme, PCV13 significantly reduced residual invasive and non-invasive pneumococcal hospital admissions in children younger than 5 years, as well as in some adult age groups. Our study design captured the total prevented hospital burden (directly and indirectly by herd protection) and
Newman, Michael Joseph
The patient was an otherwise usually fit and well 25-year-old man who presented to A&E department in extremis. The initial working diagnosis was a tension pneumothorax, and he was subsequently treated with needle thoracocentesis causing a release of air. A chest radiograph was taken, after which a chest drain was inserted. Bilious fluid was drained from the chest drain. The patient was taken for an emergency CT, which demonstrated a Bochdalek diaphragmatic hernia, with the spleen and bowel found to be causing a near total left lung collapse. He was taken to the theatre to return the bowel to the correct anatomical position, in addition to undergoing a sleeve gastrectomy, and diaphragmatic defect repair. The patient has had a complex and protracted recovery in the intensive therapy unit (ITU) with complications including wound dehiscence, gastrectomy leak requiring additional surgical repair, fluid overload and bilateral pleural empyema.
Newman, Michael Joseph
The patient was an otherwise usually fit and well 25-year-old man who presented to A&E department in extremis. The initial working diagnosis was a tension pneumothorax, and he was subsequently treated with needle thoracocentesis causing a release of air. A chest radiograph was taken, after which a chest drain was inserted. Bilious fluid was drained from the chest drain. The patient was taken for an emergency CT, which demonstrated a Bochdalek diaphragmatic hernia, with the spleen and bowel found to be causing a near total left lung collapse. He was taken to the theatre to return the bowel to the correct anatomical position, in addition to undergoing a sleeve gastrectomy, and diaphragmatic defect repair. The patient has had a complex and protracted recovery in the intensive therapy unit (ITU) with complications including wound dehiscence, gastrectomy leak requiring additional surgical repair, fluid overload and bilateral pleural empyema. PMID:24835806
Ahmed, Liju; Ip, Hugh; Rao, Deepak; Patel, Nishil; Noorzad, Farinaz
Malignant pleural effusions cause significant morbidity, but there is no gold standard minimally invasive treatment. A new therapeutic approach combines talc pleurodesis and indwelling pleural catheters (IPCs) to enable outpatient management. This case series summarizes the safety and efficacy data of all patients (24) with a symptomatic malignant pleural effusion who underwent talc pleurodeses via IPCs between December 2010 and July 2013. Successful pleurodesis was achieved in 22 procedures (92%). There was one empyema, one hydropneumothorax, one recurrent effusion, and two minor complications: one drain site wound infection and one complaint of chest pain. Twenty-two procedures (92%) were performed in the outpatient setting. This report confirms the safety and efficacy of administering talc slurry through IPCs in an outpatient setting. Studies in a larger cohort are necessary to define the role of this novel approach in the treatment algorithm of patients with this condition.
Narasimhan, Ajay; Ayyanathan, Shivanraj; Krishnamoorthy, (Late) Rajavenkatesh
A 14-year-old boy came to our outpatient department with pleuritic chest pain and dyspnea. He was found to have a loculated empyema on the right side. He was taken up for surgery and decortication was done. He developed air leak in the postoperative period. When the air leak did not settle until the 10th day, we decided to attach the atrium Pneumostat™, a modified version of the Heimlich valve to his Intercostal drainage tube and sent him home. On further follow-up, his lung expanded, and ICD could be removed. The patient remains well until the current follow-up. We present this case in an attempt to change the perceptions about various options available to drain the chest. The Heimlich valve appears to be a more compliant option than the conventional underwater seal drainage in terms of early mobility, reduced length of stay, and patient compliance. PMID:28144064
Vyhnánek, F; Fanta, J; Lisý, P; Vojtísek, O; Cáp, F
Based on the group of 22 patients operated on for a blunt injury of the thorax a diagnostic-therapeutic algorithm was evaluated in the procedure of the treatment of a severe trauma of the thorax. Acute thoracotomy or laparotomy was performed in 17 patients and in 5 of them thoracotomy was indicated only after some time interval. In the patients with acute surgery the indication was a rupture of diaphragm, massive hemotorax in case of lung laceration of bleeding from thoracic wall, rupture of bronchus and an associated injury of intra-abdominal parenchymal organs. Thoracotomy was after some time interval performed in case of empyema of thorax, post-injury paresis of diaphragm and residual hematoma in the lung parenchyma. Key words: blunt injury of thorax, diagnostic-therapeutic algorithm, indication to an acute or postponed operation.
Zisis, Charalambos; Tsirgogianni, Katerina; Lazaridis, George; Lampaki, Sofia; Baka, Sofia; Mpoukovinas, Ioannis; Karavasilis, Vasilis; Kioumis, Ioannis; Pitsiou, Georgia; Katsikogiannis, Nikolaos; Tsakiridis, Kosmas; Rapti, Aggeliki; Trakada, Georgia; Karapantzos, Ilias; Karapantzou, Chrysanthi; Zissimopoulos, Athanasios; Zarogoulidis, Konstantinos
A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters. In the current review we will focus on the chest drain systems that are in use. PMID:25815304
Grisar, Koenraad; Maes, Honorine; Politis, Constantinus
We report the case of a 65-year-old man presenting with generalised seizures after developing a right frontal brain abscess. Stereotactic aspiration and subsequent matrix assisted laser desorption/ionisation time-of-flight analyzer (MALDI-TOF) spectrometry revealed Porphyromonas gingivalis as the only causative anaerobe microorganism. Secondary incision and drainage was required due to neurological deterioration with increased dimensions of the abscess, intracranial pressure and formation of a subdural occipitoparietal empyema. Oral imaging was positive for apical periodontitis of multiple elements; therefore, the remaining dentition was removed. Targeted antibiotic treatment included intravenous ceftriaxone and ornidazole. The patient was discharged to our revalidation unit 59 days after admission to make a full recovery. To the best of our knowledge, this is the sixth reported case of P. gingivalis causing an intracranial abscess and the third case of a true intracerebral parenchymal abscess caused by this bacterium. PMID:28228396
Cesur, Salih; Arabaci, Hakan; Sözen, Tuncay Hasip; Tekeli, Emin
Intracranial tuberculoma is one of the most serious complications of tuberculous meningitis. In this report, two patients who develop intracranial tuberculoma as a complication of tuberculous meningitis have been presented. The first patient was a 35 years old male patient who were still been in therapy for cavitary tuberculosis. The other one was 42 years old male patient and have had treated for subdural empyema two years ago. There was no positivity in both of the cerebrospinal fluid (CSF) specimens of the patients by Gram and Erlich Ziehl Neelsen stained preparations, while the CSF sample of the first case yielded Mycobacterium tuberculosis in culture. The tuberculoma diagnosis of these patients managed by the help of computerized tomography (CT) and nuclear magnetic resonance imaging (NMR) methods. As a result, it was thought that CT and NMR techniques have a great role in the diagnosis and management of complications in tuberculous meningitis patients.
Marimón, José María; Morales, María; Cilla, Gustavo; Vicente, Diego; Pérez-Trallero, Emilio
To study the etiology and the utility of new molecular methods in the diagnosis of complicated pneumonia with empyema. Bacteria and viruses detection was performed by several traditional and molecular methods in the pleural fluid (PF) of 60 patients (38 children) with community-acquired pneumonia (CAP). Despite prior antimicrobial therapy in 49 (81.7%) CAP patients, an etiological diagnosis could be established in 41 (68.3%), 35 being (58.3%) Streptococcus pneumoniae. PF culture was positive in only 6 patients but each molecular test detected more than 82% of cases. Traditional culture methods have poor diagnostic sensitivity in PF because most CAP patients are under antimicrobial therapy when it is obtained. S. pneumoniae detection by molecular methods highly improves diagnosis.
Askitopoulou, Helen; Stefanakis, Georgios; Astyrakaki, Elisabeth E; Papaioannou, Alexandra; Agouridakis, Panagiotis
The collected works οf Hippocrates include a wealth of references to emergencies and acute conditions; if the physician could treat these, he would be considered superior to his colleagues. Works most relevant to current Emergency Medicine are presented. They indicate Hippocrates' remarkable insight and attention to the value of close observation, meticulous clinical examination, and prognosis. Hippocrates and his followers disdained mystery and were not satisfied until they had discovered a rational cause to diseases. They assigned great significance to distressing signs and symptoms - the famous Hippocratic face, the breathing pattern, pain, seizures, opisthotonus - pointing to a fatal outcome, which they reported to their patient. The principles of treatment of emergencies, such as angina, haemorrhage, empyema, ileus, shoulder dislocations and head injuries, are astonishingly similar to the ones used nowadays.
Cheyne, G; Runau, F; Lloyd, D M
Right upper quadrant pain is a common presenting complaint to the general and hepatobiliary surgical team. Differential diagnoses include gallstones, cholecystitis, liver and pancreatic pathology. A 64-year-old man presented to our general surgical unit with right upper quadrant pain and deranged liver function tests. He underwent ultrasonography several times as well as magnetic resonance cholangiopancreatography (MRCP) in pursuit of hepatobiliary pathology. However, it was the identification of an empyema on MRCP that led to computed tomography of the thorax and the eventual discovery of the cause of the pain: a paraspinal abscess causing T10/T11 discitis. Right upper quadrant pain and deranged liver function tests justify hepatobiliary investigation. Nevertheless, after several negative tests, the differential diagnoses should be broadened and referred pain considered.
Bali, Rishi Kumar; Sharma, Parveen; Gaba, Shivani; Kaur, Avneet; Ghanghas, Priya
Life-threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. Complications include airway obstruction, mediastinitis, necrotizing fascitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre's syndrome, cerebral abscess, orbital abscess, and osteomyelitis. The incidence of these “space infections” has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur. This study reviews complications of odontogenic infections. The search done was based on PubMed and Google Scholar, and an extensive published work search was undertaken. Advanced MEDLINE search was performed using the terms “odontogenic infections,” “complications,” and “risk factors.” PMID:27390486
Järvinen, A; Mattila, T; Appelqvist, P; Meurala, H; Mattila, S
The incidence of postoperative cardiac disturbances and the value of prophylactic digitalization were studied retrospectively in 143 patients undergoing pneumonectomy for carcinoma of the lung. Cardiac arrhythmias occurred in 29% and tachycardia episodes in 30% of the patients. The incidence of myocardial infarction was 2%. Operative mortality was 4%. The cardiac disturbances developed more often after left than after right pneumonectomy. The age of the patients, a history of angina pectoris or hypertension did not markedly increase the incidence of cardiac disturbances, neither did operative factors, such as pericardiotomy, left atrial resection, major bleeding nor postoperative empyema. Prophylactic digitalization significantly reduced postoperative cardiac disorders, their frequency being 33% in the group of patients who received prophylactic digitalis compared with 65% in the group that did not.
Kanakis, Meletios A; Misthos, Panagiotis A; Tsimpinos, Michalis D; Rapti, Nicoletta G; Chatzis, Andrew C; Lioulias, Achilleas G
Patients presenting with a sudden drop in the pleural fluid level after a pneumonectomy in the absence of a recognizable bronchopleural fistula (BPF) have been classified as cases of benign emptying of the post-pneumonectomy space (BEPS). A retrospective study of 1378 pneumonectomies identified 4 cases of BEPS (0.29%). The patients were men; median age 64 years and all had undergone a right pneumonectomy. The median time at diagnosis was 31 days postoperatively and the median follow-up time was 31 months. None of the patients experienced a documented BPF or empyema. Although BEPS is an extremely rare complication, early recognition and close patient monitoring will prevent unnecessary interventional strategies.
Molnar, Tamas F
Thoracoscopic surgery without or with video assistance (VATS) is simpler and easier to learn as it seems to be. Potential benefits of the procedure in rural surgical environment are outlined while basic requirements and limitations are listed. Thoracoscopy kit, thoracotomy tray at hand, patient monitoring, proper drainage system, pain control and access to chest physiotherapy are the basic requirements. Having headlight, bronchoscope, Ligasure and mechanical staplers offer clear advantages but they are not indispensable. Exploration and evacuation of pleural space, pleurodesis, surgery for Stage I and II thoracic empyema are evidenced fields of VATS procedures. Some of the cases can be performed under controlled local anesthesia. Acute chest trauma cannot be recommended for VATS treatment. Lung cancer is out of the scope of rural surgery.
Siqueira, Fabiolla; Kelly, Traci
Refractory ascites is defined as ascites that does not recede or that recurs shortly after therapeutic paracentesis, despite sodium restriction and diuretic treatment. To date, there is no approved medical therapy specifically for refractory ascites. Management of these patients is based upon procedures such as large-volume paracentesis and transjugular intrahepatic portosystemic shunts (TIPS), which temporarily alleviate symptoms but are not curative. These patients have a poor prognosis and are at risk for a series of complications that are associated with the condition or are secondary to therapy. The most common complications include spontaneous bacterial peritonitis, hepatic hydrothorax, spontaneous bacterial empyema, and umbilical hernia. The predicted survival rate is as low as 50% at 1 year, and prognosis worsens as patients present with comorbidities such as hepatorenal syndrome, renal failure, and hepatocellular carcinoma. The only curative treatment is liver transplantation, though current studies have shown that TIPS also increases survival.
Alonso, José Castellote
Hepatic hydrothorax is the paradigmatic pleural effusion in liver cirrhosis. It is defined as a pleural effusion in a patient with portal hypertension and no cardiopulmonary disease. The estimated prevalence of this complication in patients with liver cirrhosis is 5 to 6%. Its pathophysiology involves movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects. Thoracentesis and pleural fluid analysis are necessary for diagnosis. Initial management consists of sodium restriction, diuretics, and therapeutic thoracentesis. A transjugular intrahepatic portosystemic shunt may provide a bridge prior to liver transplantation. Spontaneous bacterial empyema is the infection of a preexisting hydrothorax. The more frequent bacteria involved are ENTEROBACTERIACEAE and gram-positive cocci. Antibiotic therapy is the cornerstone of therapy. This article reviews etiology, clinical manifestations, and therapy of these two complications of liver cirrhosis and portal hypertension.
Chang, Ming-Yu; Chang, Ming-Ling; Wu, Chang-Teng
A seven-month-old infant was admitted to our hospital with a 1-wk history of shortness of breath, dysphagia, and fever. Diagnosis of esophageal perforation following fish vertebra ingestion was made by history review, pneumomediastinum and an irregular hyperdense lesion noted in initial chest radiogram. Neck computed tomography (CT) confirmed that the foreign body located at the cricopharyngeal level and a small esophageal tracheal fistula was shown by esophagogram. The initial response to treatment of fish bone removal guided by panendoscopy and antibiotics administration was poor since pneumothorax plus empyema developed. Fortunately, the patient's condition finally improved after decortication, mediastinotomy and perforated esophagus repair. To our knowledge, this is the first case report of esophageal perforation due to fish bone ingestion in infancy. In addition to particular caution that has to be taken when feeding the innocent, young victim, it may indicate the importance of surgical intervention for complicated esophageal perforation in infancy.
Yildirim, Inci; Shea, Kimberly M.
SYNOPSIS Universal immunization of infants and toddlers with PCVs over the past 15 years has dramatically altered the landscape of pneumococcal disease. Decreases in IPD, all cause pneumonia, empyema, mastoiditis, acute otitis media and complicated otitis media have been reported from multiple countries where universal immunization has been implemented. The introduction of the vaccine has also led to expanded understanding of pneumococcal disease; observations have confirmed that most pneumococci are transmitted from children to adults, not all pneumococcal serotypes are equal in terms of common clinical syndromes, likelihood of antibiotic resistance, or likelihood of progression to disease once colonization occurs. Children with comorbid conditions have higher rates of pneumococcal disease and increased case fatality rates compared to otherwise healthy children, and protection for the most vulnerable pediatric patients will require new strategies to address the underlying host susceptibility and the expanded spectrum of serotypes observed. PMID:26610421
Kim, Hongsun; Cho, Jong Ho; Sonn, Chung-Hee; Kim, Jae-Won; Choi, Yul; Lee, Jinseon; Kim, Jhingook
The identification of circulating tumor cells (CTCs) is clinically important for diagnosing cancer. We have previously developed a size-based filtration platform followed by epithelial cell adhesion molecule immunofluorescence staining for detecting CTCs. To characterize CTCs independently of cell surface protein expression, we incorporated a chromosomal fluorescence in situ hybridization (FISH) assay to detect abnormal copy numbers of chromosomes in cells collected from peripheral blood samples by the size-based filtration platform. Aneuploid cells were detected in the peripheral blood of patients with lung cancer. Unexpectedly, aneuploid cells were also detected in the control group, which consisted of peripheral blood samples from patients with benign lung diseases, such as empyema necessitatis and non-tuberculous mycobacterial lung disease. These findings suggest that chromosomal abnormalities are observed not only in tumor cells, but also in benign infectious diseases. Thus, our findings present new considerations and bring into light the possibility of false positives when using FISH for cancer diagnosis. PMID:28382274
Spontaneous esophageal perforation is a rare and life-threatening disorder. Failure to diagnosis within the first 24-48 hours of presentation portends a poor prognosis. A patient with mixed connective tissue disease (MCTD) on low-dose prednisone and methotrexate presented moribund with chest and shoulder pain, a left hydropneumothorax, progressive respiratory failure and shock. Initial management focussed on presumed community acquired pneumonia (CAP) in a patient on immunosuppressants. Bilateral yeast empyemas were treated and attributed to immunosuppression. On day 26, the patient developed mediastinitis, and the diagnosis of esophageal perforation was first considered. A review of the literature suggests that the diagnosis and management of spontaneous esophageal perforation could have been more timely and the outcome less catastrophic. PMID:22279514
Mirpuri-Mirpuri, P G; Álvarez-Cordovés, M M; Pérez-Monje, A
The subphrenic space is defined as the area below the diaphragm and above the transverse colon. Most abscesses are due to direct subphrenic contamination associated with, surgery, local disease, or trauma, but the cause still remain undefined or unknown. It is a disease rarely diagnosed in primary care. About 55% of subphrenic abscesses are located on the right side, with 25% on the left, and 20% are multiple. These can be extended to the thoracic cavity, which sometimes produce empyema, lung abscess, or pneumonia. The mortality of subphrenic abscess is between 11%-31%, and may be due to uncontrolled infection, malnutrition, and complications of prolonged hospitalization, such as nosocomial infections. Ultrasound or computed tomography-guided percutaneous drainage is now the preferred treatment, combined with antibiotics. Copyright © 2012 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.
Preciado, A; Matthews, B D; Scarborough, T K; Marti, J L; Reardon, P R; Weinstein, G S; Bennett, M
Spillage of gallstones into the peritoneal cavity is a frequent problem during laparoscopic cholecystectomy (as much as 30%) and is frequently dismissed as a benign occurrence. However, several complications associated with spillage of gallstones have been reported recently. Most of these complications presented late after the original procedure, many with clinical pictures not related to biliary etiology, confounding and delaying adequate management. For patients presenting with intraabdominal or thoracic abscesses of unknown etiology, if there is a history of laparoscopic cholecystectomy, regardless of the time interval, certain evaluations should be considered. A sonogram and a CT scan are advisable to detect retained extraluminal gallstones, as most patients will require, not only drainage of fluid collections, but also removal of the stones. A case is described of a patient who presented with a right empyema and transdiaphragmatic abscess 18 months after a laparoscopic cholecystectomy. Treatment included decortication, enbloc resection of the abscess, repair of the diaphragm, and drainage.
Riley, T V
Pleural fluid lactic acid estimations were carried out on 60 samples by gas-liquid chromatography. Lactic acid levels in 12 patients with bacterial pleural infection were statistically significantly higher (mean, 287 mg/dl; range, 135 to 482 mg/dl) than in 18 patients with malignancy (mean, 71 mg/dl; range, 24 to 157 mg/dl) and 30 other patients with pleural effusions (mean, 19 mg/dl; range, 10 to 57 mg/dl). The determination of pleural fluid lactic acid may help in differentiating between empyema and nonbacterial pleural effusions in most cases. It is of particular value when antibiotic therapy has commenced before specimen collection and may be useful for monitoring therapy. PMID:3973003
Molnar, Tamas F
Thoracoscopic surgery without or with video assistance (VATS) is simpler and easier to learn as it seems to be. Potential benefits of the procedure in rural surgical environment are outlined while basic requirements and limitations are listed. Thoracoscopy kit, thoracotomy tray at hand, patient monitoring, proper drainage system, pain control and access to chest physiotherapy are the basic requirements. Having headlight, bronchoscope, Ligasure and mechanical staplers offer clear advantages but they are not indispensable. Exploration and evacuation of pleural space, pleurodesis, surgery for Stage I and II thoracic empyema are evidenced fields of VATS procedures. Some of the cases can be performed under controlled local anesthesia. Acute chest trauma cannot be recommended for VATS treatment. Lung cancer is out of the scope of rural surgery. PMID:19789679
Borro, Paolo; Sumberaz, Alessandro; Testino, Gianni
Even though Gemella morbillorum infection (GMI) is rare in humans, it may nevertheless, cause endocarditis, meningitis, brain abscess, pleural empyema, nephritis, mediastinitis, and--occasionally--liver abscess. We are describing the case of a 64-years-old Caucasian male admitted with fever and abdominal pain. Laboratory parameters revealed inflammation signs, and instrumental examinations showed the presence of diverticula in the ascending colon. Abdominal ultrasound (US) and computer tomography (CT) showed two focal lesions in the right liver lobe. One had the characteristics of a simple cyst; the second was hypoechoic with a low density area, possibly containing necrotic material. US-guided needle biopsy was found negative for neoplastic cells, showing purulent infiltrate. Pus culture was found positive for GMI. Systemic antibiotic therapy coupled with repeated US-guided needle aspiration, induced the resolution of the hepatic abscess. Few cases have been reported of hepatic abscess caused by GMI in immunocompetent non-cirrhotic subjects.
Asensio de la Cruz, O; Blanco González, J; Moreno Galdó, A; Pérez Frías, J; Salcedo Posadas, A; Sanz Borrell, L
Pleural effusion in children is most often due to bacterial pneumonia. Between 0.6 and 2% of pneumonias are complicated by empyema and approximately 40% of children hospitalized with pneumonia have a pleural effusion. In recent years Streptococcus pneumoniae is the most prevalent organism. Treatment is based on the early and judicious use of antibiotics, imaging techniques, thoracocentesis, pleural drainage, fibrinolytics, thoracoscopy and thoracotomy. Indications for early pleural drainage are gross pus, positive Gram stain in pleural fluid, pleural glucose less than 50mg/dL, pleural fluid pH of less than 7 and sonographic evidence of loculations. Local fibrinolytics may decrease the need for surgical treatment, with a success rate between 38 and 100%, according to the effusion stage. Thoracoscopic debridement is useful in the fibrinopurulent stage with loculations, with favorable results in 30-100% of patients, also depending on the effusion stage.
Dong, Chengwei; Wang, Yuxu; Hu, Sanyuan; Du, Futian; Ding, Wei
Acute acalculous cholecystitis has a high mortality rate due to the difficulties in early diagnosis and high rate of complications like empyema, gangrene and perforation. We report a case of 20-year-old male with acute severe pancreatitis, acute renal failure and acute peripancreatic fluid collection who was transferred to our department after blood filtration treatment in ICU. After percutaneous catheter drainage for 20 hours, the patient got a high fever. Computed tomography revealed retroperitoneal colon injury. In this case, percutaneous catheter drainage was performed again and the pus cavity was flushed regularly, after which the patient’s state gradually improved. Unpredictably, septic shock appeared on the 51st day. Repeated computed tomography revealed acute acalculous cholecystitis and abscess formation. After percutaneous transhepatic gallbladder catheterization and drainage, the patient got better gradually. Three months later the retroperitoneal catheter was removed. Four months later, ultrasound examination showed normal gallbladder and the catheter was removed. PMID:26131252
Mayberry, J F; Smart, H L; Atkinson, M
A retrospective survey was made of all the patients resident in the Nottingham area who presented with achalasia between 1959 and 1983. Initial treatment consisted of pneumatic bag dilatation in 26, hydrostatic bag dilatation in one and surgical cardiomyotomy in 22. Those treated by dilatation were older (mean age 52 years) than those treated by cardiomyotomy (mean age 42 years). Seven patients died without receiving active treatment because of old age and infirmity and in 6 this occurred before the introduction of endoscopic dilatation to the area. Initial treatment by cardiomyotomy was associated with a lower recurrence rate than treatment by bag dilatation but with a longer stay in hospital and a higher incidence of complications including empyema, chest infections and oesophageal stricture. PMID:3806541
Narasimhan, Ajay; Ayyanathan, Shivanraj; Krishnamoorthy, Late Rajavenkatesh
A 14-year-old boy came to our outpatient department with pleuritic chest pain and dyspnea. He was found to have a loculated empyema on the right side. He was taken up for surgery and decortication was done. He developed air leak in the postoperative period. When the air leak did not settle until the 10(th) day, we decided to attach the atrium Pneumostat(™), a modified version of the Heimlich valve to his Intercostal drainage tube and sent him home. On further follow-up, his lung expanded, and ICD could be removed. The patient remains well until the current follow-up. We present this case in an attempt to change the perceptions about various options available to drain the chest. The Heimlich valve appears to be a more compliant option than the conventional underwater seal drainage in terms of early mobility, reduced length of stay, and patient compliance.
Hendriks, Jeroen M.; Lauwers, Patrick
Thoracic surgery comprises major procedures which may be challenging, not only from a technical point of view but also regarding anesthetic and postoperative management. Complications are common occurrences which are also related to the comorbidity of the patients. After major lung resections pulmonary and pleural complications are often encountered. In this overview more surgically related complications are discussed, focusing on postpneumonectomy pulmonary edema, thromboembolic disease including pulmonary embolism, prolonged air leak, lobar torsion, persistent pleural space, empyema and bronchopleural fistula. Prevention, timely recognition, and early adequate treatment are key points as complications initially considered to be minor, may suddenly turn into life-threatening events. To this end multidisciplinary cooperation is necessary. Preoperative smoking cessation, adequate pain control, attention to nutritional status, incentive spirometry and early mobilization are important factors to reduce the incidence of postoperative complications. PMID:25806298
Acosta, Jorge Humberto Davila; Rantes, Claudia Isabel Lazarte; Arbelaez, Andres; Restrepo, Feliza; Castillo, Mauricio
Infections of the central nervous system (CNS) are a very common worldwide health problem in childhood with significant morbidity and mortality. In children, viruses are the most common cause of CNS infections, followed by bacterial etiology, and less frequent due to mycosis and other causes. Noncomplicated meningitis is easier to recognize clinically; however, complications of meningitis such as abscesses, infarcts, venous thrombosis, or extra-axial empyemas are difficult to recognize clinically, and imaging plays a very important role on this setting. In addition, it is important to keep in mind that infectious process adjacent to the CNS such as mastoiditis can develop by contiguity in an infectious process within the CNS. We display the most common causes of meningitis and their complications.
Lal, Chitra; Huggins, John Terrill; Sahn, Steven A
Parasitic infections are prevalent in certain parts of the world and may cause pleural involvement, which often goes unrecognized. Common parasites involving the pleura include Entamoeba histolytica, Echinococcus granulosus and Paragonimus westermani. Amebiasis can cause empyema with "anchovy sauce" pus, reactive pleural effusions and bronchopleural fistula with hydropneumothorax. Echinococcosis may result in pleural thickening, pneumothorax, secondary pleural hydatidosis and pleural effusions. Paragonimiasis may cause chylous and cholesterol pleural effusions, pleural thickening and pneumothorax. Less commonly, pulmonary eosinophilia, or Loeffler's syndrome, caused by Ascaris lumbricoides, Ancylostoma duodenale and Necator americanus and tropical pulmonary eosinophilia caused by Wuchereria bancrofti and Brugia malayi may involve the pleura. This article provides a comprehensive review of parasitic infections involving the pleura. A high index of suspicion in the appropriate clinical setting is required to facilitate prompt diagnosis and treatment of these diseases.
Belanger, Adam R; Nguyen, Kimtuyen; Osman, Umar; Gilbert, Christopher R; Allen, Katie; Al Rais, Ahmad Farid; Yarmus, Lonny; Akulian, Jason A
Pleural effusions are considered rare in cystic fibrosis (CF) patients. There is a paucity of available information in the literature concerning the nature and significance of pleural effusions in non-transplanted CF patients. We conducted a multicenter retrospective evaluation of non-transplanted adult CF patients. Given the small sample size, only descriptive statistics were performed. A total of 17 CF patients with pleural effusion were identified, of whom 9 patients underwent thoracentesis. The crude incidence of pleural effusion was 43 per 10,000 person-years in hospitalized CF patients at large CF centers. All sampled effusions were inflammatory in nature. All samples submitted for culture grew at least one organism. Pleural effusions are rare in adult non-transplanted CF patients. These fluid collections appear to be quite inflammatory with a higher rate of empyema than in the general population. Copyright © 2016 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.
Kaya, Safak; Ay, Nurettin; Baysal, Birol; Bahadir, Mehmet Veysi; Onur, Arzu; Duymus, Recai
Inflammation of the gallbladder without evidence of calculi is known as acute acalculous cholecystitis (AAC). AAC is frequently associated with gangrene, perforation, and empyema. Due to these associated complications, AAC can be associated with high morbidity and mortality. Medical or surgical treatments can be chosen according to the general condition of the patient, underlying disease and agent. Particularly in acute acalculous cholecystitis cases, early diagnosis and early medical treatment have a positive effect on the patient and protect them from surgical trauma. ACC is a rare complication of acute viral hepatitis A. Herein, we present an adult patient of acalculous cholecystitis due to acute viral hepatitis A. She responded to the conservative management. PMID:24106622
Maeda, Sumiko; Sado, Tetsu; Sakurada, Akira; Okada, Yoshinori; Kondo, Takashi
Negative-pressure wound therapy is a newly developed, noninvasive technique to manage a wide variety of wounds. This novel therapy was successfully used to heal the wound after open-window thoracostomy without surgical closure. A 46-year-old woman was admitted to hospital because of a painful mass on the right side of her chest. Radiological findings revealed an abscess on the right chest wall that had ruptured into the right lung and caused empyema. Antibiotic therapy did not yield sufficient improvement. Open-window thoracostomy was performed to achieve a sterile pleural space, and negative-pressure wound therapy was then applied. The pleural space was reduced, and the patient was discharged home with self-administered wound care. The wound healed completely in 5 months without any need for surgical closure.
Guillén, A; Brell, M; Cardona, E; Claramunt, E; Costa, J M
Pott's puffy tumour is an infrequent entity characterised by one or more subperiosteal abscesses associated with frontal bone osteomyelitis. Although cases in patients of all ages have been reported, teenagers are the most frequently affected. Early diagnosis and aggressive treatment are essential because of the high risk of severe neurological complications, such as epidural abscess, subdural empyema, and secondary septic thrombosis of the dural sinuses. This paper describes the case of a patient with a subperiosteal abscess resulting from sinusitis, with orbital and intracranial extension, and subsequent neurological complications. Despite modern methods of diagnosis and treatment, 13 new cases have been published in the last 5 years; in at least 3 (23%) of these cases there were serious neurological complications. Upper respiratory infections and sinusitis are leading causes of visits to the emergency department in the paediatric age group; however, no risk factors for poor outcome have so far been identified in any of these patients.
Deganello, Annamaria; Rafailidis, Vasileios; Sellars, Maria E; Ntoulia, Aikaterini; Kalogerakou, Kleanthi; Ruiz, Gary; Cosgrove, David O; Sidhu, Paul S
Pediatric pneumonia can be complicated by necrotizing pneumonia or a parapneumonic effusion either in the form of an empyema or a clear effusion. Ultrasonography (US) and computed tomography represent well-established modalities for evaluation of complicated pediatric pneumonia. Contrast-enhanced ultrasound (CEUS) was recently introduced and is gaining increasing acceptance in pediatric imaging. In this case series, we present our initial experience with both intravenous and intracavitary use of CEUS in children with complicated pneumonia. Intravenous CEUS accurately and confidently showed necrotizing pneumonia and delineated pleural effusions, whereas intracavitary CEUS accurately identified the chest catheter location and patency and showed the presence of loculations, suggesting the use of fibrinolytics. © 2017 by the American Institute of Ultrasound in Medicine.
Ramos, José M; Mateo, Ignacio; Vidal, Inmaculada; Rosillo, Eva M; Merino, Esperanza; Portilla, Joaquín
To describe the spectrum of infections caused by Rothia mucilaginosa. Retrospective study of 20 cases diagnosed with R. mucilaginosa from 2009 to 2012. Pulmonary infection was the most frequent clinical presentation (n=14, 70%): bronchiectasis infected (10), followed by pleural empyema (2), pneumonia (1) and acute bronchitis (1). Two episodes were of gastrointestinal origin: cholangitis secondary to biliary drainage and secondary peritonitis. Two episodes included bacteremia in patients with hematological malignancy. One patient had a surgical wound infection with bacteremia, and another had a bacteremic urinary tract infection in a patient with nephrostomy. R. mucilaginosa may be responsible for infections of the lower respiratory tract in predisposed patients. Copyright © 2013 Elsevier España, S.L. y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.
Trigui, Walid; Le Pimpec-Barthes, Françoise; Shaker, Walid; Lang-Lazdunski, Loïc; Riquet, Marc
The simultaneous occurrence of bronchopleural fistula (BPF) and esophagopleural fistula (EPF) after pneumonectomy is very rare. We describe a 60-year-old man who developed empyema associated with bronchopleural fistula as a complication of a right pneumonectomy. Initial chest tube drainage and antibiotic therapy were ineffective. Five months later ingested food particles appeared in the drainage fluid. Esophagoscopy revealed an esophageal fistula of 10 mm in diameter. After nutritional support by feeding jejunostomy both BPF and EPF were repaired by subscapular muscle myoplasty and extensive thoracoplasty through a right thoracotomy. Endoscopic examination performed 1 month after surgery showed complete closure of both fistulas and 9 months after surgery the patient was eating and gaining weight. The patient's death was due to aspiration pneumonia of another origin.
De Bast, Y; Appoloni, O; Firket, C; Capello, M; Rocmans, P; Vincent, J L
Ludwig's angina is a rare infectious condition originating in the oropharyngeal region, most commonly from the teeth. The principal symptoms consist of cervical pain, dyspnea, dysphagia, symmetrical neck swelling and fever. Serious complications include respiratory collapses, mediastinitis, pleural empyema, pericarditis and pericardial tamponade, and may result in the death of the patient. The most useful investigations in patients with suspected Ludwig's angina are clinical assessment, a cervico-thoracic CT-scan to determine the extent of the lesions, microbiological examination and panoramic radiography to detect possible dental focuses of infection. Treatment consists of ensuring adequate ventilation by securing the upper airways, broad spectrum antibiotic therapy, eradication of the source of infection, and often early surgical decompression may be necessary. Rapid diagnosis and appropriate treatment can reduce the mortality rate to 10%.
Shah, Rasik; Reddy, A Suyodhan; Dhende, Nitin P
Thoracoscopic surgery, i.e., video assisted thoracic surgery (VATS) has been in use in children for last 98 years. Its use initially was restricted to the diagnostic purposes. However, with the improvement in the optics, better understanding of the physiology with CO2 insufflation, better capabilities in achieving the single lung ventilation and newer vessel sealing devices have rapidly expanded the spectrum of the indication of VATS. At present many complex lung resections, excision of mediastinal tumors are performed by VATS in the experienced centre. The VATS has become the standard of care in empyema, lung biopsy, Mediastinal Lymphnode biopsy, repair of diaphragmatic hernia, etc. The article discusses the indications of VATS, techniques to achieve the selective ventilation and surgical steps in the different surgical conditions in children. PMID:19789677
Chang, Ming-Yu; Chang, Ming-Ling; Wu, Chang-Teng
A seven-month-old infant was admitted to our hospital with a 1-wk history of shortness of breath, dysphagia, and fever. Diagnosis of esophageal perforation following fish vertebra ingestion was made by history review, pneumomediastinum and an irregular hyperdense lesion noted in initial chest radiogram. Neck computed tomo-graphy (CT) confirmed that the foreign body located at the cricopharyngeal level and a small esophageal tracheal fistula was shown by esophagogram. The initial response to treatment of fish bone removal guided by panendoscopy and antibiotics administration was poor since pneumothorax plus empyema developed. Fortunately, the patient’s condition finally improved after decortication, mediastinotomy and perforated esophagus repair. To our knowledge, this is the first case report of esophageal perforation due to fish bone ingestion in infancy. In addition to particular caution that has to be taken when feeding the innocent, young victim, it may indicate the importance of surgical intervention for complicated esophageal perforation in infancy. PMID:17131491
Wüst, J; Lucchini, G M; Lüthy-Hottenstein, J; Brun, F; Altwegg, M
Beginning in 1990, gram-positive rods resembling Actinomyces pyogenes were found with increasing frequency in mixed cultures from various infectious processes, most of them from patients with otitis, empyema, pilonidal cysts, perianal abscesses, and decubitus ulcers. Ribotyping and hybridization showed that these gram-positive rods could be divided into five groups not related to known Actinomyces species. Biochemical markers for reliable differentiation into these groups, however, could not be found. Therefore, naming new species is not warranted unless parameters are discovered that allow identification without DNA hybridization. These gram-positive rods have been isolated only in mixed cultures with anaerobes, Staphylococcus aureus, Streptococcus "milleri," enterococci, and gram-negative rods. Their exact role in these possibly synergistic infections needs further investigation. Images PMID:8501213
Redding, Gregory J.; Carter, Edward R.
The most common clinical suppurative lung conditions in children are empyema, lung abscess, and bronchiectasis, and to a less often necrotizing pneumonia. Until recently, bronchiectasis was the most common form of persistent suppurative lung disease in children. Protracted bacterial bronchitis is a newly described chronic suppurative condition in children, which is less persistent but more common than bronchiectasis (1). In addition, the term “chronic suppurative lung disease” has been used recently to describe the clinical features of bronchiectasis when the radiographic features needed to make a diagnosis of bronchiectasis are absent. Webster’s New College Dictionary defines suppuration as the process of forming and/or discharging pus. Pus is a body fluid resulting from intense inflammation in response to infection that leads to neutrophil influx and apoptosis, microbial clearance, and often necrosis of nearby tissue. Pus is primarily composed of white blood cell debris. PMID:28289673
Singal, Rikki; Mittal, Amit; Gupta, Samita; Singh, Bir; Jain, Parul
Perforation of the gall bladder with cholecystohepatic communication is a rare cause of liver abscess. We are reporting here six rare cases of gall bladder perforation with variable clinical presentations. Most patients presented with right hypochondrium pain and fever but two patients presented with only pain in the abdomen. Ultrasonography (USG) and Computed Tomography (CT) were used for diagnosis. The patients were also successfully treated. There was a gall bladder perforation with cholecystohepatic communication, leading to liver abscess formation in most cases on USG and CT. The final diagnosis was confirmed on surgery. The perforation of the gall bladder which leads to liver abscess is a rare complication of acute, chronic or empyema gall bladder. USG and CT scans are the most important diagnostic tool in diagnosing this rare complication. In the set up, where advanced options are not available, the only treatment of choice is the conservative one or surgery, according to the status of the patients.
Van der Cruyssen, Frederic; Grisar, Koenraad; Maes, Honorine; Politis, Constantinus
We report the case of a 65-year-old man presenting with generalised seizures after developing a right frontal brain abscess. Stereotactic aspiration and subsequent matrix assisted laser desorption/ionisation time-of-flight analyzer (MALDI-TOF) spectrometry revealed Porphyromonas gingivalis as the only causative anaerobe microorganism. Secondary incision and drainage was required due to neurological deterioration with increased dimensions of the abscess, intracranial pressure and formation of a subdural occipitoparietal empyema. Oral imaging was positive for apical periodontitis of multiple elements; therefore, the remaining dentition was removed. Targeted antibiotic treatment included intravenous ceftriaxone and ornidazole. The patient was discharged to our revalidation unit 59 days after admission to make a full recovery. To the best of our knowledge, this is the sixth reported case of P. gingivalis causing an intracranial abscess and the third case of a true intracerebral parenchymal abscess caused by this bacterium. 2017 BMJ Publishing Group Ltd.
Alvis Miranda, Hernando; Castellar-Leones, Sandra Milena; Elzain, Mohammed Awad; Moscote-Salazar, Luis Rafael
Brain abscess (BA) is defined as a focal infection within the brain parenchyma, which starts as a localized area of cerebritis, which is subsequently converted into a collection of pus within a well-vascularized capsule. BA must be differentiated from parameningeal infections, including epidural abscess and subdural empyema. The BA is a challenge for the neurosurgeon because it is needed good clinical, pharmacological, and surgical skills for providing good clinical outcomes and prognosis to BA patients. Considered an infrequent brain infection, BA could be a devastator entity that easily left the patient into dead. The aim of this work is to review the current concepts regarding epidemiology, pathophysiology, etiology, clinical presentation, diagnosis, and management of BA. PMID:24174804
Le Saux, Nicole; Robinson, Joan L
Although immunization has decreased the incidence of bacterial pneumonia in vaccinated children, pneumonia remains common in healthy children. Symptoms of bacterial pneumonia frequently overlap those present with viral infections or reactive airway disease. Optimally, the diagnosis of bacterial pneumonia should be supported by a chest radiograph before starting antimicrobials. Factors such as age, vital signs and other measures of illness severity are critical when deciding whether to admit a patient to hospital. Because Streptococcus pneumoniae continues to be the most common cause of bacterial pneumonia in children, prescribing amoxicillin or ampicillin for seven to 10 days remains the mainstay of empirical therapy for nonsevere pneumonia. If improvement does not occur, consideration should be given to searching for complications (empyema or lung abscess). Routine chest radiographs at the end of therapy are not recommended unless clinically indicated. PMID:26744558
del Campo, J M; Hitado, J; Gea, G; Colmeiro, A; Lanza, A M; Muñoz, J A; Mosquera, J A
The role of mycobacteria in the cavitation of large pneumoconiotic masses is well established. In other cases softness is attributed to an ischaemic or aseptic necrosis. Five cases are described in which cavitation of the pulmonary masses was caused by anaerobic bacteria, confirmed by the growth of such bacterial in cultures after transtracheal or transpleural puncture. Repeated cultures for mycobacteria gave negative results. Two cases were acute, having serious complications such as bronchopleural fistula, empyema, and serious respiratory insufficiency. The role of anaerobes in cavitary pneumoconiosis has not been recognised previously, probably because of the special conditions required to culture these bacteria and the infrequent use of transtracheal puncture in the diagnosis of this entity. The prevalence of anaerobes as agents capable of cavitating pneumoconiotic masses remains to be established. Images PMID:6128024
Rimawi, R H; Shah, K B; Chowdhary, R A; Cook, P P
Human infections with Francisella tularensis can be acquired via numerous routes, including ingestion, inhalation, arthropod bite or direct contact with infected animals. Since 1991, there have been 25 reported cases of tularaemia in North Carolina, most of which were associated with rabbit hunting or cat bites. We present two adults cases of pulmonary and oropharyngeal tularaemia and review the reported cases since 1991-2013. We also present the fifth case of pulmonary empyema. While cavitary pneumonias are primarily treated with drainage, we illustrate a case of cavitary pneumonia associated with tularaemia successfully treated with oral ciprofloxacin after drainage. Tularaemia should be considered in patients with a perplexing radiographic image, animal exposure and lack of response to conventional empiric broad-spectrum antibiotics. Even in serious cases of pneumonic tularaemia, fluoroquinolones may provide a suitable alternative to aminoglycosides. © 2014 Blackwell Verlag GmbH.
[Community acquired pneumonia in children: Treatment of complicated cases and risk patients. Consensus statement by the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Chest Diseases (SENP)].
Moreno-Pérez, D; Andrés Martín, A; Tagarro García, A; Escribano Montaner, A; Figuerola Mulet, J; García García, J J; Moreno-Galdó, A; Rodrigo Gonzalo de Lliria, C; Saavedra Lozano, J
The incidence of community-acquired pneumonia complications has increased during the last decade. According to the records from several countries, empyema and necrotizing pneumonia became more frequent during the last few years. The optimal therapeutic approach for such conditions is still controversial. Both pharmacological management (antimicrobials and fibrinolysis), and surgical management (pleural drainage and video-assisted thoracoscopic surgery), are the subject of continuous assessment. In this paper, the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases have reviewed the available evidence. Consensus treatment guidelines are proposed for complications of community-acquired pneumonia in children, focusing on parapneumonic pleural effusion. Recommendations are also provided for the increasing population of patients with underlying diseases and immunosuppression.
Fabbian, Fabio; De Giorgi, Alfredo; Pala, M; Fratti, Daniela; Contini, Carlo
Mycobacterium fortuitum is a non-tuberculous mycobacterium that can cause pneumonia, abscess and empyema in subjects with predisposing lung diseases. However, pleurisy with effusion is rare. Herein, we report the case of a 74-year-old immunocompetent female patient without apparent risk factors, who suffered haemorrhagic pleural effusion as the main clinical manifestation. Pleural nodules were detected by computed tomography scan, and microbiological analysis revealed M. fortuitum in the absence of other pathogens. The patient was treated with ceftriaxone and ciprofloxacin, and full recovery ensued in 4 weeks. To our knowledge, this is the first reported case of haemorrhagic pleural effusion in an immunocompetent patient without underlying diseases. Although non-tuberculous mycobacterial infections are rarely accompanied by pleural involvement, M. fortuitum should be considered in such cases, especially when microbiology fails to detect the usual pathogens, and when the clinical picture is unclear.
Kerimov, R V; Badalov, R K; Medzhidov, F A; Mamedov, R I
Immediate and long-term outcomes of repeated and multistage operations were analyzed in 190 patients with pulmonary tuberculosis. The aspects of work rehabilitation were studied in these patients. The efficiency of repeated and stage surgical interventions in patients both with disseminated and complicated types of tuberculosis and with pleural empyemas and in those with uncomplicated postoperative disease is 87.5 and 92.2%, respectively. The long-term results indicated that the complete clinical effect preserved in 79.2% of patients. Work rehabilitation was achieved in 64.8% of the examinees in the long-term postoperative period. The use of repeated and stage surgical interventions in patients with pulmonary tuberculosis may rehabilitate a rather large proportion of those operated on, assuming a great socioeconomic significance.
A 25-year-old woman presented with a history of secondary amenorrhoea for the last 3 years, coinciding with her delivery. She delivered at home and had massive postpartum haemorrhage. She was brought in a state of circulatory collapse to the nearest teaching hospital, where she was resuscitated. She developed anaemia, septicaemia and extradural empyema. The complications were managed and the woman improved. Presently, she approached us for infertility. She was investigated and diagnosed with postpartum hypopituitarism, that is, Sheehan's syndrome. Her gonadotrophin levels, luteinising hormone/follicle-stimulating hormone, were normal, serum oestradiol was low and serum prolactin was also on the lower side. She had started with genital atrophy and was given three cycles of cyclic oestrogen +progesterone combination. Ovulation was induced. She conceived and her antenatal period was uneventful. She delivered a full-term baby vaginally. However, she had inadequate lactation after delivery and lost the baby at one-and-a-half months' age due to gastroenteritis.
Al-Faraj, Zahrah H; Hassan, Hoda A; Abdalhamid, Baha A; Al-Abbadi, Mousa A
Understanding the significance of cytopathological tests in evaluating various infectious processes have become very essential nowadays, as it is a safe, fast, and cost-effective procedure. We present a case of a 52-year-old male with Salmonella empyema where the causative organisms were initially identified on cytology, and subsequently confirmed by microbiological culture. Diff-Quik stained smears showed many colorless, slender, fat short bacilli, which were visualized against the blue-gray background of the smear. These bacilli were identified both intracellularly inside the histiocytes and neutrophils cytoplasm as well as extracellularly in the smear background. We consider that this negative image represents the organism and its capsule creating an area that did not take the Diff-Quik stain. The patient was treated accordingly with suitable antibiotics. A brief discussion of this interesting finding in such a rare infection with pertinent literature review is presented.
Merritt, Robert E; Reznik, Scott I; DaSilva, Marcelo C; Sugarbaker, David J; Whyte, Richard I; Donahue, Dean M; Hoang, Chuong D; Smythe, W Roy; Shrager, Joseph B
A fall in the postpneumonectomy fluid level is considered a sign of bronchopleural fistula (BPF) requiring surgical intervention. We have discovered however that in rare asymptomatic patients, this event may not require aggressive surgical treatment. After seeing a case of benign emptying of the postpneumonectomy space (BEPS), we surveyed 28 surgeons to determine its incidence and characteristics. Forty-four cases of BEPS were reported by 23 survey respondents. Among 7 fully documented cases from 4 institutions, we defined the following criteria: the patient must be asymptomatic (no fever, white cell count elevation, or fluid expectoration), negative culture results if fluid sampled (patient not receiving antibiotics), no BPF at bronchoscopy or ventilation scintigraphy scan (or both), and recovery without drainage, or retrospective assessment that the intervention was unnecessary. BEPS occurred between 5 days and 152 days after pneumonectomy (6 cases right pneumonectomy and 1 case left pneumonectomy). Four patients underwent no treatment, 1 patient underwent thoracoscopic exploration (sterile) and closure after antibiotic irrigation, 1 patient underwent thoracoscopic exploration alone, and 1 patient underwent open window thoracostomy (sterile) with eventual closure. In all 7 patients (except the patient who underwent the open window procedure) the space refilled within 8 weeks; no patient experienced a subsequent empyema/BPF. Four patients who met the initial criteria for BEPS went on to experience empyema. The incidence of BEPS appears related to pneumonectomy volume, particularly extrapleural pneumonectomy. Using surgeon volume assumptions, the incidence of BEPS is 0.65%. To our knowledge, BEPS is a previously unreported occurrence. We hypothesize that it results from postoperative intrapleural pressure shifts, with or without a microscopic BPF, that drive fluid out of the pleural space while failing to cause contamination. Awareness of BEPS' existence may allow
Huang, Yuan-Chun; Cheng, Ching-Yuan; Liao, Chiung-Ying; Hsueh, Ching; Tyan, Yeu-Sheng; Ho, Shang-Yun
Patient: Female, 60 Final Diagnosis: Acute phlegmonous esophagogastritis complicated with hypopharyngeal abscess • esophageal perforation Symptoms: Fever • painful swallowing • chest pain Medication: — Clinical Procedure: Drainage • debridement • esophageal reconstruction Specialty: Surgery Objective: Rare disease Background: Acute phlegmonous esophagogastritis is a life-threatening disease that may be combined with serious complications. We present the classical radiological and endoscopic features and treatment strategy of a middle-aged female patient suffering from acute phlegmonous esophagogastritis complicated with hypopharyngeal abscess, esophageal perforation, mediastinitis, and empyema. Case Report: A 60-year-old Taiwanese female presented at our hospital due to fever, fatigue, painful swallowing, and vague chest pain for 5 days. She had a past history of uncontrolled type 2 diabetes mellitus. On physical examination, general weakness, chest pain, odynophagia, and a fever up to 38.9°C were found. Positive laboratory findings included leukocytosis (leukocyte count of 14.58×103/μL, neutrophils 76.8%) and serum glucose 348 mg/dL (HbA1c 11.3%). A diagnosis of acute phlegmonous esophagogastritis with hypopharyngeal abscess was made based on typical computed tomography image features and clinical signs of infection. The patient received empirical antibiotic therapy initially; however, esophageal perforation with mediastinitis and empyema developed after admission. Emergency surgery with drainage and debridement was performed and antibiotics were administered. She was discharged in a stable condition on the 56th day of hospitalization. Six months later, a delayed esophageal reconstruction was performed. The patient has performed well for 9 months to date since the initial diagnosis. Conclusions: Acute phlegmonous esophagogastritis complicated with hypopharyngeal abscess and esophageal perforation is extremely rare, and requires immediate medical
Kong, Victor Y; Sartorius, Benn; Oosthuizen, George V; Clarke, Damian L
Prophylactic antibiotics for tube thoracostomy (TT) for the prevention of post-traumatic empyema (PTE) remain controversial. Literature specifically focusing on the developing world setting is limited. A retrospective study was conducted over a four-year period on patients managed with TT alone in which prophylactic antibiotics was not utilised. We documented the actual incidence of PTE in a high volume trauma service in South Africa. A total of 1002 patients who had TT in the trauma room were eligible for inclusion. Ninety-one percent (912/1002) were males and the mean age for all patients was 26 years (SD 7). Seventy-five percent (755/1002) sustained penetrating trauma (PT), while the remaining 25% (247/1002) sustained blunt trauma (BT). Six hundred and twenty patients (62%) sustained HTXs and the remaining 382 patients (38%) had PTXs. Of the 1002 patients who underwent TT, 15 (1.5%, 95% CI: 0.8-2.5%) developed PTE. The incidence of empyema in those with PT was 1.9% (14/755) and 0.4% (1/247) for BT. This difference was not statistically significant (p=0.166). All 15 patients who developed PTE were males, with a mean age of 31 years (SD 6). All 15 patients had HTX as the initial thoracic pathology. This difference was highly statistically significant when compared to PTX (p=0.002). The mean length of hospital stay was 11 days (SD 7). There were no mortalities in these patients. In our setting where prophylactic antibiotics are not routinely used, the actual incidence of PTE in our population is extremely low. In the absence of further definitive evidence to support its use, routine prophylactic antibiotics for TT is difficult to justify in a developing world setting at present. Copyright © 2015 Elsevier Ltd. All rights reserved.
Shah, Samir S; Ten Have, Thomas R; Metlay, Joshua P
To describe charges associated with primary video-assisted thoracoscopic surgery (VATS) and primary chest tube placement in a multicenter cohort of children with empyema and to determine whether pleural fluid drainage by primary VATS was associated with cost-savings compared with primary chest tube placement. Retrospective cohort study. Administrative database containing inpatient resource utilization data from 27 tertiary care children's hospitals. Patients between 12 months and 18 years of age diagnosed with complicated pneumonia were eligible if they were discharged between 2001 and 2005 and underwent early (within 2 days of index hospitalization) pleural fluid drainage. Method of pleural fluid drainage, categorized as VATS or chest tube placement. Pleural drainage in the 764 patients was performed by VATS (n = 50) or chest tube placement (n = 714). There were 521 (54%) males. Median hospital charges were $36,320 [interquartile range (IQR), $24,814-$62,269]. The median pharmacy and radiologic imaging charges were $5,884 (IQR, $3,142-$11,357) and $2,875 (IQR, $1,703-$4,950), respectively. Adjusting for propensity score matching, patients undergoing primary VATS did not have higher charges than patients undergoing primary chest tube placement. In this multicenter study, we found that the charges incurred in caring for children with empyema were substantial. However, primary VATS was not associated with higher total or pharmacy charges than primary chest tube placement, suggesting that the additional costs of performing VATS are offset by reductions in length of stay (LOS) and requirement for additional procedures. (c) 2009 Wiley-Liss, Inc.
Kobo, O; Nikola, S; Geffen, Y; Paul, M
Streptococcus anginosus Group (SAG) bacteria are common causes of pyogenic infections (PIs). We examined the association between SAG species and the presence of a PI through a retrospective, observational, cohort study, between the years 2009 and 2015. All adults with clinically significant SAG infections in one hospital in Israel were assessed for association between SAG species and the presence of a PI defined as an abscess, empyema, or deep/organ space surgical site infection. Risk factors for PI were assessed using multivariate backward stepwise logistic regression analysis. We identified 263 patients with significant SAG infections, 182 (69%) of which were caused by S. anginosus, 45 (17·1%) by S treptococcus constellatus and 36 (13·7%) by S treptococcus intermedius. The mean age of the patients was 56·8 ± 19·1 years. PIs were identified among 160 (60%) of the patients and were mostly non-bacteraemic (147/160, 91·8%), while most non-PI patients had bacteraemia (70/103, 68%). S. anginosus and S. constellatus were associated with a significantly lower incidence of PI than S. intermedius, OR 0·18 (95% CI 0·06-0·53) and 0·14 (0·04-0·48), respectively. Patients with PI were younger and, in general, had less co-morbidities. S. intermedius was associated with pyogenic non-bacteraemic infections, while S. anginosus and S. constellatus were associated with bacteraemia with no abscess or empyema formation. These data may indicate differences in virulence mechanisms of these SAG bacteria.
Ferreiro, L; Pereiro, T; San José, E; Toubes, M E; Suárez-Antelo, J; Álvarez Dobaño, J M; González Barcala, F J; Rodríguez Núñez, N; Lama, A; Valdés, L
To know the behavior of cellular components of pleural fluid can help focus the differential diagnosis of a pleural effusion. Our objective was to assess their composition in different types of pleural effusions and assess whether it provides relevant clinical information. Observational, cross-sectional and retrospective study in which the cellular components of pleural effusions of different etiology were analyzed. Pleural effusions were classified as neutrophilic, lymphocytic (≥50% of each one of them), eosinophilic (≥10%) or mesothelial (>5%) and were grouped into six diagnostic categories RESULTS: 1.467 patients were studied (354 heart failure; 59 other transudates; 349 paraneumonic; 133 tuberculous; 397 malignant and 175 other exudates). The predominance cell was lymphocytic in heart failure (44,4%), uncomplicated parapneumonic (29,2%), tuberculosis (88%) and malignant (49,6%); neutrophilic in parapneumonic (57%) and malignant (9,6%); eosinophilic in malignant (6,3%) and mesotelial in tuberculosis (12%). The most frequent etiologies with lymphocyte count ≥80% were tuberculosis (35,1%) and malignant (23,3%). Parameters with higher discriminating accuracy were: leukocytes (transudates: AUC 0,835) and percentage of neutrophils (empyemas: AUC 0,906 and complicated parapneumonic+empyemas: AUC 0,907). Nucleated cell counts will help focus the etiology of pleural effusions, since each etiology often have a characteristic cell predominance. The percentage of nucleated cells in pleural fluid not ruled out tuberculosis if there is a high count of mesothelial cells, nor a parapneumonic effusion with lymphocytic predominance, or malignancy with ≥80% lymphocytes. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.
Sustained release of bactericidal concentrations of penicillin in the pleural space via an antibiotic-eluting pigtail catheter coated with electrospun nanofibers: results from in vivo and in vitro studies
Chao, Yin-Kai; Lee, Cheng-Hung; Liu, Kuo-Sheng; Wang, Yi-Chuan; Wang, Chih-Wei; Liu, Shih-Jung
Background Inadequate intrapleural drug concentrations caused by poor penetration of systemic antibiotics into the pleural cavity is a major cause of treatment failure in empyema. Herein, we describe a novel antibiotic-eluting pigtail catheter coated with electrospun nanofibers used for the sustained release of bactericidal concentrations of penicillin in the pleural space. Methods Electrospun nanofibers prepared using polylactide-polyglycolide copolymer and penicillin G sodium dissolved in 1,1,1,3,3,3-hexafluoro-2-propanol were used to coat the surface of an Fr6 pigtail catheter. The in vitro patterns of drug release were tested by placing the catheter in phosphate-buffered saline. In vivo studies were performed using rabbits treated with penicillin either intrapleurally (Group 1, 20 mg delivered through the catheter) or systemically (Group 2, intramuscular injection, 10 mg/kg). Penicillin concentrations in the serum and pleural fluid were then measured and compared. Results In vitro studies revealed a burst release of penicillin (10% of the total dose) occurring in the first 24 hours, followed by a sustained release in the subsequent 30 days. Intrapleural drug levels were significantly higher in Group 1 than in Group 2 (P<0.001). In the former, penicillin concentrations remained above the minimum inhibitory concentration breakpoint throughout the entire study period. In contrast, serum penicillin levels were significantly higher in Group 2 than in Group 1 (P<0.001). Notably, all Group 2 rabbits showed signs of systemic toxicity (paralytic ileus and weight loss). Conclusion We conclude that our antibiotic-eluting catheter may serve as a novel therapeutic option to treat empyema. PMID:26005344
To assess the efficacy and the safety of a single-trocar technique for minimally invasive surgery of the chest in the management of multiple noncomplex thoracic diseases, a prospective study was performed and the results are presented. Between October 1998 and December 2001, 100 patients underwent video-assisted thoracic surgery through a single trocar. The patients were divided into 4 groups as follows: (1) benign, (2) malignant, (3) pleural effusion, and (4) empyema. The following data were analyzed: age, sex, forced vital capacity, forced expiratory volume in 1 second, percentage of the predicted forced expiratory volume in 1 second, type of anesthesia, anesthesia time, surgery time, intraoperative complications, morbidity, chest tube removal, hospital stay, and follow-up. The patient population consisted of 64 men and 36 women with a mean age of 62 years (range 31-92 years). General anesthesia was used in 53 patients (25 double-lumen and 28 single-lumen tube) and local anesthesia and sedation in 47 patients. Talc pleurodesis was performed in 55 patients. Mean operative time was 65 +/- 37 minutes, 48 +/- 18 minutes for simple and 67 +/- 37 minutes (P =.004) for complex pleural effusion. Mean anesthesia time was 102 +/- 85 minutes. Chest tubes were removed after 5 +/- 2 days. Mean overall hospital stay was 6 +/- 3 days, 5 +/- 2 days for benign diseases, 7 +/- 3 days for malignant diseases, and 8 +/- 3 for empyema. Morbidity was present in 19 patients. Two patients had intraoperative bleeding; 1 required a mini-thoracotomy to control it. There was no hospital mortality. Three patients had wound infection, and no patient with malignant diseases had port site metastasis. Video-assisted thoracic surgery through a single trocar is simple, effective, and beneficial for all patients in the diagnosis and treatment of noncomplex diseases of the chest. Furthermore, with this newest type of technologically advanced instrumentation it is possible to carry out simple
Nattusamy, Loganathan; Madan, Karan; Mohan, Anant; Hadda, Vijay; Jain, Deepali; Madan, Neha Kawatra; Arava, Sudheer; Khilnani, Gopi C; Guleria, Randeep
Background: Semi-rigid thoracoscopy is a safe and efficacious procedure in patients with undiagnosed pleural effusion. Literature on its utility from developing countries is limited. We herein describe our initial experience on the utility of semi-rigid thoracoscopy from a tertiary care teaching and referral center in north India. We also perform a systematic review of studies reporting the utility of semi-rigid thoracoscopy from India. Patients and Methods: The primary objective was to evaluate the diagnostic utility of semi-rigid thoracoscopy in patients with undiagnosed exudative pleural effusion. Semi-rigid thoracoscopy was performed under local anesthesia and conscious sedation in the bronchoscopy suite. Results: A total of 48 patients underwent semi-rigid thoracoscopy between August 2012 and December 2013 for undiagnosed pleural effusion. Mean age was 50.9 ± 14.1 years (range: 17–78 years). Pre-procedure clinico-radiological diagnoses were malignant pleural effusion [36 patients (75%)], tuberculosis (TB) [10 (20.83%) patients], and empyema [2 patients (4.17%)]. Patients with empyema underwent the procedure for pleural biopsy, optimal placement of intercostal tube and adhesiolysis. Thoracoscopic pleural biopsy diagnosed pleural malignancy in 30 (62.5%) patients and TB in 2 (4.17%) patients. Fourteen (29.17%) patients were diagnosed with non-specific pleuritis and normal pleura was diagnosed on a pleural biopsy in 2 (4.17%) patients. Overall, a definitive diagnosis of either pleural malignancy or TB was obtained in 32 (66.7%) patients. Combined overall sensitivity, specificity, positive predictive value and negative predictive value of thoracoscopic pleural biopsy for malignant pleural effusion were 96.77%, 100%, 100% and 66.67%, respectively. There was no procedure-related mortality. On performing a systematic review of literature, four studies on semi-rigid thoracoscopy from India were identified. Conclusion: Semi-rigid thoracoscopy is a safe and
de Abreu, Emanuelle Maria Sávio; Machado, Carla Jorge; Pastore Neto, Mario; de Rezende Neto, João Baptista; Sanches, Marcelo Dias
to investigate the effect of standardized interventions in the management of tube thoracostomy patients and to assess the independent effect of each intervention. A chest tube management protocol was assessed in a retrospective cohort study. The tube thoracostomy protocol (TTP) was implemented in August 2012, and consisted of: antimicrobial prophylaxis, chest tube insertion in the operating room (OR), admission post chest tube thoracostomy (CTT) in a hospital floor separate from the emergency department (ED), and daily respiratory therapy (RT) sessions post-CTT. The inclusion criteria were, hemodynamic stability, patients between the ages of 15 and 59 years, and injury severity score (ISS) < 17. All patients had isolated injuries to the chest wall, lung, and pleura. During the study period 92 patients were managed according to the standardized protocol. The outcomes of those patients were compared to 99 patients treated before the TTP. Multivariate logistic regression analysis was performed to assess the independent effect of each variable of the protocol on selected outcomes. Demographics, injury severity, and trauma mechanisms were similar among the groups. As expected, protocol compliance increased after the implementation of the TTP. There was a significant reduction (p<0.05) in the incidence of retained hemothoraces, empyemas, pneumonias, surgical site infections, post-procedural complications, hospital length of stay, and number of chest tube days. Respiratory therapy was independently linked to significant reduction (p<0.05) in the incidence of seven out of eight undesired outcomes after CTT. Antimicrobial prophylaxis was linked to a significant decrease (p<0.05) in retained hemothoraces, despite no significant (p<0.10) reductions in empyema and surgical site infections. Conversely, OR chest tube insertion was associated with significant (p<0.05) reduction of both complications, and also significantly decreased the incidence of pneumonias. Implementation of
Edaigbini, Sunday A; Delia, Ibrahim Z; Aminu, Muhammad B; Orogade, Abosede A; Anumenechi, Ndubuisi; Aliyu, Ibrahim D
Background: Tube thoracostomy is a lifesaving and frequently performed procedure in hospitals where the expertise and necessary tools are available. Where the ideal drainage receptacle is unavailable, the underwater seal device can be improvised with bottled water plastic can especially in emergency situations. Aims and Objectives: To determine the frequencies of the various indications and complications of tube thoracostomy with improvised underwater seal. Materials and Methods: A cross-sectional study with a structured proforma was used for assessment over a 3-year period (May 2010-April 2013). The proforma was filled at the time of the procedure by the performing surgeon and patients were followed up with serial chest X-rays until certified cured. A 1.5 L bottled water container was used as the underwater seal receptacle. The data was analysed with SPSS 15 software program. Results: A total of 167 patients were managed. There were 106 (63.5%) males and 61 (36.5%) females. The mean age was 34.85 ± 16.72 with a range of 1-80 years. The most frequent indication was for malignant/paramalignant effusion, 46 (27.5%). Others were trauma, 44 (26.3%), Parapneumonic effusion, 20 (12%), postthoracotomy 14 (8.4%), empyema thoracis 12 (7.2%), heart disease and tuberculous effusion 11 (6.6%) each, pneumothorax 8 (4.8%) and misdiagnosis 1 (0.6%). A hundred and one (60.5%) of the procedures were performed by registrars, 41 (24.6%) by consultants, house officers 15 (9%) and senior registrars 10 (6%). The overall complication rate was 16.8% with the more frequent complications been empyema (5.6%) and pneumothorax (3.6%). The average duration of tube placement was 13.02 ± 12.362 days and range of 1-110 days. Conclusion: Tube thoracostomy can be a relatively safe procedure with acceptable complication rates even with improvised underwater seal drainage bottles. PMID:25191098
Postoperative antibacterial prophylaxis for the prevention of infectious complications associated with tube thoracostomy in patients undergoing elective general thoracic surgery: a double-blind, placebo-controlled, randomized trial.
Oxman, David A; Issa, Nicolas C; Marty, Francisco M; Patel, Alka; Panizales, Christia Z; Johnson, Nathaniel N; Licona, J Humberto; McKenna, Shannon S; Frendl, Gyorgy; Mentzer, Steven J; Jaklitsch, Michael T; Bueno, Raphael; Colson, Yolonda; Swanson, Scott J; Sugarbaker, David J; Baden, Lindsey R
To determine whether extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery with tube thoracostomy reduces the risk of infectious complications compared with preoperative prophylaxis only. Prospective, randomized, double-blind, placebo-controlled trial. Brigham and Women's Hospital, an 800-bed tertiary care teaching hospital in Boston, Massachusetts. A total of 251 adult patients undergoing elective thoracic surgery requiring tube thoracostomy between April 2008 and April 2011. Patients received preoperative antibacterial prophylaxis with cefazolin sodium (or other drug if the patient was allergic to cefazolin). Postoperatively, patients were randomly assigned (at a 1:1 ratio) using a computer-generated randomization sequence to receive extended antibacterial prophylaxis (n = 125) or placebo (n = 126) for 48 hours or until all thoracostomy tubes were removed, whichever came first. The combined occurrence of surgical site infection, empyema, pneumonia, and Clostridium difficile colitis by postoperative day 28. A total of 245 patients were included in the modified intention-to-treat analysis (121 in the intervention group and 124 in the placebo group). Thirteen patients (10.7%) in the intervention group and 8 patients (6.5%) in the placebo group had a primary end point (risk difference, -4.3% [95% CI, -11.3% to 2.7%]; P = .26). Six patients (5.0%) in the intervention group and 5 patients (4.0%) in the placebo group developed surgical site infections (risk difference, -0.93% [95% CI, -6.1% to 4.3%]; P = .77). Seven patients (5.8%) in the intervention group and 3 patients (2.4%) in the placebo group developed pneumonia (risk difference, -3.4% [95% CI, -8.3% to 1.6%]; P = .21). One patient in the intervention group developed empyema. No patients experienced C difficile colitis. Extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery requiring tube thoracostomy did not reduce the
Patel, Neha A; Garber, David; Hu, Shirley; Kamat, Ameet
Intracranial complications of rhinosinusitis are rare in the post-antibiotic era. However, due to potentially devastating outcomes, prompt recognition and management are essential. This study aims to perform the first systematic review of the intracranial complications of rhinosinusitis in order to better characterize their clinical presentation, diagnosis, and treatment, and report a case of frontal lobe empyema secondary to pediatric frontoethmoid sinusitis. Ovid MEDLINE, Cochrane Library, and Google Scholar. Full-text, peer-reviewed journal publications from 1947 to January 1, 2015 in English; focus on intracranial complications of sinusitis; pediatric patients (<18 years of age); studies including data on diagnostic workup and treatment. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Sixteen studies involving 180 patients were included. An overwhelming majority of patients were young adolescent males (70%). The most common intracranial complications were subdural empyema (49%), epidural abscess (36%), cerebral abscess (21%), and meningitis (10%). Patients most often presented with nonspecific symptoms such as headache, fever, nausea and vomiting. Computed tomography with contrast or magnetic resonance imaging confirmed the diagnosis when intracranial complications were suspected. Typical treatment included surgical incision and drainage, often involving joint neurosurgical and otolaryngological procedures, combined with a long course of antibiotics. The morbidity rate was 27%, and the mortality rate was 3.3%. All studies were retrospective chart reviews, case series or case reports. A review of the currently available literature shows that with a high degree of suspicion, multidisciplinary cooperation and aggressive treatment, favorable outcomes are attainable. The most effective surgical treatment for intracranial complications remains unclear and should be investigated further. Copyright © 2016 Elsevier Ireland Ltd. All rights
Bassuner, Juri K; Rice, David C; Antonoff, Mara B; Correa, Arlene M; Walsh, Garrett L; Vaporciyan, Ara A; Garg, Naveen; Sepesi, Boris; Swisher, Stephen G; Hofstetter, Wayne L; Roth, Jack A; Mehran, Reza J
We aimed to evaluate the impact of collagen matrix in the reconstruction of the diaphragm. We queried the electronic medical record for patients who had resection of the diaphragm and simultaneous pulmonary resection between 1999 and 2016. All reconstructions were performed with either polytetrafluoroethylene or acellular dermal matrix. We evaluated the rate of empyema and herniation in each group. A total of 208 patients met inclusion criteria. Polytetrafluoroethylene was used in 168 cases (80.8%) and dermal matrix in 40 cases (19.2%). Dermal matrix was used in 8 extrapleural pneumonectomies (5.4%), in 26 pleurectomy decortications (55.3%), and in 6 other types of resections (40%). Follow-ups were for a median of 15.0 months in the polytetrafluoroethylene group and 11.6 months in the dermal matrix group. Patients in the dermal matrix group had a chest tube for a median of 2.5 days longer than patients with polytetrafluoroethylene (p = 0.006). Empyema occurred in 11 polytetrafluoroethylene reconstructions (6.5%) and 3 dermal matrix reconstructions (7.5%) (p = 0.735). Seven patients (63.6%) with polytetrafluoroethylene infection required removal of the graft, whereas none in the dermal matrix group needed removal (p = 0.351). There were nine herniations in the polytetrafluoroethylene group and four in the dermal matrix group (p = 0.281), all were acute and due to anchorage failure. Although infection rates were similar between polytetrafluoroethylene and acellular dermal matrix, re-operation for removal was not necessary in the latter. The use of a thick acellular dermal matrix may be a reasonable option when diaphragmatic reconstruction is potentially associated with a higher risk of infection. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Alsina, Laia; Basteiro, Maria G.; de Paz, Hector D.; Iñigo, Melania; de Sevilla, Mariona F.; Triviño, Miriam; Juan, Manel; Muñoz-Almagro, Carmen
Purpose Clinical, immunological and microbiological characteristics of recurrent invasive pneumococcal disease (IPD) in children were evaluated, differentiating relapse from reinfection, in order to identify specific risk factors for both conditions. Methods All patients <18 years-old with recurrent IPD admitted to a tertiary-care pediatric center from January 2004 to December 2011 were evaluated. An episode of IPD was defined as the presence of clinical findings of infection together with isolation and/or pneumococcal DNA detection by Real-Time PCR in any sterile body fluid. Recurrent IPD was defined as 2 or more episodes in the same individual at least 1 month apart. Among recurrent IPD, we differentiated relapse (same pneumococcal isolate) from reinfection. Results 593 patients were diagnosed with IPD and 10 patients died. Among survivors, 23 episodes of recurrent IPD were identified in 10 patients (1.7%). Meningitis was the most frequent form of recurrent IPD (10 episodes/4 children) followed by recurrent empyema (8 episodes/4 children). Three patients with recurrent empyema caused by the same pneumococcal clone ST306 were considered relapses and showed high bacterial load in their first episode. In contrast, all other episodes of recurrent IPD were considered reinfections. Overall, the rate of relapse of IPD was 0.5% and the rate of reinfection 1.2%. Five out of 7 patients with reinfection had an underlying risk factor: cerebrospinal fluid leak (n = 3), chemotherapy treatment (n = 1) and a homozygous mutation in MyD88 gene (n = 1). No predisposing risk factors were found in the remainder. Conclusions recurrent IPD in children is a rare condition associated with an identifiable risk factor in case of reinfection in almost 80% of cases. In contrast, recurrent IPD with pleuropneumonia is usually a relapse of infection. PMID:25738983
Sustained release of bactericidal concentrations of penicillin in the pleural space via an antibiotic-eluting pigtail catheter coated with electrospun nanofibers: results from in vivo and in vitro studies.
Chao, Yin-Kai; Lee, Cheng-Hung; Liu, Kuo-Sheng; Wang, Yi-Chuan; Wang, Chih-Wei; Liu, Shih-Jung
Inadequate intrapleural drug concentrations caused by poor penetration of systemic antibiotics into the pleural cavity is a major cause of treatment failure in empyema. Herein, we describe a novel antibiotic-eluting pigtail catheter coated with electrospun nanofibers used for the sustained release of bactericidal concentrations of penicillin in the pleural space. Electrospun nanofibers prepared using polylactide-polyglycolide copolymer and penicillin G sodium dissolved in 1,1,1,3,3,3-hexafluoro-2-propanol were used to coat the surface of an Fr6 pigtail catheter. The in vitro patterns of drug release were tested by placing the catheter in phosphate-buffered saline. In vivo studies were performed using rabbits treated with penicillin either intrapleurally (Group 1, 20 mg delivered through the catheter) or systemically (Group 2, intramuscular injection, 10 mg/kg). Penicillin concentrations in the serum and pleural fluid were then measured and compared. In vitro studies revealed a burst release of penicillin (10% of the total dose) occurring in the first 24 hours, followed by a sustained release in the subsequent 30 days. Intrapleural drug levels were significantly higher in Group 1 than in Group 2 (P<0.001). In the former, penicillin concentrations remained above the minimum inhibitory concentration breakpoint throughout the entire study period. In contrast, serum penicillin levels were significantly higher in Group 2 than in Group 1 (P<0.001). Notably, all Group 2 rabbits showed signs of systemic toxicity (paralytic ileus and weight loss). We conclude that our antibiotic-eluting catheter may serve as a novel therapeutic option to treat empyema.
Krassas, Athanase; Grima, Renaud; Bagan, Patrick; Badia, Alain; Arame, Alex; Barthes, Françoise Le Pimpec; Riquet, Marc
Thoracoplasty has lost much of its popularity and is being supplanted by space-reduction operations using muscle flaps. Our purpose is to retrospectively study the remaining indications and the evolving modifications of this ancient technique in our current surgical practice. From 1994 to 2008, 35 patients underwent a thoracoplasty procedure in a single thoracic surgery centre for treatment of infectious complications of previous thoracic surgery. The number and length of ribs excised were dictated by the size and location of the thoracic cavity to obliterate. Muscle flaps were used to buttress bronchial fistulas and to fill out residual spaces. We reviewed the immediate and long-term results concerning infection control and procedure tolerance. The infectious complications of previous thoracic surgery were related to cancer in 25, tuberculosis in six, oesophageo-pleural fistula in two, ruptured lung abscess and pleural thickening in one each. The thoracoplasty procedure was performed for: (1) post-pneumonectomy empyema, n=20 (bronchial fistula, n=11; open window thoracostomy, n=14; mean number of resected ribs, n=7.5; associated intrathoracic muscle transposition, n=12; postoperative death, n=3); (2) post-lobectomy empyema, n=8 (bronchial fistula n=8; open window thoracostomy n=1; mean number of resected ribs n=3.6; associated intrathoracic muscle transposition n=7; no death); (3) other indications, n=7 (mean number of resected ribs n=4.8; associated intrathoracic muscle transposition n=3; no death). All patients discharged from the hospital except one were cured and did not complain of symptoms of secondary lung function and shoulder impairment. Although thoracoplasty is rarely indicated nowadays, this does not imply that the procedure should be avoided. Thoracoplasty may be associated with myoplasty, which permits achieving complete space obliteration by combining resection of a few rib segments and limited intrathoracic muscle transposition. Copyright 2009
Heath, Claire J.; del Mar Cendra, Maria; Watson, Alastair; Auger, Jean-Philippe; Pandey, Anish; Tighe, Paddy; Christodoulides, Myron
Streptococcus pneumoniae (Spn) is a major causative organism of empyema, an inflammatory condition occurring in the pleural sac. In this study, we used human and Spn cDNA microarrays to characterize the transcriptional responses occurring during initial contact between Spn and a human pleural mesothelial cell line (PMC) in vitro. Using stringent filtering criteria, 42 and 23 Spn genes were up-and down-regulated respectively. In particular, genes encoding factors potentially involved in metabolic processes and Spn adherence to eukaryotic cells were up-regulated e.g. glnQ, glnA, aliA, psaB, lytB and nox. After Spn initial contact, 870 human genes were differentially regulated and the largest numbers of significant gene expression changes were found in canonical pathways for eukaryotic initiation factor 2 signaling (60 genes out of 171), oxidative phosphorylation (32/103), mitochondrial dysfunction (37/164), eIF4 and p70S6K signaling (28/142), mTOR signaling (27/182), NRF2-mediated oxidative stress response (20/177), epithelial adherens junction remodeling (11/66) and ubiquitination (22/254). The cellular response appeared to be directed towards host cell survival and defense. Spn did not activate NF-kB or phosphorylate p38 MAPK or induce cytokine production from PMC. Moreover, Spn infection of TNF-α pre-stimulated PMC inhibited production of IL-6 and IL-8 secretion by >50% (p<0.01). In summary, this descriptive study provides datasets and a platform for examining further the molecular mechanisms underlying the pathogenesis of empyema. PMID:26566142
Lin, Kuan-Yin; Wang, Chi-Chuan; Lin, Chia-Hui; Sheng, Wang-Huei; Chang, Shan-Chwen
Background Studies on the association between antibiotic treatment and outcomes in outpatients with chronic obstructive pulmonary disease (COPD) and pneumonia are scarce. This study aimed to evaluate the effectiveness of fluoroquinolones and β-lactam/β-lactamase inhibitors for pneumonia in COPD outpatients. Methods We conducted a retrospective cohort study and identified 4,851 episodes of pneumonia among COPD outpatients treated with fluoroquinolones or β-lactam/β-lactamase inhibitors from the Taiwan National Health Insurance Research Database during 2002–2011. Using the propensity score analysis, 1,296 pairs of episodes were matched for the demographic and clinical characteristics. The primary outcome was pneumonia/empyema-related hospitalization or emergency department (ED) visits, and the secondary outcomes were treatment failure, all-cause mortality and medical costs within 30 days. Results Compared with episodes treated with β-lactam/β-lactamase inhibitors, episodes treated with fluoroquinolones had similar clinical outcomes. The rates of pneumonia/empyema-related hospitalization or ED visits were 3.9% and 3.5% in the fluoroquinolone and β-lactam/β-lactamase inhibitor groups, respectively (adjusted hazard ratio [aHR], 1.11; 95% confidence interval [CI], 0.74–1.66). The percentage of treatment failure and all-cause mortality were 28.2% versus 31.3% (adjusted odds ratio, 0.86; 95% CI, 0.73–1.02) and 0.5% versus 0.4% (aHR, 1.40; 95% CI, 0.45–4.41) in the fluoroquinolone and β-lactam/β-lactamase inhibitor groups, respectively. The medical expenditures, including total medical costs (528 versus 455 US dollars) and pneumonia-related costs (202 vs. 155 USD) were also balanced between the two treatment groups (both P >0.05). Conclusions For pneumonia in COPD outpatients, fluoroquinolones were associated with similar clinical outcomes and medical expenditures compared with β-lactam/β-lactamase inhibitors. PMID:26305908
Lin, Kuan-Yin; Wang, Chi-Chuan; Lin, Chia-Hui; Sheng, Wang-Huei; Chang, Shan-Chwen
Studies on the association between antibiotic treatment and outcomes in outpatients with chronic obstructive pulmonary disease (COPD) and pneumonia are scarce. This study aimed to evaluate the effectiveness of fluoroquinolones and β-lactam/β-lactamase inhibitors for pneumonia in COPD outpatients. We conducted a retrospective cohort study and identified 4,851 episodes of pneumonia among COPD outpatients treated with fluoroquinolones or β-lactam/β-lactamase inhibitors from the Taiwan National Health Insurance Research Database during 2002-2011. Using the propensity score analysis, 1,296 pairs of episodes were matched for the demographic and clinical characteristics. The primary outcome was pneumonia/empyema-related hospitalization or emergency department (ED) visits, and the secondary outcomes were treatment failure, all-cause mortality and medical costs within 30 days. Compared with episodes treated with β-lactam/β-lactamase inhibitors, episodes treated with fluoroquinolones had similar clinical outcomes. The rates of pneumonia/empyema-related hospitalization or ED visits were 3.9% and 3.5% in the fluoroquinolone and β-lactam/β-lactamase inhibitor groups, respectively (adjusted hazard ratio [aHR], 1.11; 95% confidence interval [CI], 0.74-1.66). The percentage of treatment failure and all-cause mortality were 28.2% versus 31.3% (adjusted odds ratio, 0.86; 95% CI, 0.73-1.02) and 0.5% versus 0.4% (aHR, 1.40; 95% CI, 0.45-4.41) in the fluoroquinolone and β-lactam/β-lactamase inhibitor groups, respectively. The medical expenditures, including total medical costs (528 versus 455 US dollars) and pneumonia-related costs (202 vs. 155 USD) were also balanced between the two treatment groups (both P >0.05). For pneumonia in COPD outpatients, fluoroquinolones were associated with similar clinical outcomes and medical expenditures compared with β-lactam/β-lactamase inhibitors.
Laurikainen, E; Hujala, K; Suonpää, J; Mäki, J
Long-term draining tubes (LTD) have become a common treatment in complicated and prolonged forms of maxillary sinus empyema. Since not all patients show good recovery with this treatment we used sinus-manometry, mathematical calculations, and scanning electron microscopy (SEM) to critically analyze 6 cases with a prolonged history of the disease. Five out of the 6 patients recovered quickly after removal of the LTDs, normally performed sinus punctures, and an appropriate antibacterial treatment. One patient underwent functional endoscopic sinus surgery. Two of the 6 patients had uncommon bacterial cultures (Pseudomonas mirabilis, Klebsiella oxytoga) in their sinus secreta. Two of the removed LTDs were examined with SEM. The porous polyethylene was shown to have absorbed bacterial plague which, besides narrowing the lumen, can cause recurrent infections. In 5 other patients, the draining pressure (DP) was 0.9 +/- 0.16(M +/- SD) kg/cm2, as measured during irrigation with a No. 2 Lichtwitz needle (1.8 mm, i.d). Mathematical calculation using the Hagen-Boisseouille equation indicated that with our LTDs (0.7 mm, i.d.) the DP needs to be 40 times greater than the DP when using an ordinary Lichtwitz needle to get equal flushing capacity. We recommend i) LTD treatment of maxillary sinus empyema be closely followed up ii) that, in prolonged cases, the LTDs should be removed and the sinuses repeatedly irrigated with an ordinary needle or antrostomy, and iii) that a more suitable tubing material and insertion system (to allow a larger radius of the tube) be developed.
Edaigbini, Sunday A; Delia, Ibrahim Z; Aminu, Muhammad B; Orogade, Abosede A; Anumenechi, Ndubuisi; Aliyu, Ibrahim D
Tube thoracostomy is a lifesaving and frequently performed procedure in hospitals where the expertise and necessary tools are available. Where the ideal drainage receptacle is unavailable, the underwater seal device can be improvised with bottled water plastic can especially in emergency situations. To determine the frequencies of the various indications and complications of tube thoracostomy with improvised underwater seal. A cross-sectional study with a structured proforma was used for assessment over a 3-year period (May 2010-April 2013). The proforma was filled at the time of the procedure by the performing surgeon and patients were followed up with serial chest X-rays until certified cured. A 1.5 L bottled water container was used as the underwater seal receptacle. The data was analysed with SPSS 15 software program. A total of 167 patients were managed. There were 106 (63.5%) males and 61 (36.5%) females. The mean age was 34.85 ± 16.72 with a range of 1-80 years. The most frequent indication was for malignant/paramalignant effusion, 46 (27.5%). Others were trauma, 44 (26.3%), Parapneumonic effusion, 20 (12%), postthoracotomy 14 (8.4%), empyema thoracis 12 (7.2%), heart disease and tuberculous effusion 11 (6.6%) each, pneumothorax 8 (4.8%) and misdiagnosis 1 (0.6%). A hundred and one (60.5%) of the procedures were performed by registrars, 41 (24.6%) by consultants, house officers 15 (9%) and senior registrars 10 (6%). The overall complication rate was 16.8% with the more frequent complications been empyema (5.6%) and pneumothorax (3.6%). The average duration of tube placement was 13.02 ± 12.362 days and range of 1-110 days. Tube thoracostomy can be a relatively safe procedure with acceptable complication rates even with improvised underwater seal drainage bottles.
Li, Ruolin; Wang, Junli; Wang, Xinfeng; Wang, Maoshui
OBJECTIVES: Delay in the treatment of pleural infection may contribute to its high mortality. In this retrospective study, we aimed to evaluate the diagnostic accuracy of pleural adenosine deaminase in discrimination between Gram-negative and Gram-positive bacterial infections of the pleural space prior to selecting antibiotics. METHODS: A total of 76 patients were enrolled and grouped into subgroups according to Gram staining: 1) patients with Gram-negative bacterial infections, aged 53.2±18.6 years old, of whom 44.7% had empyemas and 2) patients with Gram-positive bacterial infections, aged 53.5±21.5 years old, of whom 63.1% had empyemas. The pleural effusion was sampled by thoracocentesis and then sent for adenosine deaminase testing, biochemical testing and microbiological culture. The Mann-Whitney U test was used to examine the differences in adenosine deaminase levels between the groups. Correlations between adenosine deaminase and specified variables were also quantified using Spearman’s correlation coefficient. Moreover, receiver operator characteristic analysis was performed to evaluate the diagnostic accuracy of pleural effusion adenosine deaminase. RESULTS: Mean pleural adenosine deaminase levels differed significantly between Gram-negative and Gram-positive bacterial infections of the pleural space (191.8±32.1 U/L vs 81.0±16.9 U/L, p<0.01). The area under the receiver operator characteristic curve was 0.689 (95% confidence interval: 0.570, 0.792, p<0.01) at the cutoff value of 86 U/L. Additionally, pleural adenosine deaminase had a sensitivity of 63.2% (46.0-78.2%); a specificity of 73.7% (56.9-86.6%); positive and negative likelihood ratios of 2.18 and 0.50, respectively; and positive and negative predictive values of 70.6% and 66.7%, respectively. CONCLUSIONS: Pleural effusion adenosine deaminase is a helpful alternative biomarker for early and quick discrimination of Gram-negative from Gram-positive bacterial infections of the pleural space
Florova, Galina; Azghani, Ali; Karandashova, Sophia; Kurdowska, Anna K.; Idell, Steven
Intrapleural processing of prourokinase (scuPA) in tetracycline (TCN)-induced pleural injury in rabbits was evaluated to better understand the mechanisms governing successful scuPA-based intrapleural fibrinolytic therapy (IPFT), capable of clearing pleural adhesions in this model. Pleural fluid (PF) was withdrawn 0–80 min and 24 h after IPFT with scuPA (0–0.5 mg/kg), and activities of free urokinase (uPA), plasminogen activator inhibitor-1 (PAI-1), and uPA complexed with α-macroglobulin (αM) were assessed. Similar analyses were performed using PFs from patients with empyema, parapneumonic, and malignant pleural effusions. The peak of uPA activity (5–40 min) reciprocally correlated with the dose of intrapleural scuPA. Endogenous active PAI-1 (10–20 nM) decreased the rate of intrapleural scuPA activation. The slow step of intrapleural inactivation of free uPA (t1/2β = 40 ± 10 min) was dose independent and 6.7-fold slower than in blood. Up to 260 ± 70 nM of αM/uPA formed in vivo [second order association rate (kass) = 580 ± 60 M−1·s−1]. αM/uPA and products of its degradation contributed to durable intrapleural plasminogen activation up to 24 h after IPFT. Active PAI-1, active α2M, and α2M/uPA found in empyema, pneumonia, and malignant PFs demonstrate the capacity to support similar mechanisms in humans. Intrapleural scuPA processing differs from that in the bloodstream and includes 1) dose-dependent control of scuPA activation by endogenous active PAI-1; 2) two-step inactivation of free uPA with simultaneous formation of αM/uPA; and 3) slow intrapleural degradation of αM/uPA releasing active free uPA. This mechanism offers potential clinically relevant advantages that may enhance the bioavailability of intrapleural scuPA and may mitigate the risk of bleeding complications. PMID:23997178
Sbiti-Rohr, Diana; Kutz, Alexander; Christ-Crain, Mirjam; Thomann, Robert; Zimmerli, Werner; Hoess, Claus; Henzen, Christoph; Mueller, Beat; Schuetz, Philipp
Objective To investigate the accuracy of the National Early Warning Score (NEWS) to predict mortality and adverse clinical outcomes for patients with community-acquired pneumonia (CAP) compared to standard risk scores such as the pneumonia severity index (PSI) and CURB-65. Design Secondary analysis of patients included in a previous randomised-controlled trial with a median follow-up of 6.1 years. Settings Patients with CAP included on admission to the emergency departments (ED) of 6 tertiary care hospitals in Switzerland. Participants A total of 925 patients with confirmed CAP were included. NEWS, PSI and CURB-65 scores were calculated on admission to the ED based on admission data. Main outcome measure Our primary outcome was all-cause mortality within 6 years of follow-up. Secondary outcomes were adverse clinical outcome defined as intensive care unit (ICU) admission, empyema and unplanned hospital readmission all occurring within 30 days after admission. We used regression models to study associations of baseline risk scores and outcomes with the area under the receiver operating curve (AUC) as a measure of discrimination. Results 6-year overall mortality was 45.1% (n=417) with a stepwise increase with higher NEWS categories. For 30 day and 6-year mortality prediction, NEWS showed only low discrimination (AUC 0.65 and 0.60) inferior compared to PSI and CURB-65. For prediction of ICU admission, NEWS showed moderate discrimination (AUC 0.73) and improved the prognostic accuracy of a regression model, including PSI (AUC from 0.66 to 0.74, p=0.001) and CURB-65 (AUC from 0.64 to 0.73, p=0.015). NEWS was also superior to PSI and CURB-65 for prediction of empyema, but did not well predict rehospitalisation. Conclusions NEWS provides additional prognostic information with regard to risk of ICU admission and complications and thereby improves traditional clinical-risk scores in the management of patients with CAP in the ED setting. Trial registration number
Valdés, L.; Alvarez, D.; San José, E.; Juanatey, J. R.; Pose, A.; Valle, J. M.; Salgueiro, M.; Suárez, J. R.
BACKGROUND--Pleural biopsy is usually considered important for the diagnosis of pleural effusions, especially for distinguishing between tuberculosis and neoplasia, even though tuberculous pleural fluid contains sensitive biochemical markers. In regions with a high prevalence of tuberculosis, and in patient groups with a low risk of other causes of pleurisy, the positive predictive value of these markers is increased. The criteria for performing a pleural biopsy under these circumstances have been investigated, using adenosine deaminase (ADA) as a pleural fluid marker for tuberculosis. METHODS--One hundred and twenty nine patients with a pleural effusion aged < or = 35 years (mean (SD) 25.2 (4.9) years) were studied. Seventy three were men. Eighty one effusions (62.8%) were tuberculous, 12 (9.3%) parapneumonic, and 10 (7.7%) neoplastic, five were caused by pulmonary thromboembolism, four by systemic lupus erythematosus, seven by empyema, three following surgery, one was the result of asbestosis, and one of nephrotic syndrome. In five cases no definitive diagnosis was reached. ADA levels were determined by the method of Galanti and Giusti. RESULTS--The diagnostic yield of procedures not involving biopsy was 94.5% (122/129). Pleural biopsy provided a diagnosis in a further two cases, but not in the remaining five. All tuberculous cases had pleural fluid levels of ADA of > 47 U/l (mean (SD) 111.1 (36.6) U/l). The only other cases in which ADA exceeded this level were six of the seven patients with empyema. Cytological examination of the pleural fluid diagnosed eight of the 10 neoplastic cases, compared with six diagnosed by pleural biopsy. CONCLUSIONS--In a region with a high prevalence of tuberculosis procedures not involving pleural biopsy have a very high diagnostic yield in patients with a pleural effusion aged < or = 35 years, making biopsy necessary only in cases in which pleural levels of ADA are below 47 U/l, pleural fluid cytology is negative and, in the
Kendja, Flavien; Yangni-Angate, Hervé; Demine, Blaise; Ouédé, Raphaël; Kouacou, Maurice
Background To report and analyze noncardiac thoracic operations performed at the Cardiology Institute of Abidjan (Institut de Cardiologie d’Abidjan) from 1977 to 2015. Methods This is a retrospective and descriptive study covering 39 years, from 1977 to 2015. This study period was divided into three periods of 13 years each: P1 from 1977 to 1989, P2 from 1990 to 2002 and P3 from 2003 to 2015. Medical records of 2014 operated patients were analyzed: 414 patients for P1, 464 patients for P2, 1,136 patients for P3. The records destroyed in a fire in 1997 were not included in the study. The age, sex, pathologies, types of operations, post-operative complications and mortality were analyzed with usual statistical tests. Results The average age varied from 35 years in P1 to 31.6 years in P3. Men predominate in all periods. Distribution of important groups of pathologies observed varies significantly over the three periods; In particular, we note an increase in trauma cases (tripling between P1 and P2, 140% between P2 and P3), and a decrease in tumors percentages, and infections and pulmonary sequelae of tuberculosis. Surgical management of thoracic trauma has increased (56.9% in P3) followed by the pleural surgery (21.3%) and pulmonary resections (13.9%). Persistent air leak >7 days was the predominant complication over the three periods. Postoperative empyema increased in P3 (14.7%). Close chest drainage-irrigation is the most frequent procedure performed to sterilize a major complication like postoperative empyema without bronchopleural fistula. Overall mortality decreased from 5.3% in P1 to 3.4% in P3. Conclusions Noncardiac thoracic surgery operations still concern infections, pulmonary sequelae of tuberculosis, thoracic tumors and many more thoracic trauma caused by current armed conflicts and terrorist attacks. But access to thoracic surgical care remains difficult for our population secondary to low economic status, and lack of a health insurance system
Mairpady Shambat, Srikanth; Chen, Puran; Nguyen Hoang, Anh Thu; Bergsten, Helena; Vandenesch, Francois; Siemens, Nikolai; Lina, Gerard; Monk, Ian R; Foster, Timothy J; Arakere, Gayathri; Svensson, Mattias; Norrby-Teglund, Anna
Staphylococcus aureus necrotizing pneumonia is recognized as a toxin-mediated disease, yet the tissue-destructive events remain elusive, partly as a result of lack of mechanistic studies in human lung tissue. In this study, a three-dimensional (3D) tissue model composed of human lung epithelial cells and fibroblasts was used to delineate the role of specific staphylococcal exotoxins in tissue pathology associated with severe pneumonia. To this end, the models were exposed to the mixture of exotoxins produced by S. aureus strains isolated from patients with varying severity of lung infection, namely necrotizing pneumonia or lung empyema, or to purified toxins. The necrotizing pneumonia strains secreted high levels of α-toxin and Panton-Valentine leukocidin (PVL), and triggered high cytotoxicity, inflammation, necrosis and loss of E-cadherin from the lung epithelium. In contrast, the lung empyema strain produced moderate levels of PVL, but negligible amounts of α-toxin, and triggered limited tissue damage. α-toxin had a direct damaging effect on the epithelium, as verified using toxin-deficient mutants and pure α-toxin. Moreover, PVL contributed to pathology through the lysis of neutrophils. A combination of α-toxin and PVL resulted in the most severe epithelial injury. In addition, toxin-induced release of pro-inflammatory mediators from lung tissue models resulted in enhanced neutrophil migration. Using a collection of 31 strains from patients with staphylococcal pneumonia revealed that strains producing high levels of α-toxin and PVL were cytotoxic and associated with fatal outcome. Also, the strains that produced the highest toxin levels induced significantly greater epithelial disruption. Of importance, toxin-mediated lung epithelium destruction could be inhibited by polyspecific intravenous immunoglobulin containing antibodies against α-toxin and PVL. This study introduces a novel model system for study of staphylococcal pneumonia in a human setting. The
Zubair, M; Habib, L; Mirza, M R; Channa, M A; Yousuf, M
This study was done to evaluate the frequency of iatrogenic gall bladder perforation (IGBP) in laparoscopic cholecystectomy and to determine its association with gender, adhesions in right upper quadrant and types of gall bladder. This retrospective descriptive study included 200 patients who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis at Jamal Noor Hospital and Hamdard University Hospital, Karachi from January 2007 to January 2009. Video recording of all 200 laparoscopic cholecystectomies were analyzed for the IGBP. The different factors; sex of the patient, type of gall bladder, presence of adhesions in the right upper quadrant, timing of perforation, site of perforation, cause of perforation and spillage of stones were recorded. Data was entered and analyzed on SPSS 15. Pearson Chi Square test was applied to check the significance of these factors in IGBP where applicable. In this study there were 173 females and 27 male patients. IGBP occurred in 51 patients (25.5%) and among them 40(23.12%) were females and 11(40.74%) males. Statistical analysis failed to prove male gender a significant factor in the IGBP (p=0.051). Spillage of stones occurred in 23 patients (11.5% in total study population). In 32(18.49%) patients with chronic calculus cholecystitis IGBP occured while in other cluster of 27 patients suffering from acute cholecystitis, empyema & mucocele, 19(70.37%) had IGBP. Hence the condition of gall bladder (acute cholecystitis, empyema and mucocele) was proved statistically a significant factor in IGBP (p=0.000). Adhesiolysis in right upper quadrant was required in 109 patients in whom 31 patients (28.44%) had IGBP while in 91 patients in whom no adhesiolysis was required, 20 patients (21.98%) had IGBP. Statistically no significant difference was present regarding this factor (p=0.296). In total of 51 patients of IGBP, fundus of gall bladder was the commonest site of perforation in 21(41.18%), followed by body of gall bladder in
Sbiti-Rohr, Diana; Kutz, Alexander; Christ-Crain, Mirjam; Thomann, Robert; Zimmerli, Werner; Hoess, Claus; Henzen, Christoph; Mueller, Beat; Schuetz, Philipp
To investigate the accuracy of the National Early Warning Score (NEWS) to predict mortality and adverse clinical outcomes for patients with community-acquired pneumonia (CAP) compared to standard risk scores such as the pneumonia severity index (PSI) and CURB-65. Secondary analysis of patients included in a previous randomised-controlled trial with a median follow-up of 6.1 years. Patients with CAP included on admission to the emergency departments (ED) of 6 tertiary care hospitals in Switzerland. A total of 925 patients with confirmed CAP were included. NEWS, PSI and CURB-65 scores were calculated on admission to the ED based on admission data. Our primary outcome was all-cause mortality within 6 years of follow-up. Secondary outcomes were adverse clinical outcome defined as intensive care unit (ICU) admission, empyema and unplanned hospital readmission all occurring within 30 days after admission. We used regression models to study associations of baseline risk scores and outcomes with the area under the receiver operating curve (AUC) as a measure of discrimination. 6-year overall mortality was 45.1% (n=417) with a stepwise increase with higher NEWS categories. For 30 day and 6-year mortality prediction, NEWS showed only low discrimination (AUC 0.65 and 0.60) inferior compared to PSI and CURB-65. For prediction of ICU admission, NEWS showed moderate discrimination (AUC 0.73) and improved the prognostic accuracy of a regression model, including PSI (AUC from 0.66 to 0.74, p=0.001) and CURB-65 (AUC from 0.64 to 0.73, p=0.015). NEWS was also superior to PSI and CURB-65 for prediction of empyema, but did not well predict rehospitalisation. NEWS provides additional prognostic information with regard to risk of ICU admission and complications and thereby improves traditional clinical-risk scores in the management of patients with CAP in the ED setting. ISRCTN95122877; Post-results. Published by the BMJ Publishing Group Limited. For permission to use (where not
Koch, Horst; Tomaselli, F; Pierer, G; Schwarzl, F; Haas, F; Smolle-Jüttner, F M; Scharnagl, E
Besides other factors, the choice of reconstructive method for full thickness thoracic wall defects depends on the morbidity of preceding surgical procedures. The pedicled latissimus dorsi flap is a reliable and safe option for reconstruction of the thorax. A posterolateral thoracotomy, however, results in division of the muscle. Both parts of the muscle can be employed to close full thickness defects of the chest wall. The proximal part can be pedicled on the thoracodorsal vessels or the serratus branch; the distal part can be pedicled on paravertebral or intercostal perforators. This retrospective study was undertaken to evaluate the reconstructive potential of both parts of the latissimus dorsi in thoracic wall reconstruction after posterolateral thoracotomy. Between 1987 and 1999, 36 consecutive patients underwent reconstruction of full-thickness thoracic wall defects with latissimus dorsi-flaps after posterolateral thoracotomies. The defects resulted from infection and open window thoracostomy (n=31), trauma (n=3) and resection of tumours (n=2). The patients' average age was 57 years (range 22-76 years). Twenty-five patients were male, 11 were female. In 31 cases the split latissimus dorsi alone was employed; in five cases additional flaps had to be used due to the size of the defects, additional intrathoracic problems or neighbouring defects. In 34 cases defect closure could be achieved without major complications. Empyema recurred in the pleural cavity in one case and one patient died of septicaemia. The 15 patients who had required a respirator in the preoperative phase could be extubated 4.8 days (average) after thoracic wall reconstruction. Postoperative hospital stay averaged 16 days. Different methods are available for reconstruction of full thickness defects of the thoracic wall. After posterolateral thoracotomy in the surgical treatment of empyema, oncologic surgery and traumatology, the latissimus dorsi muscle still retains some reconstructive
Francis, Nick A; Crocker, Joanna C; Gamper, Arla; Brookes-Howell, Lucy; Powell, Colin; Butler, Christopher C
To identify potential opportunities for earlier intervention among children who develop a complicated respiratory tract infection (RTI). Qualitative, face-to-face, individual interview study, either in hospital or at home, with parents of children admitted to hospital with a complicated RTI. Participants were recruited from a large UK teaching hospital, and described events (largely) prior to hospital admission. Parents of 22 children (12 with empyema, 8 with pneumonia, 1 with peritonsillar abscess and 1 with mastoiditis). Parents' accounts revealed missed opportunities for timely treatment resulting from parental and health service associated factors. Themes relating to parental factors included problems assessing the severity of the illness (5 parents), beliefs about accessing health services (10 parents; including fear of appearing 'neurotic', belief that their concerns would not be taken seriously, and belief that their child would not be prescribed antibiotics or would be prescribed antibiotics too readily) and feeling powerless to challenge clinical authority (7 parents). Health service associated factors included perceived problems accessing healthcare services (13 parents; including inadequate primary care triage, barriers to accessing timely consultations and past experience of problems accessing healthcare leading to failure to consult) and perceived poor quality clinical encounters (11 parents; including inadequate assessment and communication). Addressing, where appropriate, these parental (skills, fears and beliefs) and health service (access and consultation quality) associated factors may lead to more prompt care for seriously ill children.
Hughes, James M.; Remington, Jack S.
The serious and increasing problem of deep-seated Candida infection and the difficulties encountered in diagnosis of this entity prompted review of all well-documented cases of systemic candidiasis in a 39-month period at Stanford Medical Center. In only 19 of the 40. cases (47.5 percent) was the diagnosis suspected premortem; in 15 (37.5 percent) of these, the diagnosis was established. Thirty-three (82.5 percent) of the 40 patients died, and in 12 (39.4 percent) of them Candida infection was considered to be the primary cause of death or a major contributing factor. The seven survivors were treated either by specific chemotherapy or drainage of abscesses and empyema cavities. When the data were assessed in relation to underlying diseases and other possible predisposing factors, surgery was implicated in 50 percent of the total. In a study to define the prevalence of Candida in the saliva of patients with severe underlying illnesses receiving antibiotics or immunosuppressive therapy at the Stanford Medical Center, a significantly higher prevalence was noted in the multiple therapeutic modality group than in controls. In a review of reported data on methods for serological diagnosis of systemic candidiasis, only the precipitin and agglutinin methods appear promising. PMID:5031746
de la Garza Villaseñor, L
During an 11 year period, 47 patients with acute acalculous cholecystitis were operated on. Two to one male/female ratio was observed with a mean age of 55 age of 55 years. No one had a past history of biliary tract pathology but 70 per cent of the patients had risk factors, mainly diabetes mellitus, cardiovascular and collagenous diseases, some different of those reported in the world literature (sepsis, trauma, non biliary tract surgery, etc.). The ultrasound was the best diagnostic tool. Open cholecystectomy was performed in all patients and some sort of local complication was found in 85 per cent of patients (empyema, gangrene or perforation) in spite of the surgical procedure was done on emergency or early elective basis, a 31 per cent operative mortality rate was found and a 10.6% Operative mortality rates was observed. The bacterial cultures showed gram negative and anaerobic flora. This report shows that an early diagnosis and surgical treatment keeps a low morbidity and mortality rates but the gallbladder late complications have a high rates.
Baldeyrou, P; Lemoine, G; Zucker, J M; Schweisguth, O
A series of 134 children, less than 15 years of age at the time of diagnosis of tumor, treated by one oncology group and one surgeon, have been submitted to thoracotomy for pulmonary metastatic disease between 1961 and 1976. Fifteen had a thoracic exploration only because of the extent of disease and died. Three had a nodule excised which proved to be nonmetastatic at histology and are alive. One hundred and sixteen underwent 152 excisional procedures with 2 operative deaths, 1 postpneumonectomy empyema, 2 transient postoperative complications, and 4 local relapses. Fifty-one are alive 4 to 15 years after the last surgical procedure. The results are best when a single (or a few) metastasis is removed as a primary treatment followed by chemotherapy and/or radiotherapy when indicated. Results are better in Wilms' tumors than in other tumors. Radiotherapy which can lead to long term pulmonary sequelae can be avoided in half of the patients (26/51). Thoracotomy is a safe and simple procedure in children, giving rewarding results when the indications of excision, among the different means of treatment, are carefully chosen.
Reddy, Chakravarthy; Ernst, Armin; Lamb, Carla; Feller-Kopman, David
Malignant pleural effusions (MPEs) affect > 150,000 people each year in the United States. Current palliative options include pleurodesis and placement of an indwelling catheter, each with its own associated benefits. This study was conducted to determine the safety, efficacy, and feasibility of a rapid pleurodesis protocol by combining medical thoracoscopy with talc pleurodesis and simultaneous placement of a tunneled pleural catheter (TPC) in patients with symptomatic MPE. Patients with recurrent, symptomatic MPEs underwent medical thoracoscopy with placement of a TPC and talc poudrage. The TPC was drained per protocol until the output was < 150 mL/d on two consecutive drainage attempts and then removed. Patients were followed for up to 6 months. Between October 2005 and September 2009, 30 patients underwent the procedure. The median duration of hospitalization following the procedure was 1.79 days. All patients showed an improvement in dyspnea and quality of life. Pleurodesis was successful in 92% of patients, and the TPC was removed at a median of 7.54 days. Complications included fever (two patients), the need for TPC replacement (one patient), and empyema (one patient). Rapid pleurodesis can be achieved safely by combining medical thoracoscopy and talc poudrage with simultaneous TPC placement. Both hospital length of stay and duration of TPC use can be reduced significantly as compared with historical controls of either procedure alone. Future randomized trials are needed to confirm these results.
Akopov, A. L.; Bely, K. P.; Berezin, Yu. D.; Orlov, S. V.
Plasmapheresis in pulmonology is one of the leading methods of extracorporeal detoxification of patients with purulent lung and pleura diseases. However this method causes a decrease in patients' leukocyte level and humoral immunity indices. The medico-biological research conducted at the State Scientific Center of Pulmonology demonstrated that a combination of plasmapheresis with additional irradiation of the patients' reinfused erythrocyte mass with low intensive He-Ne laser light with the wavelength of 0.63 mkm considerably reduces the probability of these complications. It may be due to the fact that laser irradiation of autologous erythrocytes induces local and general stimulation, favoring in this way the inflammatory process involution. The suggested method of plasmapheresis was used in the process of treatment of 76 patients with lung abscess, empyema, purulent mediastinitis, sepsis. The essence of the method consists in irradiating with He-Ne laser the last portion of the erythrocyte mass (130 - 170 ml), diluted with saline, during its reinfusion in the course of a routine plasmapheresis. The positive impact of practical application of the above method allows to characterize it as highly effective for treatment of purulent diseases in pulmonology.
Doll, Dietrich; Matevossian, Edouard; Hoenemann, Christian; Hoffmann, Sebastian
It has long been suspected that acute infection leads to less satisfactory results in soft tissue surgery. Its influence on long-term recurrence rate in primary pilonidal sinus surgery has not been investigated yet. 583 patients (military cohort) were analyzed, comparing an incision and drainage (I&D) group preceding surgery (n = 286 pts) with a spontaneous abscess and empyema rupture group (n = 297 pts). Long-term recurrence rate up to 25 years following surgery was determined. The I&D group achieved a 20 year recurrence rate of 24 %, whereas the non-I&D-group had 35 % recurrences (p = 0.0034). Analyzing the subgroup with primary open wound treatment (n = 349 pts), the I&D group did significantly better after 20 years (16 % actuarial recurrence rate versus 34 %; p = 0.009; log-rank-test). Early I&D treatment preceding definite surgery for some weeks seem to give significant superior results compared to primary surgery without I&D. The combination of early I&D and asymmetric excision and out of the midline closure is expected to give even further improved results compared to this cohort. The optimum interval between I&D and definite surgery has still to be determined. © The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin.
Yokoyama, Yujiro; Nakagomi, Takahiro; Shikata, Daichi
In thoracic surgery, a thoracic drain is always inserted after the surgical procedure. Repair of the wound after removal of the thoracic tube is performed postoperatively, but no universally standard methods currently exists for this tube removal. Here we report a technique using triclosan-coated sutures that is used in thoracic surgery in our hospital. There are several advantages of this technique. First, there is no need for stitches removal on follow-up. Second, it prevents the leakage of pleural exudate because of the tight two-layer sutures. In addition, it was observed to be superior in terms of both wound healing and cosmetic aspects, due to the layer-to-layer sutures. The use of triclosan-coated sutures helps prevent infection and empyema is quite unlikely to occur as the result of the tight ligating of the muscular layer using these sutures. We applied this method in 168 patients over a period of 24 months. There were no complications on removal of the chest tube such as infection, fluid leakage or opening of the surgical wound. PMID:28203426
Murthy, Sudish C; Okereke, Ikenna; Mason, David P; Rice, Thomas W
Complicated pleural effusions are difficult to manage with conventional strategies. In this study, we review the safety, efficacy, and durability of PleurX catheters (Denver Biomedical, Golden, CO) for managing complicated pleural effusions and describe a patient population who might benefit. From July 1999 to February 2003, 63 PleurX catheters were placed in 58 symptomatic patients (an additional five had bilateral catheters) to manage complicated pleural effusions. Patients selected for catheter placement tended to have poor performance status (Eastern Cooperative Oncology Group < or =2) or had failed standard therapies. Of the 63 catheters, 52 (83%) were placed because of malignant complicated pleural effusions. A registry of patients was constructed, and data were obtained from review of medical records. Nonparametric estimates of freedom from reintervention and overall survival were obtained by the Kaplan-Meier method. Catheter-related complications were noted in four of 58 patients (7%) and included one each of pneumothorax, seroma, empyema, and pain syndrome. Freedom from reintervention for effusion management was 95%. Of the patients, 86% (50 of 58) experienced dyspnea relief. There were no procedure-related mortalities. Catheters remained functional up to 330 days, and four of 63 (6%) required one-time thrombolysis with tissue plasminogen activator. PleurX catheters are safe, effective, and durable solutions for complicated pleural effusions and seem to provide an attractive alternative for patients who have few other palliative options. We consider the catheters as first-line therapy for these patients.
Johnson, Bret; Rylander, Michele; Beres, Alana L
A link between childhood radiation and future cancer risks exists, and reduction of unnecessary radiation in childhood has been recommended. Pneumothoraces, pleural effusions, and many surgical procedures require placement of a chest tube/pigtail catheter. Traditional management is daily x-rays, with an x-ray after tube removal. Our hypothesis is the "post pull" x-ray rarely results in changing clinical management of the patient. With IRB approval, a 5-year retrospective chart review was performed. Inclusion criteria were chest tube or pigtail placed for any reason with complete records. Data collected were demographics, reason for and duration of placement, number of x-rays done prior to and after removal. Primary outcome was whether the "post pull" x-ray changed clinical management. A total of 179 episodes were evaluated. Seventeen were excluded for incomplete data, or death/transfer of the patient with the tube in situ. Forty-nine tubes/pigtails were placed for pneumothorax, 48 for pleural effusion/empyema, 9 for hemothorax, and 51 during operative procedure. A median of 5 x-rays was done post insertion. 99% of the patients (160/162) had a "post pull" x-ray performed after tube removal. In 9 cases the x-ray changed patient management. X-ray after chest tube/pigtail removal rarely changes patient management. We recommend considering imaging if there are clinical symptoms. Prognosis study, level II (retrospective cohort). Copyright © 2017 Elsevier Inc. All rights reserved.
Skandalakis, Panagiotis N; Lainas, Panagiotis; Zoras, Odyseas; Skandalakis, John E; Mirilas, Petros
Dominique Jean Larrey (1766-1842) has been described as the father of modern military surgery and is considered even today as the model military surgeon. He developed a plan of rapid evacuation of wounded soldiers from the battlefield during combat, using flexible medical units which he named ambulances volantes ("flying ambulances"). He won the admiration of Napoleon Bonaparte (1769-1821), who was amazed by the results of Larrey's sanitary system. Larrey spent almost 18 years with Napoleon, accompanying him in 25 campaigns, 60 battles, and more than 400 engagements. Napoleon's enormous military success was due not only to his strategy and skill but also to the medical services provided by Larrey. The surgeon became a master of wound management and limb amputation. In his vivid battlefield journals, Larrey documented the course of tetanus, the pathophysiology of cold injury, the effective control of hemorrhage, the drainage of empyema and hemothorax, the aspiration of pericardial effusion or hemopericardium, and the packing of sucking chest wounds. Larrey established a categorical rule for the triage of war casualties, treating the wounded according to the observed gravity of their injuries and the urgency for medical care, regardless of their rank or nationality.
Hersey, N.; Goode, S. D.; Peck, R. J. Lee, F.
PurposeThere have been few case reports describing cystic duct stent insertion in the management of acute cholecystitis secondary to benign disease with no case series published to date. We present our series demonstrating the role of cystic duct stents in managing benign gallbladder disease in those patients unfit for surgery.Materials and MethodsThirty three patients unfit for surgery in our institution underwent cystic duct stent insertion for the management of acute cholecystitis in the period June 2008 to June 2013. Patients underwent a mixture of transperitoneal and transhepatic gallbladder puncture. The cystic duct was cannulated with a hydrophilic guidewire which was subsequently passed through the common bile duct and into the duodenum. An 8Fr 12-cm double-pigtail stent was placed with the distal end lying within the duodenum and the proximal end within the gallbladder.ResultsTen patients presented with gallbladder perforation, 21 patients with acute cholecystitis, 1 with acute cholangitis and 1 with necrotising pancreatitis. The technical success rate was 91 %. We experienced a 13 % complication rate with 3 % mortality rate at 30 days.ConclusionCystic duct stent insertion can be successfully used to manage acute cholecystitis, gallbladder empyema or gallbladder perforations in those unfit for surgery and should be considered alongside external gallbladder drainage as a definitive mid-term treatment option.
Aldave Becerra, Juan Carlos; Cachay Rojas, Enrique
We report a 3-year-old Peruvian girl, born to non-consanguineous parents. At the age of 8 months, she had a severe pneumonia complicated with empyema that required thoracic drainage and mechanical ventilation. Although no microorganisms were isolated, the patient recovered with broad-spectrum antibiotics. Since that date, she has presented multiple episodes of pneumonia and recurrent episodes of bronchospasm. At 1 year 5 months of age, the patient began with recurrent episodes of oropharyngeal, vaginal, and skin candidiasis, which improved transiently after using oral azole drugs. At 2.5 years of age, she was admitted with lupus-like syndrome, including serositis, hemolytic anemia, thrombocytopenia, and positive antinuclear (1:80) and dsDNA (1:10) autoantibodies. Available immunologic testing was not contributory. Imaging studies revealed bilateral ethmoidal sinusitis and mild hepatomegaly. Bone marrow analysis did not showed evidence of leukemia or myelodysplasia, while renal biopsy concluded mild mesangial proliferation. Genetic studies revealed a pathogenic heterozygous signal transducer and activator of transcription 1 gain-of-function mutation (WT/P293L). The clinical status and lung function of the patient has worsened progressively. She has not achieved an optimal response to therapy, including high-dose intravenous immunoglobulin, GM-CSF, prophylactic antibiotics and antifungal drugs, so we plan to perform hematopoietic stem cell transplantation. PMID:28367431
van Aalst, J; Beuls, E A M; Cornips, E M J; Vanormelingen, L; Vandersteen, M; Weber, J W; Vles, J S H
Cases of infected dermal sinus are scarce and detailed surgical anatomical descriptions are hardly found in literature. The clinical, radiological, and surgical findings in four cases of an infected dermal sinus located at the lower spine are presented to elucidate the pathological anatomical configuration. The first case showed two dermal sinuses with a parallel course extra- and intradurally, ending in a confluence of cavities connected to the conus. In this case, as well as in the fourth case, the signs and symptoms were those of meningitis. The second case presented with meningitis and a subdural empyema, while the third case presented with an intradermoid-intramedullary abscess at the junction between the DS and the conus. This child probably showed signs and symptoms of conus involvement as early as during pregnancy. The anatomy of the nervous elements in this congenital anomaly is heavily disturbed, more particularly in case of infection, due to extensive arachnoidal scarring. The latter renders dissection laborious and recognition of anatomical details difficult, resulting in complete excision of a dermal sinus in less than half of the cases. Despite their variability in presentation, most cases of an infected dermal sinus show similar characteristic features.
Herrera Labarca, P; Prenzel Leupolt, I; García Henríquez, I
Severity and increasing incidence of serious infections due to Haemophilus influenzae in children have been stressed in recent publications. An analysis of the clinical records of the Department of Pediatrics, Hospital Roberto del Río (Santiago, Chile) was made in order to gather information about frequency and clinical feature of this kind of infections in our environement. 120 children under 3 years of age in whom H. influenzae was isolated in samples of one or more of the following sources: CSF, blood, bone marrow, pleural and synovial fluids, were admitted from January 1970 to March 1976. Among the different syndromes observed, bacterial meningitis (83.3%) was associated with other localizations in 27%. Empyema (12.5%) was often (46.6%) associated with meningitis. Both clinical entities were the most common and with a definite tendency to increase their frequency in last years. Cultures of CSF, blood and bone marrow were considered effective tests for diagnosis in severe infections due to H. influenzae. Although precise incidence figures may not be obtained from the present data, this kind of diseases may be considered frequent and severe (mortality: 26.6% in this study).
Dias de Castro, E; Leblanc, A; Sarmento, A; Cernadas, J R
Recent studies have demonstrated a low cross-reactivity between β-lactam antibiotics and carbapenems in IgE-mediated reactions. There are no studies on cross-reactivity of meropenem in patients with non-immediate hypersensitivity to cephalosporins. We describe a case of a 13-year-old male, admitted in Neurosurgery with a severe extradural empyema complicating frontal sinusitis, submitted to an emergent bifrontal craniotomy. A generalized maculopapular exanthema, fever and malaise, appeared by the 7th day of meningeal doses of ceftriaxone, clindamycin and vancomycin. Those were replaced by meropenem, with posterior worsening of the reaction and mucosal involvement. A new scheme with amikacin, metronidazole and linezolid was done with improvement. Skin prick, intradermal and patch tests to penicillins, ceftriaxone and meropenem were negative. Lymphocyte transformation test was positive to ceftriaxone and negative to meropenem.Non-immediate T cell mechanism seems to be involved. Diagnosis work-up couldn't exclude cross-reactivity between ceftriaxone and meropenem.
Matsumoto, N; Mukae, H; Nakamura-Uchiyama, F; Ashitani, J-I; Abe, K; Katoh, S; Kohno, S; Nawa, Y; Matsukura, S
To investigate the pathogenic mechanisms of eosinophilic pleural effusion in patients with paragonimiasis, we measured the levels of various chemokines including thymus and activation-regulated chemokine (TARC), eotaxin, RANTES and IL-8 in pleural effusion samples. Samples were obtained from 11 patients with Paragonimus westermani infection, six patients with pleural transudate, eight with tuberculous pleurisy and five with empyema. High percentages of eosinophils were detected in pleural fluid (range 9–100%, median 81%) of patients with paragonimiasis. TARC concentrations in pleural effusions of paragonimiasis were markedly higher than those of other groups. Eotaxin levels were also higher in pleural effusions of paragonimiasis patients, although significant difference was noted only against transudate samples. There was a significant correlation between TARC concentrations and percentages of eosinophils, and between TARC and eotaxin concentrations in pleural effusion. There were also significant correlations between TARC concentration and the titre of anti-P. westermani IgG and between eotaxin concentration and the titre of anti-P. westermani IgG. Our findings suggest that TARC contributes to the pathogenesis of eosinophilic pleural effusion in paragonimiasis. PMID:12390321
Sadarangani, Sapna P; Cunningham, Scott A; Jeraldo, Patricio R; Wilson, John W; Khare, Reeti; Patel, Robin
Emerging antimicrobial resistance in members of the Bacteroides fragilis group is a concern in clinical medicine. Although metronidazole and carbapenem resistance have been reported in Bacteroides thetaiotaomicron, a member of the B. fragilis group, they have not, to the best of our knowledge, been reported together in the same B. thetaiotaomicron isolate. Herein, we report isolation of piperacillin-tazobactam-, metronidazole-, clindamycin-, ertapenem-, and meropenem-resistant B. thetaiotaomicron from a patient with postoperative intra-abdominal abscess and empyema. Whole-genome sequencing demonstrated the presence of nimD with at least a portion of IS1169 upstream, a second putative nim gene, two β-lactamase genes (one of which has not been previously reported), two tetX genes, tetQ, ermF, two cat genes, and a number of efflux pumps. This report highlights emerging antimicrobial resistance in B. thetaiotaomicron and the importance of identification and antimicrobial susceptibility testing of selected anaerobic bacteria. Copyright © 2015, American Society for Microbiology. All Rights Reserved.
Haas, Andrew R; Sterman, Daniel H
Over 1.5 million pleural effusions occur in the United States every year as a consequence of a variety of inflammatory, infectious, and malignant conditions. Although rarely fatal in isolation, pleural effusions are often a marker of a serious underlying medical condition and contribute to significant patient morbidity, quality-of-life reduction, and mortality. Pleural effusion management centers on pleural fluid drainage to relieve symptoms and to investigate pleural fluid accumulation etiology. Many recent studies have demonstrated important advances in pleural disease management approaches for a variety of pleural fluid etiologies, including malignant pleural effusion, complicated parapneumonic effusion and empyema, and chest tube size. The last decade has seen greater implementation of real-time imaging assistance for pleural effusion management and increasing use of smaller bore percutaneous chest tubes. This article will briefly review recent pleural effusion management literature and update the latest changes in common procedural terminology billing codes as reflected in the changing landscape of imaging use and percutaneous approaches to pleural disease management.
Lu, Shay; Tsai, Jeng-Dau; Tsao, Ten-Fu; Liao, Pei-Fen; Sheu, Ji-Nan
Streptococcus pneumoniae is a common cause of infectious diseases in children that may lead to life-threatening complications. Acute purulent pericarditis is an uncommon complication of S. pneumoniae in the antibiotic era. A healthy 4-year-old girl was admitted with pneumonia and pleural effusion. She had received one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age. She rapidly developed necrotizing pneumonia, complicated by bronchopleural fistula presenting as subcutaneous emphysema and pneumothorax and acute purulent pericarditis. S. pneumoniae serotype 19A was subsequently identified from blood, empyema and pericardial fluid cultures. After appropriate antibiotic therapy and a right lower lobectomy, her condition stabilized and she promptly recovered. This case highlights two rare potential clinical complications of pneumococcal disease in a child: necrotizing pneumonia and acute purulent pericarditis. This is the first report of a child who received just one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age, as per the United States' Advisory Committee on Immunization Practice's recommendations, but who still developed severe invasive pneumococcal disease with life-threatening complications caused by S. pneumoniae serotype 19A.
Lu, Shay; Tsai, Jeng-Dau; Tsao, Ten-Fu; Liao, Pei-Fen; Sheu, Ji-Nan
Streptococcus pneumoniae is a common cause of infectious diseases in children that may lead to life-threatening complications. Acute purulent pericarditis is an uncommon complication of S. pneumoniae in the antibiotic era. A healthy 4-year-old girl was admitted with pneumonia and pleural effusion. She had received one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age. She rapidly developed necrotizing pneumonia, complicated by bronchopleural fistula presenting as subcutaneous emphysema and pneumothorax and acute purulent pericarditis. S. pneumoniae serotype 19A was subsequently identified from blood, empyema and pericardial fluid cultures. After appropriate antibiotic therapy and a right lower lobectomy, her condition stabilized and she promptly recovered. This case highlights two rare potential clinical complications of pneumococcal disease in a child: necrotizing pneumonia and acute purulent pericarditis. This is the first report of a child who received just one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age, as per the United States' Advisory Committee on Immunization Practice's recommendations, but who still developed severe invasive pneumococcal disease with life-threatening complications caused by S. pneumoniae serotype 19A.
Tsubakimoto, Maho; Murayama, Sadayuki; Iraha, Rin; Kamiya, Hisashi; Tsuchiya, Nanae; Yamashiro, Tsuneo
Peripheral bronchopleural fistulas (BPF) are communications between a peripheral bronchus or the lung parenchyma and the pleural space. Although reported cases with peripheral BPF might have typical symptoms, we postulate that there may be BPF patients without typical symptoms who are diagnosed on computed tomography (CT) for the first time. We searched retrospectively for how frequently BPF is found on CT in cases with known or suspected empyema or hydropneumothorax. Also, we examined the clinical charts to ascertain if a diagnosis of BPF was suspected in the CT reports or clinically, and to determine the outcome of each case. Thirteen thoracic cavities of 12 patients were included in this study. Of these, BPF was suspected clinically in only 1. Mention in the CT report about the presence of BPF was found in 2 cases. An apparent finding of BPF on CT was found in 7 of 13 (53%) thoracic cavities of 6 cases. The outcomes were that 1 patient died 1 month later due to multiple organ failure, and 1 patient was discharged subsequently after CT. In the other 10 cases, there was no exacerbation of the symptom regardless of definite evidence of BPF on CT. In conclusion, when there is hydropneumothorax on CT, it is important for radiologists to diligently search for findings of peripheral BPF and to document it. However, a reference about the need for a surgical approach for BPF may not be required.
Hannoodi, Faris; Ali, Israa; Sabbagh, Hussam; Kumar, Sarwan
We report a case of a 52-year-old immunocompetent Caucasian female treated for necrotizing Streptococcus intermedius pneumonia and review available literature of similar cases. Our patient presented with respiratory failure and required hospitalization and treatment in the intensive care unit. Moreover, she required surgical drainage of right lung empyema as well as decortication and resection. The review of literature revealed three cases of S. intermedius pneumonia, one of which was a mortality. Comparison of the published cases showed a highly varied prehospital course and radiological presentations, with a symptomatic phase ranging from 10 days to five months. Radiological findings varied from an isolated pleural effusion to systemic disease with the presence of brain abscesses. Immunocompetence appears to correlate well with the overall prognosis. In addition, smoking appears to be an important risk factor for S. intermedius pneumonia. In 2 (50%) of cases, pleural fluid analysis identified S. intermedius. In contrast, no organism was found in our patient, necessitating the acquisition of lung tissue sample for the diagnosis. In conclusion, both medical and surgical management are necessary for effective treatment of S. intermedius pneumonia. The outcome of treatment is good in immunocompetent individuals.
Ali, Israa; Sabbagh, Hussam; Kumar, Sarwan
We report a case of a 52-year-old immunocompetent Caucasian female treated for necrotizing Streptococcus intermedius pneumonia and review available literature of similar cases. Our patient presented with respiratory failure and required hospitalization and treatment in the intensive care unit. Moreover, she required surgical drainage of right lung empyema as well as decortication and resection. The review of literature revealed three cases of S. intermedius pneumonia, one of which was a mortality. Comparison of the published cases showed a highly varied prehospital course and radiological presentations, with a symptomatic phase ranging from 10 days to five months. Radiological findings varied from an isolated pleural effusion to systemic disease with the presence of brain abscesses. Immunocompetence appears to correlate well with the overall prognosis. In addition, smoking appears to be an important risk factor for S. intermedius pneumonia. In 2 (50%) of cases, pleural fluid analysis identified S. intermedius. In contrast, no organism was found in our patient, necessitating the acquisition of lung tissue sample for the diagnosis. In conclusion, both medical and surgical management are necessary for effective treatment of S. intermedius pneumonia. The outcome of treatment is good in immunocompetent individuals. PMID:27891283
Weigel, W; Hayek, W H; Bens, G
A fatally ending index case of septic osteoarthritis that was diagnosed retrospectively initiated this report. This patient had severe, asymmetrically distributed metaphyseal growth disturbances at many long bones. In order to determine the features of early radiologic diagnosis we report the findings of 7 further patients with neonatal septic osteoarthritis with clinical and radiological follow-up. The most important observation for early radiologic diagnosis of osteoarthritis is the displacement of fat layers along the metaphysis. Other findings of the soft tissues have the same diagnostic value as bone destruction and subperiosteal new bone formation found one to three weeks later on roentgenfilms. Detecting early signs of osteoarthritis helps in localizing the focus for bacteriologic diagnosis, which is said to be more successful than blood cultures. Diagnosing a joint empyema initiates surgical intervention for pressure relief in order to avoid necrosis of the epiphysis as seen in the femoral head in septic arthritis of the hip joint. Early diagnosis and treatment prior to destruction of the growing cartilage is necessary to avoid growth disturbances and length discrepancies of long bones. In cases of sepsis a so called "babygram" and a repeat examination 10 to 14 days later is mandatory.
Massard, G; Roeslin, N; Wihlm, J M; Dumont, P; Witz, J P; Morand, G
From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.
Oral, Sukru; Borklu, Resul Emin; Kucuk, Ahmet; Ulutabanca, Halil; Selcuklu, Ahmet
OBJECTIVE: One or two burr-hole craniostomies with subgaleal or subdural drainage system and irrigation are the most common methods for surgical treatment of CSDH. The aim of this study is to compare the advantages or disadvantages of these techniques used for CSDH. METHODS: Seventy patients were treated by burr-hole subdural drainage or subgaleal drainage system with irrigation. Our patients were classified into two groups according to the operative procedure as follows: Group I, one or two burr-hole craniostomy with subgaleal closed system drainage and irrigation (n=36), Group II, one or two burr-hole craniostomies with subdural closed drainage system and irrigation (n=38). We compared male and female ratios, complication rates, and age distribution between groups. RESULTS: There was no remarkable difference between recurrence rates of the two groups. Recurrence rate was 6.25% in Group I and 7.8% in Group II. Subdural empyema occurred in one of the patients in Group II. Symptomatic pneumocephalus did not develop in patients. Four patients were reoperated for recurrence at an average of 12–20 days after the operation with the same methods. CONCLUSION: Both of the techniques have a higher cure rate and a lower risk of recurrence. However, subgaleal drainage system is relatively less invasive, safe, and technically easy. So it is applicable for aged and higher risk patients. PMID:28058351
Chow, Siu-Kei; Clarridge, Jill E
Helcococcus spp. are Gram-positive, catalase-negative, facultatively anaerobic cocci that are associated with wound and prosthetic joint infections as well bacteremia and empyema. Five Helcococcus spp. strains were isolated from our patient population, including 2 strains of Helcococcus kunzii from trauma-associated wounds, 2 Helcococcus sueciensis strains from blood and abscess, and a novel Helcococcus spp. strain from blood associated with urosepsis. Based on the phenotypic and phylogenetic evidence, we propose that the unknown bacterium be classified as Helcococcus seattlensis sp. nov. We found that all 5 tested Helcococcus strains grew as satellite colonies around Staphylococcus aureus and, interestingly, both H. kunzii strains were isolated together with S. aureus. In addition to 16S rRNA gene sequencing, conventional methods for leucine aminopeptidase (LAP) and pyrrolidonyl arylamidase (PYR) testing can be cost-effective and efficient for differentiation of Helcococcus spp. from Abiotrophia and Granulicatella species. Using nonstandard methods, we found that all tested Helcococcus spp. had high MICs of >4/76 μg/ml for trimethoprim-sulfamethoxazole, an antibiotic commonly used to treat urinary tract infections. High MICs for erythromycin, azithromycin, and clindamycin, and intermediate to high MICs for moxifloxacin, levofloxacin, and gentamicin were also observed among the Helcococcus strains.
De Malet, Ana; Ingerto, Sheila
Salmonella Newport is a Gram-negative bacillus belonging to the Enterobacteria family and the nontyphi Salmonella (NTS), usually related to gastroenteritis. Main difference between NTS and Salmonella typhi is that the last one evolves to an invasive disease easier than NTS. These can progress to bacteremias in around 5% of cases and secondary focuses can appear occasionally, as in meningitis. An infection of the central nervous system is uncommon, considering its incidence in 0.6–8% of the cases; most of them are described in developing countries and mainly in childhood, especially neonates. Bacterial meningitis by NTS mostly affects immunosuppressed people in Europe. Prognosis is adverse, with a 50% mortality rate, mainly due to complications of infection: hydrocephalus, ventriculitis, abscesses, subdural empyema, or stroke. Choice antibiotic treatments are cefotaxime, ceftriaxone, or ceftazidime. The aim of this paper is to present a case of meningitis caused by Salmonella Newport diagnosed in a five-year-old girl living in a rural area of the province of Ourense (Spain), with favorable evolution and without neurological disorders. PMID:28058121
Pérez-Guzmán, C.; Barrera-Rodríguez, R.; Portilla-Segura, J.
Background Malignant pleural mesothelioma is a rare, invasive and often fatal neoplasm that develops in the thin layer of tissue surrounding the lungs known as the pleura. Although rare, mesotheliomas do occur in the young; their characteristics are distinct from those of older patients. Case presentation This is a case report of a 17-year-old boy who had moderate dyspnea, cough, right-sided pleuritic chest pain, fever, headache and no weight loss. Physical examination showed a right pleural effusion and chest roentgenograms revealed a homogenous opacity on lower right hemithorax. Biochemical analysis of pleural fluid showed hemorrhagic/turbid effusion compatible with exudate. It was initially treated as an empyema. The pleural fluid culture was negative. Adenosine deaminase level was 34.3 U/L (admission) and 19.02 U/L (two weeks after). Pleural fluid smear and culture for Mtb were negative. During the open pleural biopsy, thickened pleura and multiple pale yellow nodules in the lung were observed. The histopathological report was compatible with malignant pleural mesothelioma. With this diagnosis, a chemotherapy regimen with cisplatin was initiated. After two cycles, the patient had no clinical and radiological improvement. The patient is currently under regular follow up. Conclusion MPM is rare in young adults and its clinical presentation makes it different from mesothelioma in elderly patients, so it will be necessary to identify the new risk factors that can identify these patients. PMID:27222787
Pérez-Guzmán, C; Barrera-Rodríguez, R; Portilla-Segura, J
Malignant pleural mesothelioma is a rare, invasive and often fatal neoplasm that develops in the thin layer of tissue surrounding the lungs known as the pleura. Although rare, mesotheliomas do occur in the young; their characteristics are distinct from those of older patients. This is a case report of a 17-year-old boy who had moderate dyspnea, cough, right-sided pleuritic chest pain, fever, headache and no weight loss. Physical examination showed a right pleural effusion and chest roentgenograms revealed a homogenous opacity on lower right hemithorax. Biochemical analysis of pleural fluid showed hemorrhagic/turbid effusion compatible with exudate. It was initially treated as an empyema. The pleural fluid culture was negative. Adenosine deaminase level was 34.3 U/L (admission) and 19.02 U/L (two weeks after). Pleural fluid smear and culture for Mtb were negative. During the open pleural biopsy, thickened pleura and multiple pale yellow nodules in the lung were observed. The histopathological report was compatible with malignant pleural mesothelioma. With this diagnosis, a chemotherapy regimen with cisplatin was initiated. After two cycles, the patient had no clinical and radiological improvement. The patient is currently under regular follow up. MPM is rare in young adults and its clinical presentation makes it different from mesothelioma in elderly patients, so it will be necessary to identify the new risk factors that can identify these patients.
Constant, M; Nicot, R; Maes, J-M; Raoul, G; Ferri, J
Septic arthritis are serious infections rarely observed for the temporomandibular joint. They are mainly hematogenous or transmitted by contiguity. Our patient presents the case of an infection of the temporomandibular joint by maxillary sinusitis of dental origin further complicated by cerebral abscess and empyema. Initial treatment consisted of an endonasal and intraoral drainage, intravenous empirical antibiotic therapy, a close clinicoradiological monitoring, and rehabilitation following a long-term active physiotherapy. Furthermore, the patient reported the onset of a dental articulation disorder with a left side premature contact and right lateral open bite, corresponding to a significant left condylar resorption. This infectious disease is very rare for temporomandibular location; however, its general and functional outcome is determined by the precocity of the treatment. It is important to know the diagnosis and the associated symptoms even if they are not very specifically described. It is essential to consider the diagnosis when facing atypical pain of the temporomandibular joint associated with trismus. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Zhou, Menglan; Wang, Peng; Chen, Sharon; Du, Bin; Du, Jinlong; Wang, Fengdan; Xiao, Meng; Kong, Fanrong; Xu, Yingchun
Mycoplasma hominis, a well known cause of neonatal infection, has been reported as a pathogen in urogenital infections in adults; however, central nervous system (CNS) infections are rare. We report here the first case of M. hominis meningitis in China, post neurosurgical treatment for an intracerebral haemorrhage in a 71-year-old male. We describe a 71-year-old man who developed M. hominis meningitis after neurosurgical treatment and was successfully treated with combined azithromycin and minocycline therapy of 2 weeks duration, despite delayed treatment because the Gram stain of cerebrospinal fluid (CSF) yielded no visible organisms. The diagnosis required 16S rDNA sequencing analysis of the cultured isolate from CSF. Literature review of M. hominis CNS infections yielded 19 cases (13 instances of brain abscess, 3 of meningitis, 1 spinal cord abscess and 1 subdural empyema each). Delay in diagnosis and initial treatment failure was evident in all cases. With appropriate microbiological testing, antibiotic therapy (ranging from 5 days to 12 weeks) and often, multiple surgical interventions, almost all the patients improved immediately. Both our patient findings and the literature review, highlighted the pathogenic potential of M. hominis together with the challenges prompted by rare infectious diseases in particular for developing countries laboratories with limited diagnostic resources.
A 23-year-old man living on the island of Hawai‘i developed a life threatening case of eosinophilic meningitis caused by infection with Angiostrongylus cantonensis (rat lungworm disease: RLWD). He was comatose for 3 months, incurring brain and nerve damage sufficiently extensive that he was not expected to recover. The case was complicated by secondary infections of methicillin-resistant Staphylococcus aureus, Clostridium difficile, and pneumonia, which resulted in an empyema requiring a thoracoscopy and decortication. He was treated with prednisone, mebendozal, and pain medication for RLWD, and antibiotics and antifungal medications for the secondary infections. The administration of herbal supplements was requested by the family and approved, and these were administered through a gastric tube. Less than a month after being declared in a persistent vegetative state the man was able to talk, eat, and had regained some muscle functions. After release from the hospital he continued the use of supplements and received treatments of intravenous vitamin therapy. Four years after onset of the illness he is able to ride a bicycle, is a part time student, plays guitar, and is fluent in two foreign languages. RLWD is an emerging tropical disease of growing importance in Hawai‘i. PMID:23900708
Khullar, Pooja; Datta, Niloy R; Wahi, Inderjeet Kaur; Kataria, Sabeena
61 year old female presented with chief complaints of headache for 30 days, fever for 10 days, altered behavior for 10 days and convulsion for 2 days. She was diagnosed and treated as a case of carcinoma of left breast 5 years ago. MRI brain showed a lobulated lesion in the left frontal lobe. She came to our hospital for whole brain radiation as a diagnosed case of carcinoma of breast with brain metastasis. Review of MRI brain scan, revealed metastasis or query infective pathology. MR spectroscopy of the lesion revealed choline: creatinine and choline: NAA (N-Acetylaspartate) ratios of ∼1.6 and 1.5 respectively with the presence of lactate within the lesion suggestive of infective pathology. She underwent left fronto temporal craniotomy and evacuation of abscess and subdural empyema. Gram stain showed gram positive cocci. After 1 month of evacuation and treatment she was fine. This case suggested a note of caution in every case of a rapidly evolving space-occupying lesion independent of the patient's previous history. Copyright © 2015 The Authors. Production and hosting by Elsevier B.V. All rights reserved.
Akuzawa, Nobuhiro; Osawa, Tenshi; Totsuka, Masayuki; Hatori, Takashi; Imai, Kunihiko; Kitahara, Yonosuke; Kurabayashi, Masahiko
Escherichia coli (E. coli) is the most common causative bacteria of neonatal meningitis, but hematogenous intracranial E. coli infection is rare in adults. Moreover, intracranial abscess formation owing to E. coli, including brain abscesses and subdural empyema formation, is extremely rare. We herein present a case involving a patient with a brain abscess owing to E. coli following a simple renal cyst infection. A review of the literature is also presented. A 77-year-old Japanese woman with a history of polymyalgia rheumatica was admitted to our hospital because of persistent fever, right flank pain, and pyuria. Intravenous antibiotics were administered; however, her level of consciousness deteriorated 6 days after admission. Contrast-enhanced magnetic resonance imaging showed a brain abscess in the left occipital lobe and pyogenic ventriculitis. Enhanced abdominal computed tomography revealed a right renal cyst with heterogeneous content. Culture of urine, blood, and aspirated pus from the infected cyst revealed E. coli with identical antibiotic sensitivity in all sites, suggesting that the cyst infection and subsequent bacteremia might have caused the brain abscess. The patient recovered after a 6-week course of meropenem. The prognosis of patients with E. coli-associated intracranial abscess is usually poor. Advanced age and immunosuppression may be potent risk factors for intracranial abscess formation owing to the hematogenous spread of E. coli.
Minimal inhibitory concentrations (MICs) and minimal bactericidal concentrations (MBCs) of various antimicrobial agents were measured against 12 strains of Streptococcus pyogenes isolated from children with invasive infections between 2003 and 2012. The patients ranged in age from 1 day to 15 years, with patients younger than 5 years, including three neonates, accounting for a half of the patients. The disease was sepsis in four patients, skin and soft tissue infection in three patients, retropharyngeal abscess in two patients, pneumonia plus sepsis in one patient, empyema in one patient, and pyogenic arthritis in one patient. One patient with sepsis died, while cure without sequelae was achieved in all the remaining patients. When classified by type, emm1 (six strains) was the most prevalent type, followed by emm12 (two strains). The MIC90/MBC90 values were 0.015/0.015 μg/mL for penicillin G, 0.03/0.03 μg/mL for ampicillin, 0.015/0.03 μg/mL for cefotaxime, 0.03/0.03 μg/mL for ceftriaxone, 0.008/0.008 μg/mL for panipenem, 0.008/0.008 μg/mL for meropenem, and ≤0.004/≤0.004 μg/mL for doripenem, indicating the superior antimicrobial activities of carbapenem.
Cox, Mougnyan; Patel, Manisha; Deshmukh, Sandeep; Roth, Christopher G; Flanders, Adam E
Brain abscesses cause substantial morbidity and mortality even after appropriate therapy, and no underlying cause is found in 25% of cases. We investigated the added utility of contrast-enhanced chest computed tomography (CT) in the diagnostic work-up of patients presenting with cerebral abscesses and no history or prior trauma or cranial surgery. All patients presenting to a single institution with a surgically proven brain abscess were reviewed. Concurrent contrast-enhanced chest CT imaging results were reviewed when available to identify treatable predisposing causes of intracranial suppuration. This study included 31 patients with biopsy-proven abscesses. Multiple abscesses were present in 8 patients (26%). Contrast-enhanced CT was performed in 15 patients (48%). Of these 15 patients, 2 had pulmonary arteriovenous malformations, 1 had an intrapulmonary shunt, and 3 had empyemas. Definitive therapy for the chest findings was provided to 6 of the 15 patients (40%). In the remaining 9 patients, 3 had pulmonary abscesses, for which diagnostic aspiration was requested. Another patient had an incidental pulmonary embolism, resulting in same-day placement of an inferior vena caval filter (not included in chest analysis, given that the finding was incidental). Contrast-enhanced chest CT is useful for identifying treatable causes of cerebral abscesses in patients with a cerebral abscess and no history of surgery or trauma. Copyright © 2017 Elsevier Inc. All rights reserved.
Wang, Xiao-Juan; Yang, Yuan; Wang, Zhen; Xu, Li-Li; Wu, Yan-Bing; Zhang, Jun; Tong, Zhao-Hui; Shi, Huan-Zhong
The differential diagnosis of pleural effusions can present a considerable challenge, and the etiology of pleural effusions varies depending on the population studied. This study aimed to assess the efficacy and safety of medical thoracoscopy in the diagnosis of patients with undiagnosed pleural effusions in a Chinese population. Between July 2005 and June 2014, medical thoracoscopy (MT) using the semirigid instrument was performed in 833 patients with pleural effusions of unknown etiology in our Institute, where diagnostic thoracocentesis or/and blind pleural biopsy had failed to yield an answer. Demographic, radiographic, procedural, and histological data were recorded and analyzed. During this 9-year study, satisfactory pleural biopsy samples were obtained in 833 patients, and MT revealed malignant pleural effusion in 342 (41.1%) patients, benign pleural effusion in 429 (51.5%) patients, and 62 (7.4%) patients could not get definite diagnoses. The overall diagnostic efficiency of MT was 92.6% (771/833). After MT, the only severe complication was empyema, seen in 3 patients (0.4%). The most common minor complication was transient chest pain (44.1%) from the indwelling chest tube. MT is an effective and safe procedure for diagnosing pleural effusions of undetermined causes. In areas with high tuberculosis prevalence, MT should be particularly helpful in the differential diagnosis of tuberculous pleural effusion. © 2015 S. Karger AG, Basel.
Zanello, Marc; Charlier, Philippe; Corns, Robert; Devaux, Bertrand; Berche, Patrick; Pallud, Johan
On 30 June 1559, Henry II, King of France, was mortally wounded in the head by a lance during a jousting match. Despite the best efforts of his physicians, Ambroise Paré and Andreas Vesalius, King Henry died 11 days later. This article, based on previously unpublished evidence, aims at examining the historical account of his death against modern medical practice to establish the probable cause of the king's death. We also discuss what treatments the doctors in the sixteenth century may have had to offer. Historical accounts of the joust provide details of the incident including the position of the visor of the king's helmet. Descriptions of the wood fragments removed from the right orbit by Italian observers and a new translation of the autopsy by Andreas Vesalius allow an accurate description of the actual injury. Our research counters previous theories and concludes that Henry II was the victim of craniofacial trauma involving the right eye and that he died from periorbital cellulitis caused by a retained foreign body in the wound, complicated by a left interhemispheric empyema preceded by a traumatic interhemispheric haematoma. It would appear that the royal court doctors advocated a wait-and-see strategy, with little actual input from Ambroise Paré or Andreas Vesalius, with a clearly regrettable outcome.
Adina, Man Milena; Popovici, Bogdan
Pleural empyema and bronchopleural fistula (the communication between the pleural space and the airways) are early or late complications of various diseases. We present the case of a 29-year-old patient operated for cavitary pulmonary tuberculosis and giant caseoma at the age of seven, who also had fibrocavitary pulmonary tuberculosis positive for mycobacterium tuberculosis at the age of 19. The patient presented with low grade fever, chills, sweating, cough with mucopurulentsputum, dyspnea on mild exertion, perioral cyanosis, cyanosis of the limbs at exertion, anorexia, weight loss and skin suppuration on the left side of thorax. The diagnosis of chronic pulmonary suppuration, the failure of conservative therapy (multiple antibiotic treatments in the last three years), the presence and size of the bronchopleural cutaneous fistula, thepatient's surgical history (presence of "lifesaving"sutures), as well as his immunocompromised state required that conservative medical treatment (antibiotics, antimycotics and supportive medication for six months) be associated with surgery. An open window thoracostomy was selected over segmentectomy or lobectomy due to their associated risks caused by anatomic changes in the large vessels. The open window thoracostomy should not be forgotten or abandoned as it may be the only approach that ensures patient survival and the effective management of the residual cavity and chronicsuppuration in selected cases.
High, Kevin; Brywczynski, Jeremy; Guillamondegui, Oscar
The use of thoracostomy to treat tension pneumothorax is a core skill for prehospital providers. Tension pneumothoraces are potentially lethal and are often encountered in the prehospital environment. The authors reviewed the prehospital electronic medical records of patients who had undergone finger thoracostomy (FT) or tube thoracostomy (TT) while under the care of air medical crewmembers. Demographic data were obtained along with survival and complications. During the 90-month data period, 250 patients (18 years of age or older) underwent FT/TT, with a total of 421 procedures performed. The mean age of patients was 44.8 years, with 78.4% being male and 21.6% being female; 98.4% of patients had traumatic injuries. Cardiopulmonary resuscitation was required in 65.2% of patients undergoing FT/TT; 34.8% did not require cardiopulmonary resuscitation. Thirty percent of patients exhibited clinical improvement such as increasing systolic blood pressure, oxygen saturation, improved lung compliance, or a release of blood or air under tension. Patients who experienced complications such as tube dislodgement or empyema made up 3.4% of the cohort. The results of this study suggest that flight crews can use FT/TT in their practice on patients with actual or potential pneumothoraces with limited complications and generate clinical improvement in a subset of patients. Copyright © 2016 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Kesieme, Emeka B.; Dongo, Andrew; Ezemba, Ndubueze; Irekpita, Eshiobo; Jebbin, Nze; Kesieme, Chinenye
Background. Tube thoracostomy is widely used throughout the medical, surgical, and critical care specialities. It is generally used to drain pleural collections either as elective or emergency. Complications resulting from tube thoracostomy can occasionally be life threatening. Aim. To present an update on the complications and management of complications of tube thoracostomy. Methods. A review of the publications obtained from Medline search, medical libraries, and Google on tube thoracostomy and its complications was done. Results. Tube thoracostomy is a common surgical procedure which can be performed by either the blunt dissection technique or the trocar technique. Complication rates are increased by the trocar technique. These complications have been broadly classified as either technical or infective. Technical causes include tube malposition, blocked drain, chest drain dislodgement, reexpansion pulmonary edema, subcutaneous emphysema, nerve injuries, cardiac and vascular injuries, oesophageal injuries, residual/postextubation pneumothorax, fistulae, tumor recurrence at insertion site, herniation through the site of thoracostomy, chylothorax, and cardiac dysrhythmias. Infective complications include empyema and surgical site infection. Conclusion. Tube thoracostomy, though commonly performed is not without risk. Blunt dissection technique has lower risk of complications and is hence recommended. PMID:22028963
Objective—To assess the complication rate of tube thoracostomy in trauma. To consider whether this rate is high enough to support a selective reduction in the indications for tube thoracostomy in trauma. Methods—A retrospective case series of all trauma patients who underwent tube thoracostomy during a 12 month period at a large UK teaching hospital with an accident and emergency (A&E) department seeing in excess of 125 000 new patients/year. These patients were identified using the hospital audit department computerised retrieval system supplemented by a hand search of both the data collected for the Major Trauma Outcome Study and the A&E admission unit log book. The notes were assessed with regard to the incidence of complications, which were divided into insertional, infective, and positional. Results—Fifty seven chest drains were placed in 47 patients over the 12 month period. Seven patients who died within 48 hours of drain insertion were excluded. The commonest indications for tube thoracostomy were pneumothorax (54%) and haemothorax (20%); 90% of tubes were placed as a result of blunt trauma. The overall complication rate of the procedure was 30%. There were no insertional complications and only one (2%) major complication, which was empyema thoracis. Conclusion—This study reveals no persuasive evidence to support a selective reduction in the indications for tube thoracostomy in trauma. A larger study to confirm or refute these findings must be performed before any change in established safe practice. PMID:10718232
Grigorescu, D; Maghiar, A
The aim of the paper is to observe the effectiveness of prophylactic administration of antibacterials against empyema and pneumonia after tube thoracostomy for traumatic collections. Observational retrospective study over a ten years period (2002-2011), at the Oradea County Emergency Hospital on 939 patients with chest tube drainage for traumatic haemo/pneumothoraces. The morbidity by intrathoracic infections was 5,5% in the curative antibiotic group. The median number of risk factors for surgical infections and case severity were not statistically different (p=0.9653 and p=0,6601) between cases with antibioprophylaxis and curative treatment, but the incidence of intrathoracic infection in the prophylaxis group (n=86) was half (2,3%). Antibioprophylaxis was effective in over 95% of the cases and it associated in-hospital length of stay, length of stay in the ICU and costs of care significantly (p<0.0001, p<0.0001, p=0.0046) lesser than of those patients treated with curative regimen. The overall mortality was 8.6% within the curative regimen group with an attributable mortality to infections of 17.39%; but it was only 2.3% and respectively 0 within the prophylaxis group. Antibiotic prophylaxis for intrathoracic infections after tube thoracostomy for traumatic collections was justified by case severity and risk factors and was effective and cost-efficient, but it should be administered selectively.
Nasr, Mohamed M
The practice of tube thoracostomy entails high risk as it is a closed technique. Open thoracostomy and closed minithoracostomy techniques have been approved worldwide as safe modalities. Applying the concept of a new closed thoracostomy technique with high safety and simplicity is a major advancement in this regard. This was a case series pilot study introducing a new technique for closed-tube thoracostomy. Thirty-one patients with primary unilateral pneumothorax were selected for the study. All patients coming to the Emergency Department at Security Forces Hospital, Dammam City, Kingdom of Saudi Arabia, between January and August 2012, matching the study criteria were recruited to undergo the new technique. The surgical set required for the technique was defined and prepared sterile. Preinsertion and postinsertion chest x-ray and chest computed tomography scans were obtained for the entire study sample. We recruited the first 31 patients requiring tube thoracostomy who visited the Emergency Department. All procedures were performed by the author, assisted by on-call registrars. No complications were observed with the new technique. Moreover, advantages of the technique were demonstrated and documented. The new technique provides safe tube introduction and precise tube positioning, saves time, and involves no technical precautions. The technique has been applied on selected simple cases as the first trial and requires further testing in cases of hemothorax, empyema thoracis, traumatic chest injuries, and complicated pulmonary diseases that require drainage. Further evaluation of the technique by randomized studies is required.
Höhne, Julius; Brawanski, Alexander; Gassner, Holger G.; Schebesch, Karl-Michael.
Background: With decompressive craniectomy for ischemic stroke, traumatic brain injury, and skull-infiltrating tumors, the need for cranioplasty has increased. Different materials for custom-made cranioplasties have been evaluated, but a gold standard could not yet be established. We report our experience with the new custom-made titanium CRANIOTOP®cranioplasty (CL Instruments, Germany). Methods: A total of 50 consecutive patients received a CRANIOTOP cranioplasty within a 2 year interval. We reviewed the charts for time between initial surgery and cranioplasty, indication, complications, operative time, and cosmetic outcome. Postoperative imaging (computed tomography [CT] scan n = 48, magnetic resonance imaging (MRI) n = 5) was screened for fitting accuracy and for hemorrhages. Results: The most common indication for craniectomy were diffuse edema due to traumatic brain injury (n = 17, 34%) and ischemic stroke (n = 12, 24%). All patients were satisfied with the cosmetic result. In the postoperative CT scan accurate fitting was confirmed in all patients, the postoperative MRI was free of artifacts. Surgical revision was necessary in five patients because of empyema (n = 2), wound exposure (n = 2), and one cerebrospinal fluid fistula. Thus, the surgical morbidity was 10%. Conclusion: With due consideration of the limitations of this retrospective study, we feel the present data allow concluding that the custom-made titanium cranioplasty CRANIOTOP®is safe and feasible. PMID:23956931
Akarsu, Saadet; Kurt, A. Nese Citak; Dogan, Yasar; Yilmaz, Erdal; Godekmerdan, Ahmet; Aygun, A. Denizmen
The aim is to examine whether the changes in pleural fluid interleukin (IL)-1β, IL-2, IL-6, and IL-8 levels were significant in differential diagnosis of childhood pleural effusions. IL-1β, IL-2, IL-6, and IL-8 levels in pleural fluids of all 36 patients were measured. The levels of IL-1β, IL-2, IL-6, and IL-8 in pleural fluids were statistically significantly higher in the transudate group compared with those of the exudate group. The levels of IL-1β, IL-6, and IL-8 were also found to be statistically significantly higher in the empyema group compared with both the parapneumonic and the tuberculous pleural effusion groups. The levels of IL-2 and IL-6 were detected to be statistically significantly higher in the tuberculous pleural effusion group in comparison with those of the parapneumonic effusion group. The results showed that pleural fluids IL-1β, IL-2, IL-6, and IL-8 could be used in pleural fluids exudate and transudate distinction. PMID:15770060
Danielian, Sh N; Abakumov, M M; Vil'k, A P; Saprin, A A; Tatarinova, E V
It was performed retrospective analysis of 463 cases of suppurative thoracic complications after injury (232) and closed thoracic trauma (231) for 20-year period. Incidence of purulent complications was 3.2% and 1.6% in case of injury and closed thoracic trauma respectively including pleural empyema in 1.5 and 1.3%, pulmonary abscess in 0.3 and 0.4%, mediastinitis in 0.35 and 0.12%, pericarditis in 1.5 and 0.26%, osteomyelitis in 0.4 and 0.18% respectively. Factors preceding suppurative complications in case of injuries and closed trauma have been considered as predictors. Multivariant regression analysis established significant risk factors of suppurative thoracic complications. Clotted hemothorax, mediastinal hemorrhage, heart injury, late appeal for medical assistance and mechanical ventilation over 5 days were identified irrespective of character of trauma. In case of thoracic injury there were damage of osteochondrous frame, hollow thoracic and abdominal organs, gunshot wound of lung, delirium and injuries severity over 20 scores according to ISS scale. Pulmonary bleeding, sternal fracture and Glasgow Coma Scale rate<12 scores were identified as risk factors in case of closed trauma.
Georgescu, Anca Meda; Azamfirei, Leonard; Szalman, Krisztina; Szekely, Edit
Abstract Background: Over the last decades Staphylococcus aureus (SA) has become the dominant etiology of native valve infective endocarditis, with the community-acquired methicillin-sensible Staphylococcus aureus (CA-MSSA) strains being the prevailing type. Case: We report here a case of extremely severe CA-MSSA aortic valve acute endocarditis associated with persistent Staphylococcus aureus bacteremia (SAB) in a previously healthy man and include a literature review. The patient developed severe and rare complications (purpura, purulent pericarditis, intracerebral hematoma, and rhabdomyolysis) through systemic embolism; they required drainage of pericardial empyema and cerebral hematoma, the latter eventually caused a fatal outcome. The strains recovered from sequential blood culture sets and pericardial fluid were MSSA negative for genes encoding for staphylococcal toxic shock syndrome toxin (TSST)-1 and Panton–Valentine leukocidin. C, G, and I enterotoxin genes were detected. Conclusions: This case with unusually severe evolution underlines the limited ability of vancomycin to control some MSSA infections, possibly due to potential involvement of SA virulence factors, hence the importance of clinical vigilance for community SAB cases. PMID:27741135
Martínez-Martínez, L; Suárez, A I; Winstanley, J; Ortega, M C; Bernard, K
During a 34-month period (January 1991 to October 1993), 31 Corynebacterium striatum stains recovered from clinical samples from 24 patients were characterized. Twenty (64%) strains were isolated from wound exudates, 5 (16%) were isolated from bronchial aspirates, 2 (7%) were isolated from urine, 2 (7%) were isolated from endotracheal tubes, 1 (3%) was isolated from a catheter, and 1 (3%) was isolated from empyema. The organisms were identified by conventional culture and phenotypic characterization, the API CORYNE system, and cellular fatty acid composition analyses. The colonies of C. striatum could be confused with those of coagulase-negative staphylococci upon primary isolation from clinical material. A consistent phenotypic pattern was observed: all strains reduced nitrate, hydrolyzed tyrosine, and produced acid from glucose, fructose, and sucrose but not from maltose. API CORYNE profile numbers were 3100105 (28 strains) and 3000105 (3 strains). Susceptibility testing of C. striatum was performed by disk diffusion. All strains were susceptible to both imipenem and vancomycin and resistant to fosfomycin; most strains were susceptible to ampicillin and cephalosporins and resistant to clindamycin, erythromycin, and tetracycline. Performing a Gram stain of fosfomycin-resistant "Staphylococcus-like" colonies was critical in order to identify C. striatum. PMID:7494046
Infection is a major complication of military chest injuries. In a series of 142 wounded, infectious complications occurred in 7 (4.9%). Factors influencing the incidence of infection are evaluated. In this group of injuries, 81 patients were admitted soon after wounding. The intrathoracic damage was severe, due to penetration of metallic fragment. The hemothorax was treated by immediate intercostal drainage. Immediate thoracotomy was performed in 10 patients and late thoractomy in 15. One patient developed a lung abscess and 5 patients had infection following thoracotomy (7.4%). Another 61 wounded patients had been first managed in a forward hospital, including three with thoractomy for massive bleeding. Two, not in a forward hospital, had a bullet removed from the lung. Upon admission to this hospital, intercostal drains were inserted when needed and four patients underwent thoracotomy. Larger wounds were debrided in 24 patients. Late thoracotomy was perfromed in seven. Chronic empyema developed in one patient after pneumonectomy performed at the field hospital, resulting in a resuscitation or infection rate of less than 2%. Factors contributing to a low infection rate were: early drainage of hemothoraces and wide debridement of larger wounds with delayed closure and avoidance of thoracotomy as primary treatment. Resection of lung tissue was avoided. Thoraco-abdominal injuries were treated separately. The clotted hemothorax was immediately evacuated. Prolonged antibiotic therapy was usually indicated. PMID:1211991
Attariwala, Rajpaul; Picker, Wayne
Diffusion-weighted imaging (DWI) is an established functional imaging technique that interrogates the delicate balance of water movement at the cellular level. Technological advances enable this technique to be applied to whole-body MRI. Theory, b-value selection, common artifacts and target to background for optimized viewing will be reviewed for applications in the neck, chest, abdomen, and pelvis. Whole-body imaging with DWI allows novel applications of MRI to aid in evaluation of conditions such as multiple myeloma, lymphoma, and skeletal metastases, while the quantitative nature of this technique permits evaluation of response to therapy. Persisting signal at high b-values from restricted hypercellular tissue and viscous fluid also permits applications of DWI beyond oncologic imaging. DWI, when used in conjunction with routine imaging, can assist in detecting hemorrhagic degradation products, infection/abscess, and inflammation in colitis, while aiding with discrimination of free fluid and empyema, while limiting the need for intravenous contrast. DWI in conjunction with routine anatomic images provides a platform to improve lesion detection and characterization with findings rivaling other combined anatomic and functional imaging techniques, with the added benefit of no ionizing radiation. PMID:23960006
Porcel, José M; Esquerda, Aureli; Vives, Manuel; Bielsa, Silvia
To investigate the etiology of pleural effusions (PE) in adults and the accuracy of pleural fluid (PF) cytology and cultures in malignant and infectious PE, respectively. Retrospective analysis of all consecutive patients with PE undergoing diagnostic thoracentesis during the last 19 years in a university hospital. The leading causes of PE among the 3,077 patients were: cancer (27%), heart failure (21%), pneumonia (19%), tuberculosis (9%), abdominal surgery (4%), pericardial diseases (4%) and cirrhosis (3%). Tuberculosis was the most common etiology in patients <34 years of age (52%), whereas heart failure predominated in octogenarians (45%). The most common primary tumors in malignant PE were lung (37%) and breast (16%). The overall accuracy of PF cytology was 59%, although it was significantly lower in mesotheliomas (27%) and squamous cell lung cancer (25%). In infectious PE, only 30% of cultures yielded positive results, a percentage which increased two-fold (66%) in purulent fluids (empyemas). Viridans streptococci were the most commonly isolated pathogens (25.5%). The sensitivity of solid media cultures of PF for Mycobacterium tuberculosis was low (18.5%). Three-quarters of patients with PE in whom a diagnostic thoracentesis was indicated had cancer, heart failure, pneumonia or tuberculosis. PF cytology and cultures give false negative results in a significant number of cases. Copyright © 2013 SEPAR. Published by Elsevier Espana. All rights reserved.
Pettersson, T; Klockars, M; Hellström, P E
The value of determination of pleural fluid glucose, pH, lactic dehydrogenase, IgG, IgA, IgM, C3, C4, anti-IgG antibody, and hydroxyproline in distinguishing between pleural effusions caused by rheumatoid arthritis (RA) and those resulting from other diseases was studied. The series comprised seven patients with RA and 115 patients with other diseases including systemic lupus erythematosus, tuberculosis, malignant disease, empyema, pneumonia, congestive heart failure, and nonspecific pleural effusion. The low glucose concentration, the low pH and the low C4 level in rheumatoid pleural effusion were the most valuable diagnostic findings. The presence of anti-IgG antibody in pleural fluid was not specific for RA. The concentration of hydroxyproline in pleural fluid and the pleural fluid-to-plasma hydroxyproline ratio were significantly higher in RA than in tuberculosis and malignant disease. The results support the view that local metabolic and immunological phenomena as well as a high turnover of collagen occur in the pleural cavity in RA. PMID:6981226
Kastrup, Oliver; Wanke, Isabel; Maschke, Matthias
Summary: Neuroimaging plays a crucial role in the diagnosis and therapeutic decision making in infectious diseases of the nervous system. The review summarizes imaging findings and recent advances in the diagnosis of pyogenic brain abscess, ventriculitis, viral disease including exotic and emergent viruses, and opportunistic disease. For each condition, the ensuing therapeutic steps are presented. In cases of uncomplicated meningitis, cranial computed tomography (CT) appears to be sufficient for clinical management to exclude acute brain edema, hydrocephalus, and pathology of the base of skull. Magnetic resonance imaging (MRI) is superior in depicting complications like sub-/epidural empyema and vasculitic complications notably on FLAIR (fluid-attenuated inversion recovery)-weighted images. The newer technique of diffusion-weighted imaging (DWI) shows early parenchymal complications of meningitis earlier and with more clarity and is of help in differentiation of pyogenic abscess (PA) from ring enhancing lesions of other etiology. Proton magnetic resonance spectroscopy (PMRS) seems to produce specific peak patterns in cases of abscess. The presence of lactate cytosolic amino acids and absence of choline seems to indicate PA. Also in cases of suspected opportunistic infection due to toxoplasma DWI may be of help in the differentiation from lymphoma, showing no restriction of water diffusion. In patients with herpes simplex and more exotic viruses like West Nile and Murray Valley virus DWI allows earlier lesion detection and therapeutic intervention with virustatic drugs. PMID:15897953
Pathak, A. K.; Rai, N. K.; Singh, Ankita; Rai, A. K.; Rai, Pradeep K.; Rai, Pramod K.
Sedentary lifestyle of human beings has resulted in various diseases and in turn we require a potential tool that can be used to address various issues related to human health. Laser Induced Breakdown Spectroscopy (LIBS) is one such potential optical analytical tool that has become quite popular because of its distinctive features that include applicability to any type/phase of samples with almost no sample preparation. Several reports are available that discusses the capabilities of LIBS, suitable for various applications in different branches of science which cannot be addressed by traditional analytical methods but only few reports are available for the medical applications of LIBS. In the present work, LIBS has been implemented to understand the role of various elements in the formation of gallstones (formed under the empyema and mucocele state of gallbladder) samples along with patient history that were collected from Purvancal region of Uttar Pradesh, India. The occurrence statistics of gallstones under the present study reveal higher occurrence of gallstones in female patients. The gallstone occurrence was found more prevalent for those male patients who were having the habit of either tobacco chewing, smoking or drinking alcohols. This work further reports in-situ LIBS study of deciduous tooth and in-vivo LIBS study of human nail.
Bumbasirević, Marko Z; Palibrk, Tomislav; Lesić, Aleksandar R; Durasić, Ljubomir M
Baron Dupuytren, Guillaume (1777-1835), French anatomist, pathologyst and surgeon, although was a personal doctor of Napoleon, Lui XVI and Sharles X, remain known for Dupuytrene contracture, due to his name, after he described this disease of palmar fascia in 1833. He started his education at Paris at age of 12, at 18 he was chief demostrator of anatomist prosectors. In 1802. he become surgeon assistant and in 1812 professor of surgery. At age of 38 he become surgeon-in-chief in Hôtel-Dieu the most famous hospital in Europe of that time. Dipitren was a dostor of Lui VIII, who gave him the title of baron in 1823. Also, he was the doctor of Sharles X, and from Napoleon he was decorated by Legue of the Honour. He was the richest doctor of the France, and that time was named Dupuytrens time. He was working the whole day, and was dealing with all parts of surgery, but he become most prominent in orthopaedics, making connections between anatomy, pathology and surgery, what make him popular and famous. Dupuytren dies in age of 58 due to the pleural empyema, but he refused surgery. Before that he had brain stroke, from which he never recover, although he continue with lectures.
Schrader, Gabby M; Whiteside, Douglas P; Slater, Owen M; Black, Sandra R
Therapy for pyothorax, or pleural empyema, has not been described for large felids. This case describes the successful treatment of pyothorax in a captive, large felid. A 15-yr-old multiparous, female Amur tiger (Panthera tigris altaica) presented with nonspecific clinical signs caused by an insidious onset of pyothorax. Management of pyothorax cases in companion animals often involves thoracostomy tube placement with recurrent drainage of the pleural cavity, intensive supportive care, and monitoring. In this case, conservative management was elected because hospitalization was not a viable option. Thoracocentesis was performed to drain as much fluid from the chest cavity as possible, yielding more than 1.3 L. Corynebacterium sp. and unidentified anaerobic gram-positive cocci were cultured. Treatment included cefovecin subcutaneously, oral antibiotic therapy with clindamycin and marbofloxacin, meloxicam, and restricted exercise by minimizing access to the main exhibit. Significant improvement was noted clinically and radiographically 6 wk later, and no relapses were noted in the following weeks. An examination 11.5 mo later confirmed resolution.
Domeki, Yasushi; Kato, Hiroyuki
An esophageal foreign body is the term for a foreign body in the esophagus. The 2 age groups most prone to this condition are children age 9 and under (and especially toddlers age 4 and under) and elderly individuals age 70 and over. A foreign body often lodges where the esophagus is most constricted. In toddlers, the foreign body is often currency or coins or a toy. In adults, the body is often a piece of fish, dentures, a piece of meat, a pin or needle, or a drug in its blister pack packaging. In children, an esophageal foreign body is treated by fluoroscopically guided removal of the body with a balloon catheter or magnetic catheter or removal of the body via endoscopy or direct esophagoscopy under general anesthesia. In adults, the best choice for treating an esophageal foreign body is removing the body with an endoscope but there are instances where surgery is performed because the body is hard to remove endoscopically, a puncture has occurred, or empyema or mediastinitis has developed. This paper reviews the diagnosis and treatment of an esophageal foreign body.
Nicolaou, Elitsa V; Bartlett, Allison H
Necrotizing pneumonia refers to the development of necrosis, liquefication, and cavitation of the lung parenchyma from an infectious pathogen. Nearly 4% of all community-acquired pneumonias are necrotizing, although studies retrospectively evaluating the incidence have found it to be increasing during the past 20 years. Common presenting symptoms include fever, tachypnea, and cough, and most of those afflicted also develop complications such as parapneumonic effusions, empyemas, or bronchopleural fistulae. When compared to age-matched controls with parapneumonic effusions or severe pneumonias without a necrotizing component, those with necrotizing pneumonia have been shown to have more elevated white blood cell counts and inflammatory markers that take longer to normalize, a longer duration of symptoms despite initiation of therapy, and a longer hospital stay. Despite the high incidence of complications during the acute phase of illness, the overall prognosis of necrotizing pneumonia has been shown to be promising, with nearly all children surviving the illness. [Pediatr Ann. 2017;46(2):e65-e68.].
Subotic, Dragan; Yablonskiy, Piotr; Sulis, Giorgia; Cordos, Ioan; Petrov, Danail; Centis, Rosella; D’Ambrosio, Lia; Sotgiu, Giovanni
Tuberculosis (TB) is still a major public health concern, mostly affecting resource-constrained settings and marginalized populations. The fight against the disease is hindered by the growing emergence of drug-resistant forms whose management can be rather challenging. Surgery may play an important role to support diagnosis and treatment of the most complex cases and improve their therapeutic outcome. We conducted a non-systematic review of the literature based on relevant keywords through PubMed database. Papers in English and Russian were included. The search was focused on five main areas of intervention as follows: (I) diagnosis of complicated cases; (II) elimination of contagious persisting cavities, despite appropriate chemotherapy; (III) treatment of destroyed lung; (V) resection of tuberculomas; (VI) treatment of tuberculous pleural empyema. Although specific practical guidelines concerning surgical indications and approaches are currently unavailable, a summary of the evidence emerged from the scientific literature was elaborated to help the clinician in the management of severely compromised TB patients. The decision to proceed to surgery is usually individualized and a careful assessment of the patient’s risk profile is always recommended before performing any procedure in addition to appropriate chemotherapy. PMID:27499980
Introduction There have been no reports in the literature of esophageal rupture in adults resulting from an explosion of an automobile tire. We report the first case of just such an occurrence after an individual bit into a tire, causing it to explode in his mouth. Case presentation A 47-year-old Han Chinese man presented with massive hemorrhage in his left eye after he accidentally bit an automobile tire tube which burst into his mouth. He was diagnosed with esophageal rupture based on a chest computed tomography scan and barium swallow examination. Drainage of empyema (right chest), removal of thoracic esophagus, exposure of cervical esophagus, cardiac ligation and gastrostomy were performed respectively. After that, esophagogastrostomy was performed. Conclusions Successful anastomosis was obtained at the neck with no postoperative complications 3 months after the surgery. The patient was discharged with satisfactory outcomes. We present this case report to bring attention to esophageal rupture in adults during the explosion of an automobile tire tube in the mouth. PMID:23972148
Welch, C.E.; Malt, R.A.
A new art of ''interventional radiology'' has been developed in the past few years. Major applications include postoperative instrumentation of the biliary tract, percutaneous biliary drainage, tumor biopsy, abscess drainage, and intestinal-intubation procedures. Intervention by angiography encompasses injection of such substances as Pitressin (vasopressin), and embolization. These procedures have been of immense value. Fortunately, complications, such as sepsis and bleeding, have been infrequent. Computerized body tomography has also proved extremely important, particularly in the diagnosis of subphrenic abscess and pancreatic and pelvic pathology. /sup 99m/Tc-labeled-erythrocyte scans can be used to detect gastrointestinal bleeding sites. Scans can also identify hepatobiliary disease and splenic injury or differentiate the cause of jaundice. /sup 111/Indium-labeled autologous leukocytes may be useful in differentiating a pancreatic abscess from a pseudocyst. The advantage of indium scans over /sup 67/Ga scans is that a shorter time is required for maximum resolution: gallium requires 48 hours, indium 4. Another advantage is that indium is cleared through the liver and spleen and is not secreted into the bowel. /sup 67/Ga is absorbed by lymphomas and hepatocarcinomas. Nuclear magnetic resonance has many possible uses in abdominal surgery, but so far little information is available. This technique has been used to detect an empyema of the gallbladder that was not diagnosed by ultrasound. Among hepatic lesions, it can easily differentiate tumors from cysts and in that regard is superior to both ultrasound and scan. (JMT)
Ivanišević, Petar; Poljak, Nikola Kolja; Cikojević, Draško; Doršner, Katarina; Ivanišević, Milan
Dr Aleksandar Doršner (Trebinje, 1892 - Lima, 1967) was the first hospital otorhinolaryngologist in Split and Dalmatia. He graduated from the Faculty of Medicine in Prague in 1919, and specialized otorhinolaryngology in Graz and Vienna. He led and organized otorhinolaryngological service in Split Hospital from 1923 to 1934, and he also had a private practice. Temporarily he also worked outside Split in Dalmatian hinterland and in Šibenik, Zadar and Dubrovnik. Most frequently he performed the following otorhinolaryngological operations: tonsillectomies and adenoidectomies and operations of purulent middle ear inflammations with mastoiditis, nasal polyps, deviated nasal septum, maxillary sinus empyema and otorhinolaryngological trauma. In 1928 he became a member of Otorhinolaryngological section of Croatian Medical Chamber. He participated in the work of the first otorhinolaryngological congress of the former Yugoslavia in 1931, taken place in Zagreb. From 1928 he was a member of Oto-Neuro-Ophthalmological Society. From 1933 to 1937 he was a vice-president of the main board of Free Organization of Dalmatian Physicians in Split. In 1938 he left Split permanently and continued living with his family in Lima (Peru) where he died in 1967. He was an erudite. He lived for his profession which he liked very much and dedicated his life to. He is one of the most meritorious doctors in Split medical history, whom otorhinolaryngology service in Split Hospital started with.
Stewart, Lygia; Griffiss, J McLeod; Jarvis, Gary A; Way, Lawrence W
Obesity has been associated with worse infectious disease outcomes. It is a risk factor for cholesterol gallstones, but little is known about associations between body mass index (BMI) and biliary infections. We studied this using factors associated with biliary infections. A total of 427 patients with gallstones were studied. Gallstones, bile, and blood (as applicable) were cultured. Illness severity was classified as follows: none (no infection or inflammation), systemic inflammatory response syndrome (fever, leukocytosis), severe (abscess, cholangitis, empyema), or multi-organ dysfunction syndrome (bacteremia, hypotension, organ failure). Associations between BMI and biliary bacteria, bacteremia, gallstone type, and illness severity were examined using bivariate and multivariate analysis. BMI inversely correlated with pigment stones, biliary bacteria, bacteremia, and increased illness severity on bivariate and multivariate analysis. Obesity correlated with less severe biliary infections. BMI inversely correlated with pigment stones and biliary bacteria; multivariate analysis showed an independent correlation between lower BMI and illness severity. Most patients with severe biliary infections had a normal BMI, suggesting that obesity may be protective in biliary infections. This study examined the correlation between BMI and biliary infection severity. Published by Elsevier Inc.
Ahmed, Zohair; Bansal, Saurabh K; Dhillon, Sonu
A 21-year-old male with no significant past medical history, presented with right upper quadrant (RUQ) abdominal pain along with fevers and chills. Lab work revealed leukocytosis, anemia, and slightly elevated alkaline phosphatase. Viral serology for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative and he was immunocompetent. Computed tomography imaging revealed hepatic abscesses, the largest measuring 9.5 cm. Empiric antibiotics were started and percutaneous drains were placed in the abscesses. Anaerobic cultures from the abscesses grew Fusobacterium nucleatum. This is a gram negative anaerobic bacteria; a normal flora of the oral cavity. Fusobacterium is most commonly seen in Lemiere’s disease, which is translocation of oral bacteria to the internal jugular vein causing a thrombophlebitis and subsequent spread of abscesses. Our patient did not have Lemiere’s, and is the first case described of fusobacterium pyogenic liver abscess in a young immunocompetent male with good oral hygiene. This case was complicated by sepsis, empyema, and subsequent abscesses located outside the liver. These abscesses’ have the propensity to flare abruptly and can be fatal. This case not only illustrates fusobacterium as a rare entity for pyogenic liver abscess, but also the need for urgent diagnosis and treatment. It is incumbent on physicians to diagnose and drain any suspicious hepatic lesions. While uncommon, such infections may develop without any overt source and can progress rapidly. Prompt drainage with antibiotic therapy remains the cornerstone of therapy. PMID:25834342
Ahmed, Zohair; Bansal, Saurabh K; Dhillon, Sonu
A 21-year-old male with no significant past medical history, presented with right upper quadrant (RUQ) abdominal pain along with fevers and chills. Lab work revealed leukocytosis, anemia, and slightly elevated alkaline phosphatase. Viral serology for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative and he was immunocompetent. Computed tomography imaging revealed hepatic abscesses, the largest measuring 9.5 cm. Empiric antibiotics were started and percutaneous drains were placed in the abscesses. Anaerobic cultures from the abscesses grew Fusobacterium nucleatum. This is a gram negative anaerobic bacteria; a normal flora of the oral cavity. Fusobacterium is most commonly seen in Lemiere's disease, which is translocation of oral bacteria to the internal jugular vein causing a thrombophlebitis and subsequent spread of abscesses. Our patient did not have Lemiere's, and is the first case described of fusobacterium pyogenic liver abscess in a young immunocompetent male with good oral hygiene. This case was complicated by sepsis, empyema, and subsequent abscesses located outside the liver. These abscesses' have the propensity to flare abruptly and can be fatal. This case not only illustrates fusobacterium as a rare entity for pyogenic liver abscess, but also the need for urgent diagnosis and treatment. It is incumbent on physicians to diagnose and drain any suspicious hepatic lesions. While uncommon, such infections may develop without any overt source and can progress rapidly. Prompt drainage with antibiotic therapy remains the cornerstone of therapy.
Olsen, Steven M; Koch, Cody A; Ekbom, Dale C
Nasal septal abscesses (NSAs) occur between the mucoperichondrium and the nasal septum. They most often arise when an untreated septal hematoma becomes infected. The most commonly reported sequela is a loss of septal cartilage support, which can result in a nasal deformity. Other sequelae include potentially life-threatening conditions such as meningitis, cavernous sinus thrombosis, brain abscess, and subarachnoid empyema. We report the case of a 17-year-old boy who developed an NSA after he had been struck in the face with a basketball. He presented to his primary care physician 5 days after the injury and again the next day, but his condition was not correctly diagnosed. Finally, 7 days after his injury, he presented to an emergency department with more serious symptoms, and he was correctly diagnosed with NSA. He was admitted to the intensive care unit, and he remained hospitalized for 6 days. Among the abscess sequelae he experienced was septic arthritis, which has heretofore not been reported as a complication of NSA. He responded well to appropriate treatment, although he lost a considerable amount of septal cartilage. He was discharged home on intravenous antibiotic therapy, and his condition improved. Reconstruction of the nasal septum will likely need to be pursued in the future.
Munghate, Anand; Kumar, Ashwani; Singh, Harnam; Singh, Gurpreet; Singh, Bimaljot; Chauhan, Mahak
Colorectal cancer is one of the most common cancer worldwide .Its incidence is reported to be increasing in developing countries. It commonly presents with weight loss, anaemia, lump abdomen, change of bowel habit, obstruction or fresh rectal bleeding. Beside these common modes of presentations, there are some rare manifestations which masqueraded as different disease like obstructive jaundice, empyema gall bladder or cholecystitis. A 60-year-old male presented to hospital with right sided pain abdomen. On abdominal examination mild tenderness was present in right hypochondrium. Intra operatively gall bladder was separated from the adjoining gut, peritoneum and liver bed and was removed. On further exploration, there was a large mass in the vicinity of the gall bladder related to transverse colon. Extended right hemicolectomy was done. Histopathological examination of gut mass revealed adenocarcinoma of transverse colon with free margins and gall bladder showed cholecystitis with no evidence of malignancy. We present an interesting case of colon cancer colon that caused diagnostic confusion by mimicking as cholecystitis. Colorectal cancer constitutes a major public health issue globally. Therefore, public awareness, screening of high-risk populations, early diagnosis and effective treatment and follow-up will help to reduce its occurance and further complications.
Martin, Morgan S.; Lobo, Monica
Background. We describe the unusual case of a recently transplanted cadaveric renal transplant recipient who presented with recurrent pulmonary mucormycosis. Case Report. An 18-year-old man with end stage renal disease secondary to congenital renal agenesis status after cadaveric kidney transplant 4 months before presented with acute onset of fever, hemoptysis, and back pain. The patient underwent an emergent left lower lobectomy due to the critical nature of his illness. He was also treated with amphotericin with resolution of his symptoms. One week later, he had evidence of recurrent disease on imaging with a surgical site infection. He underwent reexploration with evacuation of an empyema and debridement of a surgical site infection. He was continued on IV antifungal therapy with isavuconazonium and amphotericin. Radiographic clearance of disease with three months of treatment was apparent with no evidence of recurrence at seven-month follow-up. Discussion. Opportunistic infections in solid organ transplant patients represent a significant source of morbidity and mortality. Most patients are treated with prophylactic anti-infective agents. However, rare infections such as pulmonary mucormycosis remain a risk. The transplant physician must be aware of these uncommon infections and their treatment strategies, including the management of uncommon recurrent disease. PMID:28386509
Background Escherichia coli (E. coli) is the most common causative bacteria of neonatal meningitis, but hematogenous intracranial E. coli infection is rare in adults. Moreover, intracranial abscess formation owing to E. coli, including brain abscesses and subdural empyema formation, is extremely rare. We herein present a case involving a patient with a brain abscess owing to E. coli following a simple renal cyst infection. A review of the literature is also presented. Case presentation A 77-year-old Japanese woman with a history of polymyalgia rheumatica was admitted to our hospital because of persistent fever, right flank pain, and pyuria. Intravenous antibiotics were administered; however, her level of consciousness deteriorated 6 days after admission. Contrast-enhanced magnetic resonance imaging showed a brain abscess in the left occipital lobe and pyogenic ventriculitis. Enhanced abdominal computed tomography revealed a right renal cyst with heterogeneous content. Culture of urine, blood, and aspirated pus from the infected cyst revealed E. coli with identical antibiotic sensitivity in all sites, suggesting that the cyst infection and subsequent bacteremia might have caused the brain abscess. The patient recovered after a 6-week course of meropenem. Conclusion The prognosis of patients with E. coli-associated intracranial abscess is usually poor. Advanced age and immunosuppression may be potent risk factors for intracranial abscess formation owing to the hematogenous spread of E. coli. PMID:24934996
Clancy, U; Ronayne, A; Prentice, M B; Jackson, A
We describe the rare occurrence of an Actinomyces meyeri cerebral abscess in a 55-year-old woman following a dental extraction. This patient presented with a 2-day history of hemisensory loss, hyper-reflexia and retro-orbital headache, 7 days following a dental extraction for apical peridonitis. Neuroimaging showed a large left parietal abscess with surrounding empyema. The patient underwent craniotomy and drainage of the abscess. A. meyeri was cultured. Actinomycosis is a rare cause of cerebral abscess. The A. meyeri subtype is particularly rare, accounting for less than 1% of specimens. This case describes an unusually brief course of the disease, which is usually insidious. Parietal lobe involvement is unusual as cerebral abscesses usually have a predilection for the frontal and temporal regions of the brain. Although there are no randomised trials to guide therapy, current consensus is to use a prolonged course of intravenous antibiotics, followed by 6–12 months of oral therapy. PMID:25870213
Clancy, U; Ronayne, A; Prentice, M B; Jackson, A
We describe the rare occurrence of an Actinomyces meyeri cerebral abscess in a 55-year-old woman following a dental extraction. This patient presented with a 2-day history of hemisensory loss, hyper-reflexia and retro-orbital headache, 7 days following a dental extraction for apical peridonitis. Neuroimaging showed a large left parietal abscess with surrounding empyema. The patient underwent craniotomy and drainage of the abscess. A. meyeri was cultured. Actinomycosis is a rare cause of cerebral abscess. The A. meyeri subtype is particularly rare, accounting for less than 1% of specimens. This case describes an unusually brief course of the disease, which is usually insidious. Parietal lobe involvement is unusual as cerebral abscesses usually have a predilection for the frontal and temporal regions of the brain. Although there are no randomised trials to guide therapy, current consensus is to use a prolonged course of intravenous antibiotics, followed by 6-12 months of oral therapy. 2015 BMJ Publishing Group Ltd.
Abraham, Sherly; Rivero, Haidy G; Erlikh, Irina V; Griffith, Larry F; Kondamudi, Vasantha K
Cholelithiasis, or gallstones, is one of the most common and costly of all the gastrointestinal diseases. The incidence of gallstones increases with age. At-risk populations include persons with diabetes mellitus, persons who are obese, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives. Most patients are asymptomatic; gallstones are discovered incidentally during ultrasonography or other imaging of the abdomen. Asymptomatic patients have a low annual rate of developing symptoms (about 2% per year). Once symptoms appear, the usual presentation of uncomplicated gallstones is biliary colic, caused by the intermittent obstruction of the cystic duct by a stone. The pain is characteristically steady, is usually moderate to severe in intensity, is located in the epigastrium or right upper quadrant of the abdomen, lasts one to five hours, and gradually subsides. If pain persists with the onset of fever or high white blood cell count, it should raise suspicion for complications such as acute cholecystitis, gallstone pancreatitis, and ascending cholangitis. Ultrasonography is the best initial imaging study for most patients, although additional imaging studies may be indicated. The management of acute biliary colic mainly involves pain control with nonsteroidal anti-inflammatory drugs or narcotic pain relievers. Oral dissolution therapy is usually minimally successful and used only if the patient cannot undergo surgery. Laparoscopic cholecystectomy remains the surgical choice for symptomatic and complicated gallstones, with a shorter hospital stay and shorter convalescence period than open cholecystectomy. Percutaneous cholecystostomy is an alternative for patients who are critically ill with gallbladder empyema and sepsis.
Ferreiro, Lucía; San José, María Esther; Valdés, Luis
Pleural infections have high morbidity and mortality, and their incidence in all age groups is growing worldwide. Not all infectious effusions are parapneumonic and, in such cases, the organisms found in the pleural space are not the same as those observed in lung parenchyma infections. The diagnostic difficulty lies in knowing whether an infectious effusion will evolve into a complicated effusion/empyema, as the diagnostic methods used for this purpose provide poor results. The mainstays of treatment are to establish an early diagnosis and to commence an antibiotic regimen and chest drain as soon as possible. This should preferably be carried out with fine tubes, due to certain morphological, bacteriological and biochemical characteristics of the pleural fluid. Fluid analysis, particularly pH, is the most reliable method for assessing evolution. In a subgroup of patients, fibrinolytics may help to improve recovery, and their combination with DNase has been found to obtain better results. If medical treatment fails and surgery is required, video-assisted thoracoscopic surgery (VATS) is, at least, comparable to decortication by thoracotomy, so should only undertaken if previous techniques have failed. Further clinical trials are needed to analyze factors that could affect the results obtained, in order to define new evidence-based diagnostic and therapeutic strategies that provide more effective, standardized management of this disease.
John B. Murphy was a prominent surgeon who lived in Chicago from the 1880s until his death in 1916. During his career, he was associated with both Rush Presbyterian and Northwestern Medical Schools. He was responsible for popularizing the use of an artificial pneumothorax as an effective adjunct in the treatment of pulmonary tuberculosis. This modality was not, however, his original concept. In addition to all of the fields of general surgery, Murphy undertook the management of empyema and lesions of the chest wall and also performed thoracoplasty procedures. Although he had done several thoracotomy procedures in his laboratory, he rarely undertook this operation in a clinical setting. Drop ether anesthesia was used for all surgical procedures. Murphy did not use closed water seal drainage of the chest. His oration on thoracic surgery, given at the annual meeting of the AMA, in 1898, was an excellent monograph on the subject and undoubtedly contributed to the increased interest and progress in this field of surgery. Murphy was a wise surgeon, an able technician and a scholarly teacher. The high regard in which he was held by his contemporaries is best expressed by the remark of William Mayo, "...he was the surgical genius of our generation".
Andreetti, Claudio; D'Andrilli, Antonio; Ibrahim, Mohsen; Ciccone, Anna Maria; Maurizi, Giulio; Mattia, Antonio; Venuta, Federico; Rendina, Erino A.
The aim of the study was to assess the feasibility, efficacy and safety of the use of a conical self-expandable stent for the treatment of post-pneumonectomy bronchopleural fistula (PPBPF). Between April 2008 and November 2010, six patients underwent treatment for the PPBPF by the introduction of a tracheobronchial conical fully covered self-expandable nitinol stent with the aim of excluding the bronchial dehiscence from the airflow. We secured the prosthesis to the tracheal mucosa with titanium helical fasteners tacks. Five patients presented with a bronchial fistula larger than 5 mm following right (4) or left (1) pneumonectomy. One patient had an anastomotic dehiscence after right tracheal sleeve pneumonectomy. A chest tube showed the absence of empyema in all cases. Immediate resolution of the bronchial air leak was obtained in all the patients. Permanent closure of the bronchial dehiscence without recurrence was achieved in all the patients at a mean follow-up time of 13 months (range 3–32). The bronchial stent was successfully removed in all patients without sequelae 71–123 days after its implantation. The use of the conical self-expandable Silmet® stent has proved to be an effective, safe and fast method to treat even large PPBPFs. PMID:22268070
Kim, Yong Joo; Shin, Tae Beom
Objective To evaluate the technical feasibility and clinical efficacy of percutaneous transhepatic cholecystolithotomy under fluoroscopic guidance in high-risk surgical patients with acute cholecystitis. Materials and Methods Sixty-three consecutive patients of high surgical risk with acute calculous cholecystitis underwent percutaneous transhepatic gallstone removal under conscious sedation. The stones were extracted through the 12-Fr sheath using a Wittich nitinol stone basket under fluoroscopic guidance on three days after performing a percutaneous cholecystostomy. Large or hard stones were fragmented using either the snare guide wire technique or the metallic cannula technique. Results Gallstones were successfully removed from 59 of the 63 patients (94%). Reasons for stone removal failure included the inability to grasp a large stone in two patients, and the loss of tract during the procedure in two patients with a contracted gallbladder. The mean hospitalization duration was 7.3 days for acute cholecystitis patients and 9.4 days for gallbladder empyema patients. Bile peritonitis requiring percutaneous drainage developed in two patients. No symptomatic recurrence occurred during follow-up (mean, 608.3 days). Conclusion Fluoroscopy-guided percutaneous gallstone removal using a 12-Fr sheath is technically feasible and clinically effective in high-risk surgical patients with acute cholecystitis. PMID:21430938
Nunes, Rodrigo Barboza; Müller, Bruno Francisco; Cipriano, Federico Enrique Garcia; Coltro, Pedro Soler; Farina, Jayme Adriano
Treatment of bronchial fistula (BF) after pulmonary lobectomy is a challenge. Often, patients require long hospital stay, have recurrent empyema and pneumonia, are susceptible to sepsis, often need broad-spectrum antibiotics, as well as various surgical approaches. With the advent and growing evidence of the benefits of negative pressure therapy (NPT), its use in some patients with BF has been reported with encouraging results concerning its feasibility and cost-effectiveness. The aim of this study was to demonstrate the application of NPT as a resource for BF treatment and comparatively analyze the overall cost of treatment. RESUMO O tratamento de fístula brônquica (FB) após lobectomia pulmonar é um desafio. Muitas vezes, o paciente demanda longo tempo de internação, apresenta recidivas de empiema e pneumonia, pode evoluir para sepse, frequentemente necessita de antibioticoterapia de amplo espectro, bem como de várias abordagens cirúrgicas. Com o advento e acúmulo de evidências dos benefícios da terapia por pressão negativa (TPN), seu uso em alguns pacientes com FB tem sido relatado com resultados animadores relativos à sua viabilidade e ao seu custo-efetividade. O objetivo deste estudo foi demonstrar a aplicação de TPN como recurso para tratamento da FB e analisar comparativamente o custo global do seu tratamento.
Hall, Walter A; Truwit, Charles L
Infection involving the cerebrum is a true neurosurgical emergency that requires rapid diagnosis and appropriate surgical and medical intervention to achieve good clinical outcome. Because of the potential for devastating neurological sequelae, it is imperative that neurosurgeons be involved in the diagnosis and management of these serious conditions once an infection is suspected. With the advent of computed tomography and magnetic resonance imaging, it is now possible to detect an infectious process early in its course and follow the response to therapy. Although significantly more effective than in the past, antimicrobial therapy alone is insufficient to eradicate most intracranial infections, especially in the presence of compression or displacement of the cerebrum. Surgery remains an essential part of the management of intracranial infection because of its ability to provide immediate relief from pressure on neural structures and thereby result in clinical improvement. The most common infections affecting the brain, namely, cranial epidural abscess, subdural empyema, brain abscess, viral infection, tuberculosis, and neurocysticercosis, can each be associated with significant mass effect on the cerebrum that is greatly reduced through surgery. This relief, in combination with newer antimicrobial agents that have an improved ability to cross the blood brain barrier, has led to a reduction in the infection-related morbidity and mortality rates associated with intracranial infections. Combining advanced imaging and surgical techniques in the form of intraoperative magnetic resonance image-guided neurosurgery may further enhance clinical outcomes in these once uniformly fatal diseases.
Nakamura, Hiroshige; Taniguchi, Yuji; Miwa, Ken; Adachi, Yoshin; Fujioka, Shinji; Haruki, Tomohiro
As a method of chest drainage, we analyzed the extended utility of silastic flexible drains (Blake drains, Ethicon, Inc., Somerville, NJ) for general thoracic surgery. In 420 cases of general thoracic surgery, Blake drains were used. To examine the utility of Blake drains, we investigated the diseases for which they were used, their effectiveness in addressing postoperative complications. The treated diseases for which Blake drains were used comprised 181 cases of primary lung cancer, 44 cases of metastatic lung tumor, 57 cases of benign lung disease, 32 cases of mediastinal tumor, 6 cases of myasthenia gravis, 76 cases of spontaneous pneumothorax, 14 cases of chest wall and/or pleural tumor, 6 cases of empyema, and 4 cases of diaphragmatic disease. Blake drains functioned efficiently in 3 cases of re-operation for postoperative bleeding, 2 cases of adhesion therapy with drugs for persistent air leaks, and 1 case of re-operation for chylothorax. There were no cases of either complications or patient complaints of discomfort resulting from drain placement. The use of Blake drains for general thoracic surgery is considered to be an acceptable option, and it is necessary to proceed with further investigations of larger numbers of cases.
Yeh, Pin-Hung; Hsu, Po-Kai
It is challenging to establish one-lung ventilation in difficult airway patients. Surgical pneumothorax under spontaneous breathing to obtain well-collapsed lung is a feasible method for thoracic surgery. A 76-year-old man with right empyema was scheduled for decortication. The patient had limited mouth opening due to facial cellulitis extending from the left cheek to neck. Generally, lung isolation is achieved by double-lumen endotracheal tube or bronchial blocker. Double-lumen tube insertion is difficult for patients with limited mouth opening and right-side placement of bronchial blocker usually causes insufficient deflation. We introduce an alternative lung isolation technique by surgical pneumothorax under spontaneous breathing simply with an endotracheal tube placement. This technique has never been applied into the management of difficult one-lung ventilation. By this method, we provide an ideal surgical condition with safer, less time-consuming, and less skill-demanding anesthesia. It would be an alternative choice for management of one-lung ventilation in the difficult lung isolation patient.
Lang-Lazdunski, L; Chapuis, O; Pons, F; Jancovici, R
Videothoracoscopy represents a valid and useful approach in some patients with blunt chest trauma or penetrating thoracic injury. This technique has been validated for the treatment of clotted hemothorax or posttraumatic empyema, traumatic chylothorax, traumatic pneumothorax, in patients with hemodynamic stability. Moreover, it is probably the most reliable technique for the diagnosis of diaphragmatic injury. It is also useful for the extraction of intrathoracic projectiles and foreign bodies. This technique might be useful in hemodynamically stable patients with continued bleeding or for the exploration of patients with penetrating injury in the cardiac area, although straightforward data are lacking to confirm those indications. Thoracotomy or median sternotomy remain indicated in patients with hemodynamic instability or those that cannot tolerate lateral decubitus position or one-lung ventilation. Performing video-surgery in the trauma setting require expertise in both video-assisted thoracic surgery and chest trauma management. The contra-indications to videothoracoscopy and indications for converting the procedure to an open thoracotomy should be perfectly known by surgeons performing video-assisted thoracic surgery in the trauma setting. Conversion to thoracotomy or median sternotomy should be performed without delay whenever needed to avoid blood loss and achieve an adequate procedure.
Mursalova, G Kh
The differential diagnostic signs of disseminated pulmonary processes were defined by computed tomography. A hundred and sixty-seven patients, including 117 (70%) with disseminated pulmonary tuberculosis (DPT) and 50 (30%) with alveolitis, were examined. Their mean age was 32.3 +/- 5.1 years; the history of disease averaged 4.6 +/- 1.2 years. Acute, subacute, and chronic DPT was observed in 17 (14.5%), 32 (27.3%), and 68 (58.1%) patients, respectively. Idiopathic fibrosing alveolitis (IFA) was seen in 38 patients; 12 patients had exogenous allergic alveolitis (EAA). IFA and EAA were chronic. Patients with DPT had most commonly signs, such as focal masses (45.3%), intra- and interlobular septal thickening (35%), lung tissue reticulation (35%), centrilobular empyema (29%), only focal masses being detected in its acute form, and other signs being more pronounced in its subacute and particularly chronic form. Glassy dark patches, the opal glass syndrome, were a common sign in patients with alveolitis. Septal thickening, lung tissue meshwork, and centrilobular emphysema were encountered only in patients with IDA and small-nodular focal masses and bronchial wall thickening were present in those with EAA.
Kaye, Michael D.
Pancreatitis, in common with many other upper abdominal diseases, often leads to pleuropulmonary complications. Radiological evidence of pleuropulmonary abnormality was found in 55% of 58 cases examined retrospectively. The majority of such abnormalities are not specific for pancreatitis; but a particular category of pleural effusions, rich in pancreatic enzymes, is a notable exception. A patient with this type of effusion, complicated by a spontaneous bronchopleural fistula and then by an empyema, is reported. The literature relating to pancreatic enzyme-rich pleural effusions (pathognomonic of pancreatitis) is reviewed. Of several possible mechanisms involved in pathogenesis, transdiaphragmatic lymphatic transfer of pancreatic enzymes, intrapleural rupture of mediastinal extensions of pseudocysts, and diaphragmatic perforation are the most important. The measurement of pleural fluid amylase, at present little employed in this country, has considerable diagnostic value. Enzyme-rich effusions are more commonly left-sided, are often blood-stained, are frequently associated with pancreatic pseudocysts, and—if long standing—may be complicated by a bronchopleural fistula. Images PMID:4872925
George, Robert S.; Kostopanagiotou, Kostas; Papagiannopoulos, Kostas
OBJECTIVES The extracellular matrix (XCM Biologic Tissue Matrix) is a non-cross-linked 3D patch derived from porcine dermis. Once implanted, it is infiltrated by recipient's cells and becomes incorporated in the repair. Here, we report the first series of using this device for chest wall reconstruction. METHODS The XCM Biologic Tissue Matrix was utilized to provide the restoration of chest wall defects. It was used either alone or in conjunction with the Synthes titanium system to provide additional support. The decision was made intraoperatively. RESULTS Since April 2010, 21 (12 females) patients received the device. Average age at operation was 47 ± 17 years. Eleven (52%) patients had the patch inserted alone, while the remaining 10 received it in combination with another implantable medical device. The biological tissue matrix was used to reconstruct chest wall defects in cancer involving chest wall (n = 9), chest wall deformity (n = 6), chest wall hernia (n = 5) and chest wall repair following empyema drainage (n = 1). Complications were witnessed in 3 patients receiving the combined XCM and Synthes bar mechanisms; infection (n = 2) and bar displacement and infection (n = 1). CONCLUSIONS The XCM patch can be safely used to provide the strength required for chest wall reconstruction and to replace previously infected reconstructions. PMID:24263580
Glatstein, Miguel; Scolnik, Dennis; Bensira, Liat; Domany, Keren Armoni; Shah, Mansi; Vala, Snehal
Although Mycobacterium fortuitum (MF) is a non-tuberculous mycobacterium that rarely causes disease, there are reported cases of pneumonia, lung abscess, and empyema in subjects with predisposing lung disease. We report a neonate, without predisposing disease or risk factors, who manifested pneumonia and lung abscess. The patient was initially treated with amoxicillin-clavulanic acid and gentamycin, and subsequently with piperazilin, tazobactam, and vancomycin when there was no improvement. Pleural nodules were detected on computed tomography, and microbiology revealed MF in the absence of other pathogens and a week later the organism was identified in culture as MF, confirmed on four separate samples. The MF was sensitive to amikacin and clarithromycin and the patient was continued on oral clarithromycin for two more weeks until full recovery. To our knowledge, this is the first reported case of MF abscess in a neonate. MF should be sought in similar patients, especially when microbiology fails to detect the usual pathogens, and when the clinical picture is unclear.
Erkan, Levent; Fýndýk, Serhat; Uzun, Oğz; Atýcý, Atilla G; Light, Richard W
The objective of this study was to describe the clinical course and response to treatment of five patients who developed loculated pleural effusions as complications of pulmonary thromboembolism (PTE). The clinical charts of five patients who had loculated pleural effusions in the course of their PTE were reviewed, with special attention paid to the duration of symptoms before diagnosis, the pleural fluid analysis findings, and the response of the loculations to anticoagulant therapy. In a tertiary care academic medical center, the five patients described in the present study had multiple locules of pleural fluid seen on chest radiographs and thoracic CT scans. In all cases, the diagnosis of PTE had been delayed for at least 2 weeks after symptoms developed. The loculated pleural fluid had led to the mistaken diagnosis of empyema in three cases. The pleural fluid in all cases was exudative, with a predominance of lymphocytes. With anticoagulant therapy, the loculations largely disappeared within the first few days of therapy. Although most pleural effusions secondary to PTE are relatively small and free-flowing, this study demonstrates that PTE can lead to loculated pleural effusions. The loculations occurred in patients who had been symptomatic from their PTE for > 2 weeks. In each instance, the pleural fluid was a lymphocytic exudate. The effusions rapidly resolved with the institution of anticoagulant therapy. PTE should be included in the differential diagnosis of a loculated pleural effusion, particularly if the pleural fluid contains predominantly lymphocytes.
Nacaroğlu, Hikmet Tekin; Bahçeci Erdem, Semiha; Gülez, Nesrin; Ünsal Karkıner, Canan Şule; Devrim, İlker; Genel, Ferah; Köker, Mustafa Yavuz; Can, Demet
Chronic granulomatous disease (CGD) is a genetically heterogeneous primary immunodeficiency that is characterized by recurrent and life-threatening infections resulting from defects in phagocyte nicotinamide adenine dinucleotide phosphate (NADPH) oxidase system and granuloma formation due to increased inflammatory response. The most commonly involved organs are the lungs, skin, lymph nodes, and liver due to infection. It may present with recurrent pneumonia, hilar lymphadenopathy, empyema, abscess, reticulonodular patterns, and granulomas due to lung involvement. In recent years, mycobacterial disease susceptibility has been reported in CGD cases. This article presents two male cases, one of whom is aged 18 months and the other is aged 5 years, who were diagnosed with CGD and tuberculosis during examination due to extended pneumonia. This report is presented because CGD should be considered not only in the presence of skin abscesses and Aspergillus infections, but also in the differential diagnosis for cases with BCG-itis and/or tuberculosis. It should be kept in mind that mycobacterial infections can occur during the course of the disease.
Wagener, Jeffrey S; Kupfer, Oren
Dornase alfa (Pulmozyme) is one of the most commonly used medications to treat the lung disease of cystic fibrosis (CF). As other respiratory medications have entered the clinical market, understanding the proper use and indication for dornase alfa is increasingly important. In addition, dornase alfa is being used to treat other medical conditions. This review covers recent publications and expanding indications. Understanding dornase alfa's mechanism of action and impact on the pathophysiology of CF leads to an improved understanding of optimal therapy, ways to improve adherence and use with other medications. Most importantly, routine use of dornase alfa is associated with improved lung function and survival in patients with CF. Outside of CF, potential uses include treating patients with empyema or on mechanical ventilation. Dornase alfa has been available for clinical use for nearly 20 years and is one of the most commonly used medications in patients with CF. Routine use is associated with a reduced rate of pulmonary deterioration and improved survival. Recent clinical reports suggest that dornase alfa may have clinical value with other medical problems such as complicated pneumonia and mechanically ventilated patients with atelectasis.
Oak, S N; Parelkar, S V; Akhtar, T; Joshi, M; Pathak, R; Viswanath, N; V, K Satish Kumar; Ravikiran, K; Manjunath, L; Ahmed, A
Context: Minimal access surgery (MAS) in children are common place and performed worldwide with gratifying results as the learning curve of the surgeon attains plateau. We share our experience of this technically evolving modality of surgery, performed at our setup over a period of 5 years. We also review and individually compare the data for commonly performed procedures with other available series. Author also briefly discuss potential advantages of MAS in certain debatable conditions performed quickly and with cosmesis as open procedure. Materials and methods: We performed 677 MAS in children aged between 7 days and 12 years. Five hundred and sixty-eight of these were Laparoscopic procedures and 109 were Video assisted thoracoscopic surgeries (VATS). In all laparoscopic procedures, the primary port placement was by the Hasson's open technique. We have used 5, 3 and 2 mm instruments. Our study include 259 inguinal hernia, 161 Appendectomies, 95 VATS for empyema, 51 orchiopexies, 49 diagnostic laparoscopy, 29 cholecystectomies, 22 adhesionlysis and other uncommonly performed procedures. Results: The ultimate outcome of all the performed procedures showed gratifying trend, the data of which are discussed in detail in the article. Conclusion: As we gained experience the operating time showed a decreasing trend, the complication rates and conversion rate also reduced. The advantages we came across were better postoperative appearances, less pain and early return to unrestricted activities. PMID:21188009
Sinitsyn, M V; Semenov, G I; Latyshev, A N; Agkatsev, T V; Kessel', M M
The authors present concise data on the history of surgical treatment for pulmonary tuberculosis at the Research Institute of Phthisiopulmonology, I. M. Sechenov Moscow Medical Academy (1918-2008). They analyze the results of surgical treatment in 1007 patients with different forms of pulmonary tuberculosis in the past 10 years. The most common indications for surgical treatment are tuberculoma (44.2%), fibrocavernous and cirrhotic tuberculosis (37.8%), chronic pleuritis and pleural empyema (7.3%). There are prevalent resection-type operations (77.7%), with fatal cases after pneumonectomy (3.9%), lobectomy (0.6), and minor resections (0%). The proportion of thorocoplastic operations was 4.1% without fatal cases. Mini-invasive surgery using video-assisted technologies have received wide recognition in the diagnosis and surgical treatment of pulmonary tuberculosis. The results of treatment depend on the extent and presence of complications of a tuberculous process, comorbidity, suppressed immunity, and the scope of a surgical intervention. Overall, the efficiency of surgical treatment of patients with pulmonary tuberculosis is 90% or more.
Verma, Akash; Taha, Aza; Venkateswaran, Sridhar; Tee, Augustine
INTRODUCTION This study aimed to assess the effectiveness of medical thoracoscopy (MT) and thoracoscopic talc poudrage (TTP) in patients with exudative pleural effusion. METHODS We evaluated the diagnostic yields, complications and outcomes of MT and TTP in 41 consecutive patients with symptomatic pleural effusions who were planned to undergo both procedures from 1 December 2011 to 30 November 2012. Data was reviewed retrospectively and prospectively up to March 2013. RESULTS Among the 41 patients, 36 underwent MT with the intent of biopsy and talc pleurodesis, 2 underwent MT for pleurodesis only and 3 had failed MT. Aetiologies of pleural effusion included lung cancer (n = 14), tuberculosis (n = 9), breast cancer (n = 7), ovarian cancer (n = 2), malignant mesothelioma (n = 1), congestive cardiac failure (n = 1), peritoneal dialysis (n = 1) and hepatic hydrothorax (n = 1); pleural effusion was undiagnosed in five patients. The overall diagnostic yield of MT, and the yield in tubercular and malignant pleural effusions were 77.8%, 100.0% and 82.6%, respectively; it was inconclusive in 22.2%. Complications that occurred were self-limiting, with no procedure-related mortality. The 30-day mortality rate was 17.1%. A total of 15 patients underwent TTP. The 30-, 60- and 90-day success rates were 77.8%, 80.0% and 80.0%, respectively, with one patient having complications (i.e. empyema). The 30-day mortality was 40.0%. CONCLUSION MT is a safe procedure with high diagnostic yields in undiagnosed pleural effusions. TTP is an effective method to stop recurrence of pleural effusions. PMID:26034319
Ekim, Meral; Ekim, Hasan
Objectives: Purulent pericarditis is a collection of purulent effusion in the pericardial space. It has become a rare entity with the increased availability and use of antibiotics. In contrast to pleural empyema, there are few data regarding the biochemical parameters of purulent pericardial effusion to aid diagnosis. Therefore, in this study, we have evaluated the diagnostic utility of biochemical tests in patients with purulent pericarditis. Methods: Between September 2004 and September 2012, we treated fifteen children with purulent pericarditis and tamponade. There were 8 boys and 7 girls, ranging in age from 8 months to 14 years, with a mean age of 5.3 ± 3.2 years. Echocardiographic diagnosis of cardiac tamponade was made in all patients. All patients underwent immediate surgical drainage due to cardiac tamponade. The diagnosis of purulent pericarditis was supported by biochemical tests. Anterior mini-thoracotomy or subxiphoid approach was performed for surgical drainage. Results: The most common clinical findings were tamponade, hepatomegaly, tachycardia, fever refractory antibiotic therapy, dyspnea, tachypnea, cough, and increased jugular venous pressure. Central venous pressure decreased and arterial tension increased immediately after the evacuation of purulent effusion during operation in all patients. The pericardial effusion had high lactic dehydrogenase, and low glucose concentration, confirming purulent pericarditis. Also, pH (mean± SD) was 7.01 ± 0.06. The culture of pericardial effusions and blood samples were negative. Conclusion: Biochemical tests are useful guideline when assessing the pericardial effusions. However, these tests should be interpreted with the clinical and operative findings. PMID:25097529
Giachetto, Gustavo; Pirez, María Catalina; Nanni, Luciana; Martínez, Adriana; Montano, Alicia; Algorta, Gabriela; Kaplan, Sheldon L; Ferrari, Ana María
Optimal therapeutic efficacy of beta-lactam antibiotics for treatment of pneumococcal pneumonia is thought to be associated with the serum concentration greater than the minimum inhibitory concentration for 40-50% of the interdose interval at site of infection. Establish whether intravenous administration of ampicillin 400 mg/kg/day or penicillin 200,000 IU/kg/day in 6 divided doses reaches serum and or pleural concentrations above 4 microg/ml for at least 40% of the interdose interval. Hospitalized healthy children 1 month-14 years old with community-acquired bacterial pneumonia and empyema were eligible. Blood samples were obtained 30 min (C1) and 3 h (C2) after an antibiotic dose. Pleural fluid samples were obtained 1 and 4 h after the same dose in which blood samples were obtained. The concentrations were measured by high performance liquid chromatography. The study included 17 patients treated with ampicillin and 13 treated with penicillin. For ampicillin, mean serum concentrations were C1 37.3 +/- 19 microg/ml and C2 11 +/- 10.2 microg/ml and mean pleural fluid concentrations were C1 25.8 +/- 9.9 microg/ml and C2 16.2 +/- 7.9 microg/ml. For penicillin, mean serum concentrations were C1 21.8 +/- 16.4 microg/ml and C2 23.9 +/- 3.4 microg/ml. Mean pleural fluid concentrations were C1 10.9 +/- 2.2 microg/ml and C2 7.7 +/- 3.4 microg/ml. In 8 of 30 patients, serum C2 was <4 microg/ml; in all of them serum concentrations were >4 microg/ml for >40% of the interdose interval. This study of the pharmacokinetics of beta-lactam antibiotics in children with bacterial pneumonia may help in the development of therapeutic guidelines for the treatment of pneumococcal pneumonia.
Background Surgery for pulmonary aspergillosis is infrequent and often challenging. Risk assessment is imprecise and new antifungals may ameliorate some surgical risks. We evaluated the medical and surgical management of these patients, including perioperative and postoperative antifungal therapy. Methods Retrospective study of patients who underwent surgery for pulmonary aspergillosis between September 1996 and September 2011. Results 30 patients underwent surgery with 23 having a preoperative tissue diagnosis while 7 were confirmed post-resection. The median age was 57 years (17–78). The commonest presenting symptoms were cough (40%, n = 12) and haemoptysis (43%, n = 13). Twelve (40%) patients had simple aspergilloma (including 2 with Aspergillus nodules) while the remaining 18 (60%) had chronic cavitary pulmonary aspergillosis (CCPA) (complex aspergilloma). Most of the patients had underlying lung disease: tuberculosis (20%, n = 6), asthma (26%, n = 8) and COPD (20%, n = 6). The procedures included lobectomy 50% (n = 15), pneumonectomy 10% (n = 3), sublobar resection 27% (n = 8), decortication 7% (n = 2), segmentectomy 3% (n = 1), thoracoplasty 3% (n = 1), bullectomy and pleurectomy 3% (n = 1), 6% (n = 2) lung transplantation for associated disease. Median hospital stay was 9.5 days (3–37). There was no operative and 30 day mortality. Main complications were prolonged air leak (n = 7, 23%), empyema (n = 6, 20%), respiratory failure requiring tracheostomy /reintubation (n = 4, 13%). Recurrence of CCPA was noted in 8 patients (26%), most having prior CCPA (75%). Taurolidine 2% was active against all 9 A. fumigatus isolates and used for pleural decontamination during surgery. Conclusions Surgery in patients with chronic pulmonary aspergillosis offered good outcomes with an acceptable morbidity in a difficult clinical situation; recurrence is problematic. PMID:23915502
Radev, R; Nenkov, R; Kornovski, S; Dokov, V; Kuzmanov, Ia; Kuzmanov, S; Nenkova, S; Nanev, B
In recent years, together with the well-known high-frequency electro-coagulation, the application of plasma coagulation has been also introduced in the clinical practice. The argon plasma coagulator (APC) is one of the representatives of this surgical technique. By its nature, the APC represents a non-contact electrothermal tissue coagulation, combining the principle of the augmented surface and enhanced autogenous haemostatic mechanisms. The main objective of this study was to evaluate whether APC is an effective and safe modality in the open pulmonary surgery. For the period from 01.01.2003 to 30.01.2004 year, in the Clinic of Thoracic Surgery, we have applied the technique of APC to 15 patients. The distribution by sex was: 10 males and 5 females. According to the nosological units, the distribution was as follows: pulmonary carcinoma in 3, pulmonary echinococcosis in 4, pleural empyema in 6, pulmonary abscessus in 1 and esophageal ahalasia in 1 patient. In our practice, we have used an argon plasma coagulator of BERCHTOLD GmbH. A power setting of 20W with exposition time 15 s and an argon gas flow setting of 1,5-2 1/h have been used in our series. Energy dose applied in our patients didn't exceed 300 J/cm2. The results we have obtained demonstrate the following fundamental advantages of APC: a possibility to work with long electrode--tissue distance; a possibility for large surface coagulation as well as coagulation under variable angle, limited and well controlled depth of penetration, substantial reduction of carbonization; regular distribution of the energy over the whole coagulating surface, a possibility to treat effectively larger bleeding surfaces. Although initial, our experience gives us the confidence to recommend the use of APC as an effective and safe procedure in the pulmonary surgery.
Terra, Ricardo Mingarini; Teixeira, Lisete Ribeiro; Bibas, Benoit Jacques; Pego‐Fernandes, Paulo Manuel; Vargas, Francisco Suso; Jatene, Fabio Biscegli
OBJECTIVES: To evaluate the effectiveness and safety of pleurodesis carried out entirely on an outpatient basis in patients with recurrent malignant pleural effusions and Karnofsky Performance Status scores ≤70. METHODS: This study was a prospective trial comprising patients with symptomatic recurrent malignant pleural effusion and Karnofsky Performance Status scores ≤70 but >30. All selected patients underwent pleural catheter placement (14 Fr) in an outpatient facility. When chest radiography revealed post‐drainage lung expansion of >90%, pleurodesis (3 g of talc) was performed. Catheters were maintained until the daily output was <100 mL/day. The patients were evaluated in the first month and every three months thereafter for fluid recurrence, the need for additional procedures, and complications. RESULTS: During the study period (January 2005 to July 2007), 64 patients (24 men, 40 women), with an average age of 61.4 years, underwent elective chest tube drainage. Primary sites of the underlying malignancy were breast (27), lung (22), and others (15). Sixty‐six pleural catheters were placed (bilaterally in 2 patients), and 52 talc pleurodesis procedures were performed. Fourteen patients had a trapped lung and were excluded from the trial. No complications were observed during catheter placement or pleurodesis. Post‐pleurodesis complications included catheter obstruction (4 patients) and empyema (1). The average drainage time was 9.9 days. The recurrence rate observed in patients that were alive 30 days after pleurodesis was 13.9% (5/36 patients). Six patients required additional procedures after the pleurodesis. The average survival time was 101 days. CONCLUSION: In this study, talc pleurodesis was safely performed in an outpatient setting with good efficacy and a reasonable complication rate, thereby avoiding hospital admission. PMID:21484035
Benedix, Frank; Willems, Tobias; Kropf, Siegfried; Schubert, Daniel; Stübs, Patrick; Wolff, Stephanie
Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy with gastric tube reconstruction. Little is known about risk factors that can predict this debilitating complication. Patients who underwent elective esophagectomy from 2008 to 2016 in a single center were retrospectively reviewed. Diagnosis of DGE was based on clinical, radiological, and endoscopic findings. Uni- and multivariate analyses were performed to identify patient-, tumor-, and procedure-related factors that increase the risk of DGE. One hundred eighty-two patients were included. Incidence of DGE was 39.0%. Overall, 27 (14.8%) needed an endoscopic intervention. Patients in the DGE group had a longer hospital stay (p < 0.01). No differences were found for the 30-day (p = 1.0) and hospital mortality (p = 1.0). On univariate analyses, a significant influence on DGE was demonstrated for pre-existing pulmonary comorbidity (p = 0.04), an anastomotic leak (p < 0.01), and postoperative pulmonary complications (pneumonia: p = 0.02, pleural empyema: p < 0.01, and adult respiratory distress syndrome: p = 0.03). Furthermore, there was a non-significant trend toward an increased risk for DGE for the following variable: female gender (p = 0.09) and longer operative time (p = 0.09). On multivariate analysis, only female gender (p = 0.03) and anastomotic leak (p = 0.01) were significantly associated with an increased risk for DGE. DGE is a frequent complication following esophagectomy that can successfully be managed with conservative or endoscopic measures. DGE did not increase mortality but was associated with increased morbidity and prolonged hospitalization. We identified risk factors that increase the incidence of DGE. However, this has to be confirmed in future studies with standardized definition of DGE.
Tagarro, Alfredo; Bote, Patricia; Sánchez, Aida; Otheo, Enrique; Sanz, Juan-Carlos; Sanz-Rosa, David
In the Region of Madrid, universal immunization with the 13-serotypes pneumococcal conjugate vaccine (PCV13) started in May 2010. In July 2012, public funding ceased. Vaccination coverage decreased from >95% to 82% in 2013 and to 67% in 2014. Our aim was to investigate the impact of PCV13 withdrawal from Madrid Region universal immunization program on the incidence of complicated pneumococcal bacteremia. We performed a multicenter retrospective cohort study, from 2009 to 2014. Participants were children aged <14 years with Streptococcus pneumoniae bacteremia. Complications were defined as any condition requiring intensive care or surgery. Sequelae were conditions lasting ≥90 days. A total of 168 patients were recruited. One-fourth of both immunized and nonimmunized patients had complications. Global complications increased after PCV13 withdrawal. About 28% of PCV13 serotypes presented complications. Complications caused by PCV13 serotypes did not increase after July 2012. Non-PCV13 serotypes increased progressively from 2009 on, and 23% presented complications. A significant risk of complications was found for patients with meningitis, empyema, C-reactive protein >100 mg/L and serotype 1. A multivariate analysis indicated that complications were associated with meningitis and hospital admission after July 2012. Sequelae were significantly associated with children <2 years of age, meningitis and non-PCV13 serotypes. The incidence of complications caused by PCV13 serotypes did not increase 2 years after PCV13 withdrawal. Nevertheless, all-serotypes complications increased. The likely cause was that non-PCV13 serotypes (associated with meningitis) are on the rise.
Vaneckova, Pavla; Bambrick, Hilary
Background While morbidity outcomes for major disease categories during extreme heat have received increasing research attention, there has been very limited investigation at the level of specific disease subcategories. Methodology/Principal Findings We analyzed daily hospital admissions for cardiovascular (CVD), respiratory (RD), genitourinary (GU) and mental diseases (MD), diabetes (DIA), dehydration (DEH) and ‘the effects of heat and light’ (HEAT) in Sydney between 1991 and 2009. We further investigated the sensitivity to heat of subcategories within the major disease groups. We defined hot days as those with temperatures in the 95th and 99th percentiles within the study period. We applied time-stratified case-crossover analysis to compare the hospital admissions on hot days with those on non-hot days matched by day of the week. We calculated the odds ratios (OR) of admissions between the two types of days, accounting for other environmental variables (relative humidity, ozone and particulate matter) and non-environmental trends (public and school holidays). On hot days, hospital admissions increased for all major categories except GU. This increase was not shared homogeneously across all diseases within a major category: within RD, only ‘other diseases of the respiratory system’ (includes pleurisy or empyema) increased significantly, while admissions for asthma decreased. Within MD, hospital admissions increased only for psychoses. Admissions due to some major categories increased one to three days after a hot day (e.g., DIA, RD and CVD) and on two and three consecutive days (e.g., HEAT and RD). Conclusions/Significance High ambient temperatures were associated with increased hospital admissions for several disease categories, with some within-category variation. Future analyses should focus on subgroups within broad disease categories to pinpoint medical conditions most affected by ambient heat. PMID:23408986
Wijnia, Jan W; Oudman, Erik; van Gool, Willem A; Wierdsma, André I; Bresser, Esmay L; Bakker, Jan; van de Wiel, Albert; Mulder, Cornelis L
Wernicke encephalopathy can have different clinical outcomes. Although infections may precipitate the encephalopathy itself, it is unknown whether infections also modify the long-term outcome in patients developing Korsakoff syndrome. To determine whether markers of infection, such as white blood cell (WBC) counts and absolute neutrophil counts in the Wernicke phase, are associated with cognitive outcomes in the end-stage Korsakoff syndrome. Retrospective, descriptive study of patients admitted to Slingedael Korsakoff Center, Rotterdam, The Netherlands. Hospital discharge letters of patients with Wernicke encephalopathy were searched for relevant data on infections present upon hospital admission. Patients were selected for further analysis if data were available on WBC counts in the Wernicke phase and at least 1 of 6 predefined neuropsychological tests on follow-up. Infections were reported in 35 of 68 patients during the acute phase of Wernicke-Korsakoff syndrome-meningitis (1), pneumonia (14), urinary tract infections (9), acute abdominal infections (4), sepsis (5) empyema, (1) and infection "of unknown origin" (4). The neuropsychological test results showed significant lower scores on the Cambridge Cognitive Examination nonmemory section with increasing white blood cell counts (Spearman rank correlation, ρ = -0.34; 95% CI: -0.57 to -0.06; 44 patients) and on the "key search test" of the behavioral assessment of the dysexecutive syndrome with increasing absolute neutrophil counts (ρ= -0.85; 95% CI: -0.97 to -0.42; 9 patients). Infections may be the presenting manifestation of thiamine deficiency. Patients with Wernicke-Korsakoff syndrome who suffered from an infection during the acute phase are at risk of worse neuropsychological outcomes on follow-up. Copyright © 2016 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Kaluskar, S K
The study of the nose is as old as civilisation. Various conditions affecting its structure and function has been documented in Edwin Smith Papyrus in hieroglyphic script, an Egyptian writing system of the mid -4th Millennium BC.The major contribution for the complete reconstruction of the nose originated in India by Sushruta in around 600 BC. Writing in Sanskrit in the form of verses he described in detail the technique of total reconstruction, which is still being practiced today as Indian Rhinoplasty. This surgical reconstruction paved the way to modern plastic surgery in Europe and United States in 18th century. Sushruta contributed not only to the plastic surgery of the nose, but described entire philosophy of Head and Neck and other surgery as well. Other notable contributors were Greek physicians, Hippocrate and Galen, and at the birth of the Christianity, Celsus wrote eight books of medical encyclopaedia, which described various conditions affecting nose.Septal and Sinus surgery, in comparison to rhinoplasty did not develop until 17th century. Septal surgery began with total septectomy, sub mucous resection by Killian & Freer in early 20th century and later septoplasty by Cottle in middle of 20th century.Sinus surgery probably originated in Egypt, where instruments were used to remove brain through the ethmoid sinuses as part of the mummification process. In 18th century, empyema of the maxillary sinus was drained through the tooth socket or anterior wall of the sinus, which lead to the evolution of radical procedures of removal of mucous membrane and inferior meatal antrostomy. In the late 20th century, improved understanding of the mucociliary mechanism described by Prof. Messerklinger and Nasal Endoscopy described by Prof. Draf with the development of fibre optics and CT imaging, heralded a new era, which evolved in functional endoscopic sinus surgery. New technology further enhanced the scope of endoscope being used "around and beyond" the nose.
Filippini, Arnaldo; Pagliaricci, Laura; Pomidori, Augusto
The authors report a case of reconstruction of the gastrointestinal tract in a young woman of 36 years of age who, after ingesting muriatic acid, and after a series of consecutive operations found herself without an oesophagus (from the hypopharynx) stomach and colon. She was fed with a jejunostomy and had a large pharyngostomy to prevent sialorrhoea. After one year, the patient manifested the need to resume eating by mouth. The problem was serious due both to the anastomosis above the level of the larynx and the very long period of rehabilitation. The technical problem included the need to avoid the thoracic cavity due to the previous empyema, and thus to bring a viable jejunal loop up to the neck in a subject already operated on four times. The solution was a Roux loop at the level of the 4th-5th jejunal arcade brought to the neck via a subcutaneous presternal route and anastomised in a supraglottic location at the level of the right pyriform sinus. The viability of the loop was guaranteed by an arterial shunt with a branch of the mesenteric artery by means of a segment of saphenous vein and a venous shunt over the right internal jugular vein to guarantee venous flow. The pharyngo-jejunal anastomosis was done with a 21 mm circular stapler with a rotary head after a partial parietal resection of the laryngeal cartilage and under the protection of a provisional tracheostomy. After 4 months' treatment, partly in intensive care and partly in a rehabilitation centre with logopaedic assistance, the tracheal cannula could be removed and the patient is now able to eat by mouth with normal phonation.
Wang, Xiao-hui; Yu, Jie; Liang, Ping; Yu, Xiao-ling; Cheng, Zhi-gang; Han, Zhi-yu; Liu, Fang-yi
To analyze the major complications of percutaneous cooled-tip microwave ablation for the treatment of primary liver cancer and the possible risk factors of severe complications in a series of 693 patients. The clinicopathological data of 693 patients with primary liver cancer who underwent ultrasound-guided percutaneous cooled-tip microwave (MW) ablation in our hospital over the past 5 years were retrospectively analyzed, and the risk factors of severe complications were explored. In a total of 693 patients with 898 primary liver tumors were treated and 1111 MW ablation sessions were performed. The mean diameter of tumors was (2.5 ± 1.2) cm and the range was 0.4 - 10.0 cm. Three deaths occurred in the peri-ablation period, including one case died of multiorgan failure, one case died of pulmonary embolism and one case died of hepatorenal syndrome. Major complications occurred in 27 (3.9%) patients, including 12 pleural effusion requiring thoracentesis (1.7%), 10 tumor seeding (1.4%), 3 liver abscess and empyema (0.4%), 1 hemorrhage requiring arterial embolization (0.1%), and 1 bile duct injury (0.1%). The Chi-square test results showed that the diameter of tumors, number of MW ablation sessions and histological type of tumor were significantly associated with the major complications rate (P < 0.05). The multiple variables 1ogistic regression analysis showed that only type of tumors was associated with the major complication rate (P < 0.05). Results of this study confirm that cooled-tip MW ablation is a relatively low-risk and effective minimally invasive procedure for the treatment of primary liver cancer. Proper direction for the treatment of cholangiocarcinoma (ICC) patients as well as fewer ablated tumor numbers during one hospital stay may help minimize the major complication rate in patients with primary liver cancer treated by ultrasound-guided percutaneous cooled-tip microwave ablation.
Padrón-Arredondo, Guillermo; de Atocha Rosado-Montero, Manuel
Acute appendicitis and acute cholecystitis are among the most common diagnoses that general surgeons operate on. However, it is rarely described in its synchronous form. A 43 year-old woman attending the clinic for right upper quadrant pain of 11 days duration. The patient refers to intermittent radiating pain in the right side, with positive Murphy, tachycardia, and fever. The laboratory results showed white cells 16,200/mm(3), glucose 345 mg/dl, abnormal liver function tests. Acute cholecystitis was reported with ultrasound. A Masson-type incision was made, noting an enlarged pyogenic gallbladder with thickened walls, sub-hepatic abscess of approximately 300 ml, greenish-yellow colour, and foetid. An anterograde subtotal cholecystectomy is performed due to difficulty in identifying elements of Calot triangle due to the inflammatory process, opening it and extracting stones. The right iliac fossa is reviewed, finding a plastron and a sub-serous retrocaecal appendix perforated in its middle third with free fecalith and an abscess in the pelvic cavity. An anterograde appendectomy was performed and the patient progressed satisfactorily, later being discharged due to improvement. In this patient, with a history of recurrent episodes of gallbladder pain and disseminated acute abdominal pain without peritoneal irritation, clinical suspicion was exacerbated cholecystitis with probable empyema of the gallbladder. Open surgery approach for this patient allowed access to both the appendix and gallbladder in order to perform a complete exploration of the abdominal cavity. The synchronous presentation of cholecystolithiasis and complicated appendicitis has not been reported in the literature. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.
Weissberg, D; Schachner, A
Video-assisted thoracic surgery (VATS) is one of the main medical revolutions of the past decade. For its satisfactory performance, the following prerequisites are essential: (1) knowledge and experience in thoracic surgery; (2) team of experienced anesthesiologists; (3) preoperative assessment of respiratory function; (4) adequate postoperative care; and (5) instruments specially designed for thoracoscopic surgery. VATS is routinely performed under general anesthesia with double lumen endotracheal intubation for separate control of each lung. Insufflation of carbon dioxide must not exceed 1-3 mm Hg. Too high pressure may cause harmful reduction of venous return and mediastinal shift with impairment of ventilation. Presence of adhesions should be determined by finger exploration of the pleural cavity. Operative ports should be placed carefully, avoiding damage to the intercostal nerves and vessels. The video technique can be used with efficiency for the following indications: pneumothorax, resection of pulmonary nodules, biopsies of lung, pleura and mediastinal structures, resection of mediastinal tumors, management of empyema, and hemostasis and closure of lacerations after trauma. Indications for esophageal procedures include esophagomyotomy for achalasia and resections of benign lesions. Repair of perforated esophagus is a matter of controversy, but in early stages it can be done thoracoscopically. Although video-pericardioscopy has been performed by some surgeons, this procedure can be done easier and faster using the direct approach without the video equipment. There are differences of opinion with regard to major pulmonary and esophageal resections for cancer. The apparent advantage of diminished pain is offset by inadequate resection, spread of malignant cells and potential damage to the resected specimen with loss of important information concerning pathology. Complications of VATS are few, and include prolonged air leak, dysrhythmia, respiratory failure
Colella, Sara; Fioretti, Federica; Massaccesi, Chiara; Primomo, Gian L; Panella, Gianluca; D'Emilio, Vittorio; Pela, Riccardo
Although pleural effusion (PE) can be caused by several pathologies like congestive heart failure, infections, malignancies, and pulmonary embolism, it is also a common finding in chronic kidney disease (CKD). Diagnostic thoracentesis is of limited value in the differential diagnosis, and the role of more invasive investigations like medical thoracoscopy (MT) is still unclear. To evaluate the usefulness of MT in unexplained PE in CKD. In the electronic database of our Institution, we retrospectively searched for patients with CKD who underwent MT for unexplained PE between January 2008 and August 2016. Ten patients were included in the present study. The average age was 72.4 years, the male:female ratio 9:1 and the average blood creatinine value 5.96 mg/dL. The average follow-up was 18 months.A thoracentesis showed an exudate was found in 9 patients and in 1 case pleural fluid characteristics were not recorded for technical reasons; in none of them the cytologic or microbiological analyses were considered diagnostic.The clinical suspicion was a neoplastic (5) or an infectious disease (5). In 4 patients with recurrent PE, MT was performed to obtain talc pleurodesis.No immediate procedure-related complications were recorded; 1 patient developed empyema after 2 months. In 6 cases final diagnosis was chronic uremic pleuritis, hydrothorax in 2, and chronic lymphocytic pleurisy in 2. MT represents a safe and effective diagnostic and therapeutic procedure in patients with CKD, that itself is a common cause of exudative effusion, and those patients may not require MT.
Karamchandani-Patel, Gital; Hanson, Eric P.; Saltzman, Rushani; Kimball, C. Eve; Sorensen, Ricardo U.; Orange, Jordan S.
Background Hypomorphic mutations in the NF-κB essential modulator (NEMO) gene result in a variable syndrome of somatic and immunological abnormalities. Clinically relevant genotype-phenotype associations are essential to understanding this complex disease. Objective Two unrelated boys with novel NEMO mutations altering codon 223 were studied for similarity in phenotype in consideration of potential genotype-phenotype associations. Methods Clinical and Laboratory features including cell counts, immunoglobulin quantity and quality, NK cell cytotoxicity, Toll-like and TNF receptor signaling were evaluated. Since both mutations affected NEMO codon 223 and were novel, consideration was given to new potential genotype-phenotype associations. Results Both patients were diagnosed with hypohydrotic ectodermal dysplasia and had severe or recurrent infections. One had recurrent sinopulmonary infections and the other necrotizing soft tissue MRSA infection and Streptococcus anginosus subdural empyema with bacteremia. NEMO gene sequence demonstrated a three-nucleotide deletion (c.667_669delGAG) in one patient and a substitution (667G>A) in the other. These predict either the deletion of NEMO glutamic acid 223 or it being replaced with lysine, respectively. Both patients had normal serum IgG levels but poor specific antibodies. NK cell cytotoxicity, Toll-like and TNF receptor signaling was also impaired. Serious bacterial infection did not occur in both patients after immunoglobulin replacement therapy. Conclusions Two different novel mutations affecting NEMO glutamic acid 223 resulted in clinically relevant similar phenotypes providing further evidence to support genotype-phenotype correlations in this disease. They suggest NEMO residue 223 is required for ectodermal development and immunity and is apparently dispensable for quantitative IgG production, but may be required for specific antibody production. PMID:21704885
Cordice, J. W.; Chitkara, R. K.
Despite the generally salutary experience in recent years of managing suppurative pleuropulmonary disease, empyemas and lung abscesses have persisted and increased in incidence in hospitals such as Queens Hospital Center that serve large numbers of the socioeconomically disadvantaged. This study documents the etiology, clinical presentation, treatment, and treatment results of suppurative pleuropulmonary disease at Queens Hospital Center, which serves a large segment of the urban poor, many of whom are black. Results indicate that contributory or antecedent etiologic factors include a history of prior disease (specifically pneumonia, lung abscess, obstructive lung disease, pulmonary neoplasia, and tuberculosis); a predisposition to constitutional or immunologic deficiencies (specifically, alcoholism, anemia/malnutrition, drug abuse, and acquired immunodeficiency syndrome [AIDS]); conditions contributing to tracheobronchial aspiration (specifically, alcoholism and seizure disorders); and a miscellaneous group such as prior surgery, cardiovascular disease, and sepsis syndrome. The patients in this study were young with maximal incidence occurring in the third to fifth decades of life. Patients were predominantly male (75%) and black (66%). There were 18 deaths (23%), with sepsis being the cause in 10 (56%). Most surgical interventions were conservative, ie, bronchoscopies (48), thoracenteses (43), and tube thoracotomies (39). Thirty-one open thoracotomies were performed for drainage, decortication, or pulmonary resection. The surgical mortality was three cases or 5% of the patients who underwent surgery. The designated incidence of proven AIDS in this series (29%) was low, undoubtedly because many patients refused testing, and the multiple gram-positive and gram-negative infections that were seen did not conform to the Centers for Disease Control criteria for diagnosis and case reporting for AIDS.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:1602513
Tcherveniakov, Peter; De Siqueira, Jonathan; Milton, Richard; Papagiannopoulos, Kostas
Prolonged drainage and air leaks are recognized complications of elective and acute thoracic surgery and carry significant burden on inpatient stay and outpatient resources. Since 2007, we have run a ward-based, nurse-led clinic for patients discharged with a chest drain in situ. The aim of this study is to assess its cost-effectiveness and safety. We present a retrospective review of the activity of the clinic for a period of 12 months (November 2009-10). An analysis of the gathered data is performed, focusing specifically on the duration of chest tube indwelling, the indications, complications and cost efficiency. The nurse-led clinic was housed in the thoracic ward with no additional fixed costs. Seventy-four patients were reviewed (53 males, 21 females, mean age of 59) and subsequently discharged from the clinic in this time period, accounting for 149 care episodes. Thirty-three (45%) of the patients underwent a video-assisted thoracoscopic surgery procedure, 35 (47%) of them a thoracotomy and 7 (9%) had a bedside chest tube insertion. Following hospital discharge, the chest tubes were removed after a median of 14 days (range 1-82 days). Fifty-eight percent of the patients were reviewed because of a prolonged air leak, 26% for persistent fluid drainage and 16% due to prolonged drainage following evacuation of empyemas. For the care episodes analysed, we estimate that the clinic has generated an income of €24,899 for the department. Hourly staffing costs for the service are significantly lower compared with those of the traditional outpatient clinic: €15 vs. €114. Our results show that a dedicated chest tube monitoring clinic is a safe and efficient alternative to formal outpatient clinic review. It can lead to shorter hospital stays and is cost effective.
Dabdoub, Carlos B; Adorno, Juan Oscar; Urbano, Jair; Silveira, Elisabeth N; Orlandi, Bianca Maria M
Infection of a subdural hematoma is an unusual cause of subdural empyema, with fewer than 50 cases reported in the literature. The appropriate surgical option for this entity has not been determined because of its rarity. We present a case report of a post-traumatic subdural hematoma infected with Escherichia coli that was successfully treated with craniotomy. In addition, we performed a PubMed search to comprehensively illustrate the causative organism, source of infection, clinical picture, surgical treatment, and outcome for this condition. This article presents an update on the condition. A 55-year-old man was admitted to our hospital complaining of headache, seizure, and urinary incontinence. He had a history of alcoholism and several hospitalizations for mild head trauma. Neuroimaging studies revealed a chronic hematic collection in the left frontal-parietal region. Laboratory tests showed increased C-reactive protein levels. In addition, surgical results revealed an infected subdural hematoma. A bacterial culture of the purulent specimen identified E. coli. In view of the urinary complaint and leukocyturia, the cause of the infected subdural hematoma was postulated as a urinary tract infection. Infected subdural hematoma is an unusual disorder. We must keep in mind the possibility of this complication when seeing a patient who presents with any of the 3 most common symptoms in this review. In these patients, craniotomy should be the method of surgical drainage, especially in adults. It ensures maximal drainage of the loculated pus and allows the total removal of the infected hematoma capsule. Copyright © 2016 Elsevier Inc. All rights reserved.
van Hoek, Albert Jan; Andrews, Nick; Waight, Pauline A.; George, Robert; Miller, Elizabeth
Background Differences in pathogenicity between pneumococcal serotypes are important when assessing the potential benefit of different valency vaccines. We investigated the effect of serotype on clinical presentation, outcome, and quality of life lost from invasive pneumococcal disease (IPD) in the context of the 7, 10, and 13 valent pneumococcal conjugate vaccines (PCV7, PCV10, PCV13). Method Serotyped IPD cases in England were linked to the national dataset of hospital admissions for April 2002 to March 2011. Based on patients’ diagnostic codes and vital status at the end of the admission, disease focus (meningitis, empyema, sepsis, or respiratory disease) and case fatality rates by serotype and age group (5, 5–64, and 65 years and over) were obtained. Using these data the quality adjusted life years (QALY) lost from the IPD remaining when use of PCV7 stopped in 2010 was estimated for the serotypes covered by higher valency vaccines. Results The linked dataset contained 23,688 cases with information on diagnosis, mortality, and serotype. There were significant differences between serotypes in the propensity to cause meningitis, death, and QALY loss in each of the investigated age groups. As a result, vaccines’ coverage of disease burden differed by endpoint. For example, in children under 5 years in 2009/10, PCV10 covered 39% of meningitis, 19% of deaths and 28% of the QALY loss of attributable to IPD, whereas the respective percentages for PCV13 were 65%, 67%, and 66%. The highest QALY loss per serotype in this age group was for 6A. Non-PCV serotypes causing the highest QALY loss were 22F and 33F in <5 year olds and 31 in older individuals. Conclusion Marked differences exist between serotypes in clinical presentation and outcome, and these should be considered when evaluating the potential impact of higher valency vaccines on overall disease burden and associated QALY loss. PMID:22815698
Jun, Chung Hwan; Yoon, Jae Hyun; Wi, Jin Woo; Park, Seon Young; Lee, Wan Sik; Jung, Sook In; Park, Chang Hwan; Joo, Young Eun; Kim, Hyun Soo; Choi, Sung Kyu; Rew, Jong Sun
To evaluate the risk factors and clinical outcomes in patients with spontaneous rupture of pyogenic liver abscess (PLA). A total of 602 patients diagnosed with PLA between January 2004 and July 2013 were retrospectively analyzed. Among them, 23 patients experienced a spontaneous rupture of liver abscess (SRLA). The prevalence of SRLA was 3.8%. Using multivariate analysis, liver cirrhosis (OR 4.651, P = 0.009), gas-forming abscesses (OR 3.649, P = 0.026), abscess ≥6 cm in diameter (OR 10.989, P = 0.002) and other septic metastases (OR 1.710, P = 0.047) were risk factors for SRLA. Regarding the site of rupture, 20 (87.0%) patients had a localized rupture, specifically, subphrenic abscess in 3 (13.0%), peri-hepatic abscess in 10 (43.5%), localized peritoneal abscess in 3 (13.0%) and empyema in 4 (17.5%); and the other 3 (13%) had peritonitis. Ruptures resulting in peritonitis require urgent surgery, whereas localized ruptures were managed with surgical or percutaneous drainage in addition to appropriate antibiotics. The in-hospital mortality rate of SRLA was 4.3%. Patients with cirrhosis, having abscess ≥6 cm in diameter, gas-forming abscesses and other septic metastases in those with PLA should be monitored closely and may need early intervention for SRLA. © 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.
Lussiez, Alisha; Bevins, Jack; Plaska, Andrew; Rosin, Vadim; Reddy, Rishindra M
General surgery residents' exposure to cardiothoracic (CT) surgery rotations has decreased, which may affect resident satisfaction. We surveyed general surgery graduates to assess the relationships among rotation satisfaction, CT disease exposure, rotation length, mentorship, and mistreatment. A survey assessing CT curriculum, exposure, mentorship, and satisfaction was forwarded to general surgery graduates from 17 residency programs. A Wilcoxon rank-sum test was used to assess statistical significance of ordinal level data. Statistical significance was defined as p < 0.05. This study was conducted at the University of Michigan Health System in Ann Arbor, MI, a tertiary care center. The survey was sent to approximately 1300 graduates of general surgery residency programs who graduated between the years of 1999 to 2014. A total of 94 responses were completed and received. Receiving adequate exposure to CT procedures and disease management was significantly associated with higher satisfaction ratings for all procedures, particularly thoracotomy incisions (p < 0.001), empyemas and pleural effusions (p < 0.001), and lung cancer care (p < 0.001). The absence of mistreatment and good/very good mentorship were both positively associated with higher reported satisfaction (p = 0.018 and p < 0.001, respectively). Increased length of time on CT rotation was neither associated with improved levels of satisfaction nor with an improvement in the quality of mentorship. Rotation satisfaction is positively associated with procedure exposure, better mentorship, and the absence of mistreatment. Longer rotation length was not associated with satisfaction. Shorter rotations are not detrimental to training if they have focused clinical exposure and invested mentors to maximize resident satisfaction. These specific markers of rotation quality are useful in curricular design. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Mattos, Jose L; Colman, Kathryn L; Casselbrant, Margaretha L; Chi, David H
To review all cases intratemporal and intracranial complications of acute otitis media (AOM) in infants and children from 1998 to 2013. Retrospective chart review of 109 consecutive patients admitted for complications of AOM during a 15-year period at a tertiary-care children's hospital. The main outcomes are: (1) complications of AOM, (2) bacteriology, (3) management strategies. In our population, complications included mastoiditis (86.1%), subperiosteal abscess (38%), facial nerve palsy (16.7%), sigmoid sinus thrombosis (8.3%) and epidural abscess (7.4%). Other complications included post-auricular cellulitis, otic hydrocephalus and elevated intracranial pressure, internal jugular thrombosis, cranial nerve VI palsy and Gradenigo's syndrome, labyrinthine fistula, sensorineural hearing loss, and cerebellar infarct. Sixty-one patients (56%) received antibiotics prior to presentation. Cultures revealed Streptococcus pneumoniae in 36 patients (33.3%), other bacteria in 30 patients (27.8%), and "no growth" in 33 patients (30.5%). Nine patients (8.3%) did not undergo culture. Of the patients with S. pneumoniae, 20 cultures (55%) were found to be multidrug-resistant. Eleven patients (10.2%) were treated non-surgically, 31 (31%) were treated with myringotomy and intravenous antibiotics. Forty patients (97.5%) presenting with subperiosteal abscess required mastoid surgery. Thirteen of 18 (72.2%) patients with facial paralysis had full recovery. Eight of 10 (80%) patients with epidural abscess empyema required mastoid surgery and incision and drainage of the abscess. Complications of AOM are uncommon, yet continue to have potentially serious consequences. The bacteriology in this population reveals an increasing trend of multi-drug resistant S. pneumoniae as the causative organism. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Kumar, Sunil; Agarwal, Nitin; Rattan, Amulya; Rathi, Vinita
Context: Thoracic trauma causes significant morbidity; however, many deaths are preventable and few patients require surgery. Intercostal chest drainage (ICD) for hemo/pneumothorax is simple and effective; the main problem is residual hemothorax, which can cause lung collapse and empyema. Aims: Our study aimed to analyze the relationship between radiological chest tube parameters (position and intrathoracic length) and the frequency of residual hemothorax. Settings and Design: This prospective analytical study was conducted in a large tertiary care hospital in north India over 2 years till March 2013. Materials and Methods: Patients of chest trauma aged 18-60 years, with hemothorax or hemopneumothorax requiring ICD insertion were included in the study. Bedside ICD insertion was performed as per current standards. Immediate post-ICD chest radiographs were used to record lung status and ICD position (chest tube zone and intrapleural length). Residual hemothorax was defined as any collection identified on radiological investigations after 48 hours of ICD placement. Statistical Analysis: Univariate analysis was performed with the chi-square test or Student's t-test as appropriate, while multivariate analysis using stepwise logistic regression; a P-value < 0.05 was significant. Results: Out of 170 patients of chest trauma, 154 underwent ICD insertion. Most patients were young (mean age: 31.7 ± 12 years) males (M:F = 14:1). Ninety-seven patients (57.1%) had isolated chest injuries. Blunt trauma (n = 119; 77.3%) and motor vehicle accidents (n = 72; 46.7%) were the commonest causes. Mean hospital stay was 9 ± 3.94 days, and mortality 2/154 (1.1%). Residual hemothorax was seen in 48 (31%). No ICD zone or length was significantly associated with residual hemothorax on univariate or multivariate analysis. Conclusion: Intrapleural ICD zone or length does not affect the frequency of residual hemothorax. PMID:25400388
Sorge, Roberto; Akopov, Andrej; Congregado, Miguel; Grodzki, Tomasz
Background A survey amongst the European Society of Thoracic Surgeons (ESTS) members has been performed to investigate the currents trends, rates of adoption as well as potential for future expansion of non-intubated thoracic surgery (NITS) performed under spontaneous ventilation. Methods A 14-question-based questionnaire has been e-mailed to ESTS members. To facilitate the completion of the questionnaire, questions entailed either quantitative or multiple-choice answers. Investigated issues included previous experience with NITS and number of procedures performed, preferred types of anesthesia protocols (i.e., thoracic epidural anesthesia, intercostal or paravertebral blocks, laryngeal mask, use of additional sedation), type of procedures, ideal candidates for NITS, main advantages and technical disadvantages. Non-univocal answer to multiple-choice questions was permitted. Results Out of 105 responders, 62 reported an experience with NITS. The preferred types of anesthesia were intercostal blocks with (59%) or without (50%) sedation, followed by laryngeal mask with sedation (43%) and thoracic epidural anesthesia with sedation (20%). The most frequently performed procedures included thoracoscopic management of recurrent pleural effusion (98%), pleural decortication for empyema thoracis and lung biopsy for interstitial lung disease (26% each); pericardial window and mediastinal biopsy (20% each). More complex procedures such as lobectomy, lung volume reduction surgery and thymectomy have been performed by a minority of responders (2% each). Poor-risk patients due to co-morbidities (70%) and patients with poor pulmonary function (43%) were considered the ideal candidates. Main advantages included faster, recovery (67%), reduced morbidity (59%) and shorter hospital stay with decreased costs (43% each). Reported technical disadvantages included coughing (59%) and poor maneuverability due to diaphragmatic and lung movements (56%). Overall, 69% of responders indicated
James, D R; Golovsky, G; Thornton, J M; Goodchild, L; Havlicek, M; Martin, P; Krockenberger, M B; Marriott, Dje; Ahuja, V; Malik, R; Mor, S M
Brucellosis caused by Brucella suis is a notifiable disease that has recently emerged in dogs in New South Wales (NSW). Given the potential for zoonotic transmission, euthanasia of affected dogs is recommended, but this action is not mandatory. We report the clinical management of three dogs that underwent treatment at their owners' request. A 14-month-old spayed female crossbreed originally obtained from an urban animal shelter underwent extensive investigations in 2011-12 for lameness and back pain, culminating in decompressive laminectomy. Diagnosis of multifocal discospondylitis and spinal empyema was made, with B. suis cultured from surgical biopsy specimens. The dog responded to long-term treatment using rifampicin and doxycycline. A second case of B. suis infection was diagnosed in January 2016 in a 3-year-old crossbreed pig-hunting dog with unilateral testicular enlargement. Following serological diagnosis the dog was given preliminary therapy using rifampicin and doxycycline, the affected testis was resected and the patient given a further month of combination therapy. In March 2016 a 7-year-old crossbreed pig-hunting dog with brucellosis was handled similarly, although both testes were removed. Brucellosis should be considered in the differential diagnosis of back pain, discospondylitis, lameness, abortion, prostatic abscessation and testicular/epididymal enlargement in dogs, especially if there is exposure to feral pigs or consumption of uncooked feral pig meat. Euthanasia is the only guarantee of reducing the public health risk to zero. However, where treatment is desired by the owner, combination therapy using rifampicin and doxycycline appears to be effective, when combined with surgical resection of infected tissues. Further monitoring of dogs during and after treatment is required to document cure. © 2017 Australian Veterinary Association.
Bishay, Ayman; Raoof, Suhail; Esan, Adebayo; Sung, Arthur; Wali, Siraj; Lee, Leonard Y.; George, Liziamma; Saleh, Anthony; Baumann, Michael
BACKGROUND: New information is available on pleural diseases. The authors selected articles to make recommendations on diagnostic and treatment aspects of pleural diseases. MATERIALS AND METHODS: Eleven articles published in the English language between 2004 and 2007 were chosen. The basis of selection of the articles was the impact on daily practice, change in prior thinking of a disease process or specific treatment modality, as well as proper design and execution of the study. 5-amino-laevulinic acid with fluorescent light combined with white light may allow further diagnostic yield in undiagnosed pleural disease. FDG-PET may allow prognostication of patients with pleural tumors. Utilizing ultrasound by trained Emergency Department physicians is a rapid and effective technique to evaluate non-traumatic pleural effusions in symptomatic patients. Serum osteopontin levels may distinguish patients exposed to asbestos with benign disease from those with pleural mesothelioma. Administration of streptokinase in patients with empyema does not need for surgical drainage, length of hospital stay, or mortality as compared to conventional treatment with chest tube drainage and intravenous antibiotics. Silver nitrate may be an alternative agent to talc for producing pleurodesis. Routine use of graded talc (50% particles greater than 25 microns) is recommended to reduce the morbidity associated with talc pleurodesis. Study design does not permit us to conclude that aspiration of spontaneous pneumothorax is as effective as chest tube drainage. Pleural catheter may prove to be an important palliative modality in treating debilitated patients or patients with trapped lung who show symptomatic improvement with drainage; however, at the present time, these catheters cannot be considered a first line treatment option for patients with malignant pleural effusion. One of the studies reviewed showed no significant difference in tract metastasis in patients with malignant mesothelioma
Nyale, George Mwamnemo; Anderson, Ronald; Patel, Atulkumar Ramanlal; Feldman, Charles
There are few studies that have documented the clinical presentation, complication rate and outcome of cardiothoracic referrals from a Pulmonology Service, particularly in developing countries. Furthermore, the impact of human immunodeficiency virus (HIV) status on such referrals and their outcomes is not well documented. This was a retrospective audit of combined pulmonologist/cardiothoracic consultations, undertaken among the tertiary academic hospitals attached to the University of the Witwatersrand, Johannesburg, South Africa, over a 10 years period (2001-2010) in order to document the clinical features of these referrals and to determine any impact of HIV status on trends in disease presentations, complications and outcome. A total of 847 patients were evaluated on whom a variety of surgical procedures was performed, 50.4% being therapeutic, 32.8% diagnostic and 16.9% both therapeutic and diagnostic. HIV status was known in 488 cases. Of these 229 (46.9%) were HIV-seropositive and 259 (53.1%) -seronegative. The main reasons for referral were for infective conditions, including tuberculosis (TB), pleural disease/effusion/empyema, and other bacterial infections, with significantly more of the TB patients being HIV-seropositive (P<0.0001).There was a trend for increasing presentations for TB and pleural conditions, particularly during the last 4-5 years of the audit, coinciding with an increase in the numbers of HIV-positive referrals. HIV status had no impact on the frequency of surgical complications or mortality. The audit indicates an increasing referral rate of HIV-seropositive patients to cardiothoracic services in Johannesburg, particularly in association with TB and pleural diseases. However with careful cardiothoracic/pulmonologist evaluation of the cases the frequency of complications and mortality appear to be no different from that of HIV-seronegative cases.
Ogola, Gerald O; Shafi, Shahid
We have previously shown that overall cost of hospitalization for emergency general surgery (EGS) diseases is more than $28 billion annually and rising. The purposes of this study were to estimate the costs associated with specific EGS diseases and to identify factors associated with high-cost hospitalizations. The American Association for the Surgery of Trauma definition was used to identify hospitalizations of adult EGS patients in the 2010 National Inpatient Sample data. Cost of each hospitalization was obtained using cost-to-charge ratio in National Inpatient Sample. Regression analysis was used to estimate the cost for each EGS disease adjusted for patient and hospital characteristics. Hospitalizations with cost exceeding 75th percentile for each EGS disease were compared with lower-cost hospitalizations to identify factors associated with high cost. Thirty-one EGS diseases resulted in 2,602,074 hospitalizations nationwide in 2010 at an average adjusted cost of $10,110 (95% confidence interval, $10,086-$10,134) per hospitalization. Of these, only nine diseases constituted 80% of the total volume and 74% of the total cost. Empyema chest, colorectal cancer, and small intestine cancer were the most expensive EGS diseases with adjusted mean cost per hospitalization exceeding $20,000, while breast infection, abdominal pain, and soft tissue infection were the least expensive, with mean adjusted costs of less than $7,000 per hospitalization. The most important factors associated with high-cost hospitalizations were the number and type of procedures performed (76.2% of variance), but a region in Western United States (11.3%), Medicare and Medicaid payors (2.6%), and hospital ownership by public or not-for-profit entities (5.6%) were also associated with high-cost hospitalizations. A small number of diseases constitute a vast majority of EGS hospitalizations and their cost. Attempts at reducing the cost of EGS hospitalization will require controlling the cost of
Harilingam, Mohan Raj; Shrestha, Ashish Kiran; Basu, Sanjoy
AIM: Laparoscopic cholecystectomy (LC) is considered the ‘gold standard’ intervention for gall bladder (GB) diseases. However, to avoid serious biliovascular injury, conversion is advocated for distorted anatomy at the Calot's triangle. The aim is to find out whether our technique of laparoscopic modified subtotal cholecystectomy (LMSC) is suitable, with an acceptable morbidity and outcome. PATIENTS AND METHODS: A retrospective analysis of prospectively collected data of 993 consecutive patients who underwent cholecystectomy was done at a large District General Hospital (DGH) between August 2007 and January 2015. The data are as follows: Patient's demographics, operative details including intra- and postoperative complications, postoperative stay including follow-up that was recorded and analysed. RESULTS: A total of 993 patients (263 males and 730 female) were included. The median age was 52*(18-89) years. Out of the 993 patients, 979 (98.5%) and 14 (1.5%) were listed for laparoscopic and open cholecystectomy, respectively. Of the 979 patients, 902 (92%) and 64 (6.5%) patients underwent LC ± on-table cholangiography (OTC) and LMSC ± OTC, respectively, with a median stay of 1* (0-15) days. Of the 64 patients, 55 (86%) had dense adhesions, 22 (34%) had acute inflammation, 19 (30%) had severe contraction, 12 (19%) had empyema, 7 (11%) had Mirizzi's syndrome and 2 (3%) had gangrenous GB. The mean operative time was 120 × (50-180) min [Table 1]. Six (12%) patients required endoscopic retrograde cholangiopancreatography (ERCP) postoperatively, and there were four (6%) readmissions in a follow-up of 30 × (8-76) months. The remaining 13 (1.3%) patients underwent laparoscopic cholecystectomy converted to an open cholecystectomy. The median stay for open/laparoscopic cholecystectomy converted to open cholecystectomy was 5 × (1-12) days. CONCLUSION: Our technique of LMSC avoided conversion in 6.5% patients and believe that it is feasible and safe for difficult GBs
Rello, J; Torres, A; Ricart, M; Valles, J; Gonzalez, J; Artigas, A; Rodriguez-Roisin, R
All episodes of ventilator-associated pneumonia (VAP) caused by Staphylococcus aureus were prospectively analyzed for a 30-mo period. Methicillin-sensitive S. aureus (MSSA) was isolated in 38 episodes and methicillin-resistant S. aureus (MRSA) in 11 others. The two groups were similar regarding sex, severity of underlying diseases, prior surgery, and presence of renal failure, diabetes, cardiopathy, and coma. MRSA-infected persons were more likely to have received steroids before developing infection (relative risk [RR] = 3.45, 95% confidence interval [CI] = 1.38-8.59), to have been ventilated > 6 d (RR = 2.03, 95% CI = 1.36-3.03), to have been older than 25 yr (RR = 1.50, 95% CI = 1.09-2.06), and to have had preceding chronic obstructive pulmonary disease (RR = 2.76, 95% CI = 0.89-8.56) than MSSA-infected patients. MSSA-infected persons were more likely than MRSA-infected patients to have cranioencephalic trauma (RR = 1.94, 95% CI = 1.22-3.09). All patients with MRSA VAP had previously received antibiotics, compared with only 21.1% of those with MSSA infection (p < 0.000001). The incidence of empyema was similar in both groups; nevertheless, the presence of bacteremia and septic shock was more frequent in the MRSA group. Finally, mortality directly related to pneumonia was significantly higher among patients with MRSA episodes (RR = 20.72, 95% CI = 2.78-154.35). This analysis was repeated for monomicrobial episodes, and the difference remained statistically significant. We conclude that MRSA and MSSA strains infect patients with different demographic profiles; previous antibiotic therapy is the most important risk factor for developing MRSA infection.(ABSTRACT TRUNCATED AT 250 WORDS)
Ramos, Alexander D.; Rolston, John D.; Gauger, Grant E.; Larson, Paul S.
Case series Patient: Male, 87 • Male, 62 Final Diagnosis: Spinal subdural abscess Symptoms: Fever • pain • weakness Medication: — Clinical Procedure: Laminectomy • durotomy • drainage • debridement Specialty: Neurosurgery Objective: Rare disease Background: Spinal subdural abscesses, also known as empyemas, are rare infectious lesions, the exact incidence of which is unknown. Presentation is typically dramatic, with back pain, fever, motor, and sensory deficits. Rapid identification and surgical intervention with laminectomy, durotomy, and washout provides the best outcomes. While hematogenous spread of an extra-spinal infection is the most common cause of this condition, a significant number of cases result from iatrogenic mechanisms, including lumbar punctures, epidural injections, and surgery. Case Report: Here we present 2 cases: 1) an 87-year-old man with type 2 diabetes, schizophrenia, mild cognitive impairment, and symptomatic lumbar spinal stenosis and 2) a 62-year-old man with a prior L3–4 spinal fusion with symptomatic lumbar spinal stenosis. In both cases, patients underwent laminectomy for spinal stenosis and developed epidural abscess. Following successful drainage of the epidural abscess, they continued to be symptomatic, and repeat imaging revealed the presence of a subdural abscess that was subsequently evacuated. Case 1 had significant improvement with residual lower-extremity weakness, while Case 2 made a complete neurological recovery. Conclusions: These cases illustrate patients at increased risk for developing this rare spinal infection, and demonstrate that rapid recognition and surgical treatment is key to cure and recovery. Review of the literature highlights pertinent risk factors and demonstrates nearly one-third of reported cases have an iatrogenic etiology. The cases presented here demonstrate that a subdural process should be suspected in any patient with intractable pain following treatment of an epidural abscess. PMID
Ramos, Alexander D; Rolston, John D; Gauger, Grant E; Larson, Paul S
BACKGROUND Spinal subdural abscesses, also known as empyemas, are rare infectious lesions, the exact incidence of which is unknown. Presentation is typically dramatic, with back pain, fever, motor, and sensory deficits. Rapid identification and surgical intervention with laminectomy, durotomy, and washout provides the best outcomes. While hematogenous spread of an extra-spinal infection is the most common cause of this condition, a significant number of cases result from iatrogenic mechanisms, including lumbar punctures, epidural injections, and surgery. CASE REPORT Here we present 2 cases: 1) an 87-year-old man with type 2 diabetes, schizophrenia, mild cognitive impairment, and symptomatic lumbar spinal stenosis and 2) a 62-year-old man with a prior L3-4 spinal fusion with symptomatic lumbar spinal stenosis. In both cases, patients underwent laminectomy for spinal stenosis and developed epidural abscess. Following successful drainage of the epidural abscess, they continued to be symptomatic, and repeat imaging revealed the presence of a subdural abscess that was subsequently evacuated. Case 1 had significant improvement with residual lower-extremity weakness, while Case 2 made a complete neurological recovery. CONCLUSIONS These cases illustrate patients at increased risk for developing this rare spinal infection, and demonstrate that rapid recognition and surgical treatment is key to cure and recovery. Review of the literature highlights pertinent risk factors and demonstrates nearly one-third of reported cases have an iatrogenic etiology. The cases presented here demonstrate that a subdural process should be suspected in any patient with intractable pain following treatment of an epidural abscess.
Karkhanis, Vinaya S; Joshi, Jyotsna M
A pleural effusion is an excessive accumulation of fluid in the pleural space. It can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura, or to a systemic disorder. Patients most commonly present with dyspnea, initially on exertion, predominantly dry cough, and pleuritic chest pain. To treat pleural effusion appropriately, it is important to determine its etiology. However, the etiology of pleural effusion remains unclear in nearly 20% of cases. Thoracocentesis should be performed for new and unexplained pleural effusions. Laboratory testing helps to distinguish pleural fluid transudate from an exudate. The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process. Immunohistochemistry provides increased diagnostic accuracy. Transudative effusions are usually managed by treating the underlying medical disorder. However, a large, refractory pleural effusion, whether a transudate or exudate, must be drained to provide symptomatic relief. Management of exudative effusion depends on the underlying etiology of the effusion. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence. Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease. Percutaneous closed pleural biopsy is easiest to perform, the least expensive, with minimal complications, and should be used routinely. Empyemas need to be treated with appropriate antibiotics and intercostal drainage. Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula. PMID:27147861
Hassan, Ibrahim; Newton, Pippa
Background. Pyogenic ventriculitis is a well-known complication of meningitis, brain abscesses and intraventricular drains. Primary pyogenic ventriculitis is a rare entity and few cases have been described so far. We report the first case of primary pyogenic ventriculitis in an adult caused by Neisseria meningitidis and present an overview of all reported adult primary pyogenic ventriculitis cases in the English literature. Methods. A PubMed search was performed using the terms ependymitis, ventricular empyema, pyocephalus and ventriculitis. Filter was set for adults and English. Articles in which pyogenic ventriculitis was a complication of well-known risk factors were excluded. A total of five cases of primary pyogenic ventriculitis were identified. Results. There were seven adult patients. Only one patient showed signs of meningeal irritation. Four patients had positive blood cultures with Escherichia coli (one patient), methicillin-resistant Staphylococcus aureus (one patient), one patient was bacteraemic with Enterococcus faecalis, Escherichia coli and Peptostreptococcus spp., and N. meningitidis (our patient). In four patients cerebrospinal fluid was sent for culture, which yielded methicillin-sensitive Staphylococcus aureus (one patient), Peptostreptococcus spp. (one patient), Streptococcus intermedius (one patient, identified via 16S PCR) and Listeria monocytogenes (one patient). Cerebrospinal fluid cell count was determined in four patients and showed pleocytosis in all four cases. Ventricular drainage was performed in four patients. Five patients survived. Discussion. We report the first case of pyogenic ventriculitis caused by N. meningitidis. Primary pyogenic ventriculitis is a rare entity with various clinical presentations caused by various bacterial species. Treatment consists of adequate antimicrobial therapy, and ventricular drainage may be necessary. PMID:28348798
Straatman, Jennifer; van der Wielen, Nicole; Nieuwenhuijzen, Grard A P; Rosman, Camiel; Roig, Josep; Scheepers, Joris J G; Cuesta, Miguel A; Luyer, Misha D P; van Berge Henegouwen, Mark I; van Workum, Frans; Gisbertz, Suzanne S; van der Peet, Donald L
Esophagectomy for cancer can be performed in a two-stage procedure with an intrathoracic anastomosis: the Ivor Lewis esophagectomy. A growing incidence of distal and gastroesophageal junction adenocarcinomas and increasing use of minimally invasive techniques have prompted interest in this procedure. The aim of this study was to assess short-term results of minimally invasive Ivor Lewis esophagectomy (MIE-IL). A retrospective cohort study was performed from June 2007 until September 2014, including patients that underwent MIE-IL for distal esophageal and gastroesophageal junction cancer in six different hospitals in the Netherlands and Spain. Data were collected with regard to operative techniques, pathology and postoperative complications. In total, 282 patients underwent MIE-IL, of which 90.2 % received neoadjuvant therapy. Anastomotic leakage was observed in 43 patients (15.2 %), of whom 13 patients (4.6 %) had empyema, necessitating thoracotomy for decortication. With an aggressive treatment of complications, the 30-day and in-hospital mortality rate was 2.1 %. An R0-resection was obtained in 92.5 % of the patients. After neoadjuvant therapy, 20.1 % of patients had a complete response. Minimally invasive Ivor Lewis esophagectomy for distal esophageal and gastroesophageal junction adenocarcinomas is an upcoming approach for reducing morbidity caused by laparotomy and thoracotomy. Anastomotic leakage rate is still high possibly due to technical diversity of anastomotic techniques, and a high percentage of patients treated by neoadjuvant chemoradiotherapy. An aggressive approach to complications leads to a low mortality of 2.1 %. Further improvement and standardization in the anastomotic technique are needed in order to perform a safe intrathoracic anastomosis.
Potechin, Rajini; Amjadi, Kayvan; Srour, Nadim
Pleural effusions are a common complication of end-stage renal disease.These effusions are occasionally refractory to medical management, but few options are then available. Indwelling pleural catheter insertion (IPC) has been well described for the management of malignant pleural effusions and, more recently, of nonmalignant effusions of other origin. We aimed to analyze our experience and to evaluate the safety and feasibility of using IPCs for pleural effusion associated with end-stage renal disease. We constructed a cohort of patients who underwent IPC insertion for pleural effusions associated with end-stage renal disease. The IPCs were inserted as a palliative measure in patients who had thoracentesis twice within the preceding 2 weeks, no evidence of infection and either failure to respond, complications or intolerance to maximal medical therapy, or if IPC insertion would enable discharge when the patient was hospitalized mainly for dyspnea due to pleural effusion. There were nine IPCs inserted in eight patients. Patients had significant dyspnea at baseline with a median baseline dyspnea index of 1.5 [interquartile range (IQR) 0–3]. Dyspnea improved significantly 2 weeks after catheter insertion with a median transitional dyspnea index of 6 (IQR 4.5–7.0). There was no occurrence of empyema or other major complications.Serum albumin did not decrease after catheter insertion. IPCs were removed in four patients(50%) and successful spontaneous pleurodesis occurred in three patients (37.5%) after a median of 77 days (IQR 9–208). IPC insertion for pleural effusions associated with end-stage renal disease appears safe and effective. Larger studies are needed, particularly regarding the impact of this intervention on quality of life.
Maslove, David M; Chen, Benson Tze-Ming; Wang, Helena; Kuschner, Ware G
Pleural effusions are common in critically ill patients. Most effusions in intensive care unit (ICU) patients are of limited clinical significance; however, some are important and require aggressive management. Transudative effusions in the ICU are commonly caused by volume overload, decreased plasma oncotic pressure, and regions of altered pleural pressure attributable to atelectasis and mechanical ventilation. Exudates are sequelae of pulmonary or pleural infection, pulmonary embolism, postsurgical complications, and malignancy. Increases in pleural fluid volume are accommodated principally by chest wall expansion and, to a lesser degree, by lung collapse. Studies in mechanically ventilated patients suggest that pleural fluid drainage can result in improved oxygenation for up to 48 hours, but data on clinical outcomes are limited. Mechanically ventilated patients with pleural effusions should be semirecumbant and treated with higher levels of positive-end expiratory pressure. Rarely, large effusions can cause cardiac tamponade or tension physiology, requiring urgent drainage. Bedside ultrasound is both sensitive and specific for diagnosing pleural effusions in mechanically ventilated patients. Sonographic findings of septation and homogenous echogenicity may suggest an exudative effusion, but definitive diagnosis requires pleural fluid sampling. Thoracentesis should be carried out under ultrasound guidance. Antibiotic regimens for parapneumonic effusions should be based on current pneumonia guidelines, and anaerobic coverage should be included in the case of empyema. Decompression of the pleural space may be necessary to improve respiratory mechanics, as well as to treat complicated effusions. While small-bore catheters inserted under ultrasound guidance may be used for nonseptated effusions, surgical consultation should be sought in cases where this approach fails, or where the effusion appears complex and septated at the outset. Further research is needed to
Ben-Or, Sharon; Feins, Richard H; Veeramachaneni, Nirmal K; Haithcock, Benjamin E
The use of fibrinolytics has been described for the treatment of complex pleural processes. This has evolved from streptokinase to urokinase to alteplase. Intrapleural fibrinolysis has added an alternative to surgical intervention in patients with complex pleural processes. This study describes the use of alteplase as an alternative to surgical intervention for these processes. From December 2004 to March 2009, 118 patients required alteplase for complex pleural processes. The type of tube thoracostomy, pleural process, antithrombotic type, international normalized ratio, prothrombin time, partial thromboplastin time, platelets, doses, and outcomes were reviewed for each patient. Complications and the need for additional interventions were evaluated. Patients received one to eight doses of intrapleural alteplase through a tube thoracostomy. Indications for intrapleural alteplase were empyema (n = 32; 27.1%), loculated pleural effusion (n = 44; 37.3%), hemothorax (n = 13; 11.0%), parapneumonic effusion (n = 25; 21.2%), and malignant effusion (n = 6; 5.1%). The success rate was 86.4% (102 of 118 patients). The incidence of bleeding was 8.5% (n = 10). Binary analysis did not demonstrate an increase in bleeding with abnormal coagulation variables. Of the patients with a bleeding complication, 7 required operative interventions. Twenty (16.9%) required a second tube thoracostomy for incomplete evacuation of the pleural process. Nine (7.6%) required an operative intervention for incomplete evacuation of the pleural process. Intrapleural alteplase appears to be effective in treating complex parapneumonic processes. Systemic anticoagulation, prothrombin time, partial thromboplastin time, international normalized ratio, and platelet count do not appear to be risk factors for bleeding complications. One or two doses of alteplase appear most successful. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Ekpe, Eyo E; Akpan, M U
Management of pleural fluid collection not due to trauma increases workload of the paediatric thoracic surgeons, while delay or inappropriate treatment worsens the prognosis of the disease. This study aimed at assessing the outcome of therapeutic tube thoracostomy in non-traumatic paediatric pleural fluid collections and identifying factors responsible for treatment failure with tube thoracostomy. Prospective analysis of socio-demographic characteristics, clinical features, clinical diagnosis, radiological diagnosis, and bacteriological diagnosis including bacteria cultured with sensitivity pattern, also treatment offered including tube thoracostomy with duration of tube thoracostomy and length of hospitalisation, indication for additional surgical procedure with type, and outcome of treatment of 30 paediatric patients with non-traumatic pleural fluid collection. Thirty paediatric patients with various causes of non-traumatic pleural fluid collection in 34 pleural spaces were analysed. Their ages ranged between six months and 16 years (mean = 6.5 years) and M:F ratio of 2:1. Pleural effusion and empyema thoracis accounted for 46% and 40% with staphylococcus aureus and streptococcus pneumoniae cultured in 10% each and a high negative culture rate of 46%, which was higher with age. The parents of 40% of the patients belonged to social class 3. Success rate of tube thoracostomy was 86% in unilateral cases, 50% in bilateral cases and 81% in all cases. Alternative treatment with thoracotomy and decortications gave a success rate of 100%. Thoracotomy with decortication is superior to tube thoracostomy in paediatric non-traumatic pleural fluid collection and should be chosen as the primary treatment option when there is bilateral disease, chronicity, loculated effusion, thickened pleural membranes or trapped lung.
Sanad, Mohammed; Shouman, Waheed; Gharib, Amal F.
Objective Angiopoietins are involved in the pathogenesis of a variety of human diseases. We tried to evaluate the application of pleural and serum Angiopoietin-1 and 2 in categorizing pleural effusions (PEs) into exudates and transudates in children. Methods Pleural fluid (PF) and serum Angiopoietin (Ang)-1 and Ang-2 were measured in 80 children with PEs (40 transudative and 40 exudative) by using enzyme-linked immunosorbent assay. Findings PF Ang-2 levels were significantly higher in pleural exudates than in transudates (P 0.012). PF Ang-2 levels were significantly higher than serum Ang-2 levels in patients with pleural exudates and transudates (P<0.001). PF Ang-2 levels were higher in tuberculous than in non-tuberculous pneumonic PEs and empyema (P=0.01). PF Ang-2 levels correlate with serum Ang-2 levels (P<0.003). PF Ang-1 levels were significantly lower than serum Ang-1 levels both in patients with exudates and those with transudates (P<0.001). Cutoff points of serum and PF Ang-2, differentiating between transudative and exudative effusions were 3ng/ml and 8ng/ml respectively. Predictive potentials of serum and PF Ang-2 cutoff points were: Sensitivity 90% and 95% respectively, specificity 92.50% and 97.50% respectively, positive predictive value 92.30% and 97.40% respectively and negative predictive value 90.20% and 95.10% respectively. Conclusion Ang-2 levels were elevated in exudative PEs and correlated with levels of markers of pleural inflammation and pleural vascular hyperpermeability. It could categorize PE to exudates and transudates with valuable discriminative properties. That was detected more obviously in pleural fluids than in serum. PMID:23056802
White, Abby; Kucukak, Suden; Lee, Daniel N; Swanson, Scott J
Mechanical staplers are widely employed in minimally invasive anatomic lung resections, but have limitations when managing smaller pulmonary arterial and venous branches. Published data is lacking regarding the safety and efficacy of pulmonary vessel ligation using ultrasonic shears. We describe a single-surgeon experience employing ultrasonic shears for the ligation of pulmonary vasculature during lobectomy and segmentectomy, primarily in the setting of video-assisted thoracic surgery (VATS) resection. A retrospective chart review was conducted for all patients, who underwent anatomic resection, between 2008 and 2014. Charts were divided into 2 groups based on method of ligation (energy based or conventional). Dictated operative reports were reviewed and patient demographics, tumor characteristics, and complications were recorded. Ultrasonic shears were used for pulmonary vessel ligation (5 to 6 mm) in 82 of 283 anatomic resections. A total of 118 vessels were ligated with ultrasonic shears. The majority of patients (83%) in the energy-based ligation group underwent VATS resection. There were fewer complications in the energy-based ligation group (26% vs 38%; p = 0.05); however, rates of intraoperative transfusion, prolonged air leak, empyema, and return to the operating room were similar across the 2 groups, and no statistically significant difference was found. There were no postoperative complications directly attributable to ultrasonic vessel ligation. Energy-based ligation of small-diameter pulmonary vessels is a safe and useful adjunct in anatomic VATS resection and a viable alternative to mechanical stapling. Its narrow profile and thin blades make it ideal for ligation of pulmonary vasculature, particularly where the size and necessary clearance of mechanical staplers prohibit safe dissection. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Morales, Carlos H; Mejía, Camila; Roldan, Luis Alberto; Saldarriaga, Maria Fernanda; Duque, Andres Felipe
The study aimed to establish the benefits of using chest tubes with negative pleural suction against trapped water in patients with penetrating or blunt chest trauma who underwent tube thoracostomy, in terms of the incidence of complications, such as persistent air leak, clotted hemothorax, empyema, and duration of stay. Patients who underwent tube thoracostomy because of traumatic pneumothorax, hemothorax, or hemopneumothorax were randomly assigned into one of two groups: in Group 1, the three-bottle drainage system was connected to a negative suction; in Group 2, no suction was given. Patients who required mechanical ventilation or emergency surgery (thoracotomy or thoracoscopy) either at the time of admission to the institution or immediately after the tube thoracostomy, patients who had histories of thoracic procedures or chronic pulmonary diseases (chronic obstructive pulmonary disease, diffuse interstitial lung disease), and patients with multiple injuries with severe traumatic brain injury and a Glasgow Coma Scale (GCS) score less than 8 of 15 were excluded from the study. Hospital stay, duration of tube thoracostomy, prolonged fistula, and other clinical variables were compared. One hundred ten patients were included, 56 in the group with suction and 54 in the group without suction. There were no differences in the demographic characteristics of each group. There were no differences between the groups in terms of hospital stay (p = 0.22), duration of tube thoracostomy (p = 0.35) (3 days in each group), or complications. However, the probability of air leak presence in time was greater for the Group 1 patients with negative suction versus the Group 2 patients (p = 0.023). The use of negative pleural suction did not demonstrate advantages over the three-bottle chest drainage system without suction in patients with uncomplicated traumatic pneumothorax, hemothorax, or hemopneumothorax. Therapeutic study, level II.
Siddiqui, Faisal G; Memon, Ahmer A; Abro, Arshad H; Sasoli, Nazeer A; Ahmad, Lubna
Selective approach for sending cholecystectomy specimens for histopathology results in missing discrete pathologies such as premalignant benign lesions such as porcelain gallbladder, carcinoma-in-situ, and early carcinomas. To avoid such blunders therefore, every cholecystectomy specimen should be routinely examined histologically. Unfortunately, the practice of discarding gallbladder specimen is standard in most tertiary care hospitals of Pakistan including the primary investigators' own institution. This study was conducted to assess the feasibility or otherwise of performing histopathology in every specimen of gallbladder. This cohort study included 220 patients with gallstones for cholecystectomy. All cases with known secondaries from gallbladder, local invasion from other viscera, traumatic rupture of gallbladder, gross malignancy of gallbladder found during surgery was excluded from the study. Laparoscopic cholecystectomy was performed in majority of cases except in those cases where anatomical distortion and dense adhesions prevented laparoscopy. All gallbladder specimens were sent for histopathology, irrespective of their gross appearance. Over a period of two years, 220 patients with symptomatic gallstones were admitted for cholecystectomy. Most of the patients were females (88%). Ninety two per cent patients presented with upper abdominal pain of varying duration. All specimens were sent for histopathology. Two hundred and three of the specimens showed evidence chronic cholecystitis, 7 acute cholecystitis with mucocele, 3 acute cholecystitis with empyema and one chronic cholecystitis associated with poly. Six gallbladders (2.8%) showed adenocarcinoma of varying differentiation along with cholelithiasis. The histopathological spectrum of gallbladder is extremely variable. Incidental diagnosis of carcinoma gall bladder is not rare; if the protocol of routine histopathology of all gallbladder specimens is not followed, subclinical malignancies would fail to
Weber, D J; Wolfson, J S; Swartz, M N; Hooper, D C
Pasteurella multocida, a small, gram-negative coccobacillus , is part of the normal oral flora of many animals, including the dog and cat. P. multocida is the etiologic agent in a variety of infectious disease syndromes. We have reported 34 cases of infection caused by P. multocida and have reviewed the English literature. P. multocida infections may be divided into three broad groups: 1. Infections resulting from animal bites and scratches : The most common infections caused by P. multocida are local wound infections following animal bites or scratches . Cats are the source of infection in 60 to 80% of cases and dogs in the great majority of the remainder. Local infections are characterized by the rapid appearance of erythema, warmth, tenderness, and frequently purulent drainage. The most common local complications are abscess formation and tenosynovitis. Serious local complications include septic arthritis proximal to bites or scratches , osteomyelitis resulting from direct inoculation or extension of cellulitis, and the combination of septic arthritis and osteomyelitis, most commonly involving a finger or hand after a cat bite. 2. Isolation of P. multocida from the respiratory tract: The isolation of P. multocida from the respiratory tract must be interpreted differently than its isolation from other systemic sites. Most commonly P. multocida found in the respiratory tract is a commensal organism in patients with underlying pulmonary disease, but serious respiratory tract infections including pneumonia, empyema, and lung abscesses may develop. Most patients with respiratory tract colonization or infection have a history of animal exposure. 3. Other systemic infections: P. multocida is recognized as a pathogen in a variety of systemic infections including bacteremia, meningitis, brain abscess, spontaneous bacterial peritonitis, and intra-abdominal abscess. P. multocida often acts as an opportunistic pathogen with a predilection for causing bacteremia in patients
Spyropoulos, George; Kontakiotis, Theodoros; Spyratos, Dionysios; Iakovidis, Dimitrios; Zoglopitis, Fotis; Zarogoulidis, Konstantinos
Background Thoracoscopy with local anesthesia or medical thoracoscopy is an invasive method which is rather valuable not only for the approach of undiagnosed exudative pleural effusions but also for the treatment of symptomatic malignant effusions with the conduct of pleurodesis. This is a review of those patients who underwent medical thoracoscopy in the period May 2011 to September 2012 in the Pulmonary Department the Aristotle University of Thessaloniki. Patients and methods Thirty nine thoracoscopies were conducted in our Department since May 2011. Twenty nine patients with cytological test negative for malignancy underwent diagnostic thoracoscopy. Eleven of those procedures were diagnostic and positive for malignancy, while 12 were non-diagnostic and 2 with limited evidence of malignancy. The biopsy results of 2 thoracoscopies showed granulomatous infection and other 2 nonspecific chronic inflammation. Out of all the diagnoses which were positive for malignancy, 2 were related to mesothelioma, 5 to adenocarcinoma (4 of them originated from lungs and one of unknown primary origin) while 1 patient was diagnosed with metastatic papillary adenocarcinoma originated from the thyroid and another one with lymphoma. There were also patients carrying diagnosed illness intending pleurodesis in cases of malignant recrudescent pleural effusions in mesothelioma, lung adenocarcinoma and biliary carcinoma who underwent thoracoscopy. Another patient with recrudescent pneumothorax underwent pleurodesis with talc. Results The major complications which emerged either during the procedure or after the thoracoscopy were two: one patient developed allergy in lidocaine intake for the local anesthesia having as a result to quit the procedure while another patient developed an empyema several weeks later. Conclusions Thoracoscopy with local anesthesia is a safe procedure, tolerable for the patient, which has a significant diagnostic value and only a small percentage of complications.
Vaneckova, Pavla; Bambrick, Hilary
While morbidity outcomes for major disease categories during extreme heat have received increasing research attention, there has been very limited investigation at the level of specific disease subcategories. We analyzed daily hospital admissions for cardiovascular (CVD), respiratory (RD), genitourinary (GU) and mental diseases (MD), diabetes (DIA), dehydration (DEH) and 'the effects of heat and light' (HEAT) in Sydney between 1991 and 2009. We further investigated the sensitivity to heat of subcategories within the major disease groups. We defined hot days as those with temperatures in the 95(th) and 99(th) percentiles within the study period. We applied time-stratified case-crossover analysis to compare the hospital admissions on hot days with those on non-hot days matched by day of the week. We calculated the odds ratios (OR) of admissions between the two types of days, accounting for other environmental variables (relative humidity, ozone and particulate matter) and non-environmental trends (public and school holidays). On hot days, hospital admissions increased for all major categories except GU. This increase was not shared homogeneously across all diseases within a major category: within RD, only 'other diseases of the respiratory system' (includes pleurisy or empyema) increased significantly, while admissions for asthma decreased. Within MD, hospital admissions increased only for psychoses. Admissions due to some major categories increased one to three days after a hot day (e.g., DIA, RD and CVD) and on two and three consecutive days (e.g., HEAT and RD). High ambient temperatures were associated with increased hospital admissions for several disease categories, with some within-category variation. Future analyses should focus on subgroups within broad disease categories to pinpoint medical conditions most affected by ambient heat.
van der Weg, Gerben; Wikkeling, Marald; van Leeuwen, Maarten; Ter Avest, Ewoud
A 70-year-old patient was referred to our emergency department with severe retrosternal pain after forceful vomiting. Computed tomography (CT) scan revealed a left-sided oesophageal rupture with accompanying pneumomediastinum and bilateral pleural effusions. Conservative treatment with cessation of oral intake, intravenous broad-spectrum antibiotics, parenteral fluids and nutrition and left sided tube thoracostomy was initiated initially. After 5 days, however, the patient deteriorated. Follow-up CT scan demonstrated a mediastinal fluid collection as well as loculated pleural empyema. Open thoracotomy with mediastinal debridement and pleural drainage was performed, after which he made a slow but full recovery. Spontaneous oesophageal rupture due to an abrupt rise in intraluminal pressure caused by vomiting is also known as Boerhaave's syndrome. It is a rare but potentially life-threatening condition. Many patients present with atypical symptoms, and therefore, physicians should have a high index of suspicion in any patient presenting with vomiting and retrosternal pain. When Boerhaave's syndrome is suspected, a CT scan of the thorax and upper abdomen should be performed since treatment depends on clinical and radiological findings. Conservative management (cessation of oral intake, nasogastric decompression, administration of intravenous fluids and parenteral nutrition, intravenous broad-spectrum antibiotics and proton pump inhibitors and tube thoracostomies) may only be considered in patients with a contained rupture without systematic symptoms of infection. In these patients, endoscopic bridging of the tear with a self-expandable stent is also an option. Primary surgical repair (either by thoracotomy or by video assisted thoracoscopy (VATS)) should be considered when patients present with sepsis and/or large non-contained leaks or with severe mediastinal decontamination.
Background Nosocomial and ventilator-associated pneumonia (VAP) are causes of significant morbidity and mortality in hospitalized patients. We analyzed a) the incidence and the outcome of pneumonias caused by different pathogens in the intensive care unit (ICU) of a medium-sized twenty-four bed community hospital and b) the incidence of complications of such pneumonias requiring surgical intervention such as thoracotomy and decortication. Results We retrospectively reviewed the charts of patients diagnosed with nosocomial and ventilator-associated pneumonia in our ICU. Their bronchoalveolar lavage (BAL) and sputum cultures, antibiograms, and other clinical characteristics, including complications and need for tracheostomy, thoracotomy and decortication were studied. In a span of one year (2011–12), 43 patients were diagnosed with nosocomial pneumonia in our ICU. The median simplified acute physiology score (SAPS II) was 39. One or more gram negative organisms as the causative agents were present in 85% of microbiologic samples. The three most prevalent gram negatives were Stenotrophomonas maltophilia (34%), Pseudomonas aeurginosa (40%), and Acinetobacter baumannii (32%). Twenty eight percent of bronchoalveolar samples contained Staphylococcus aureus. Eight three percent of patients required mechanical ventilation postoperatively and 37% underwent tracheostony. Thirty five percent underwent thoracotomy and decortication because of further complications such as empyema and non-resolving parapneumonic effusions. A. baumannii, Klebsiella pneumonia extended spectrum beta lactam (ESBL) and P. aeurginosa had the highest prevalence of multi drug resistance (MDR). Fifteen patients required surgical intervention. Mortality from pneumonia was 37% and from surgery was 2%. Conclusion Nosocomial pneumonias, in particular the ones that were caused by gram negative drug resistant organisms and their ensuing complications which required thoracotomy and decortication, were the
Penido, Norma de Oliveira; Chandrasekhar, Sujana Sreedevi; Borin, Andrei; Maranhão, André Souza de Albuquerque; Gurgel Testa, José Ricardo
It is an erroneous but commonly held belief that intracranial complications (ICCs) of chronic and acute otitis media (COM and AOM) are past diseases or from developing countries. These problems remain, despite improvements in antibiotic care. This paper analyzes the occurrence and clinical characteristics and course of the main ICCs of otitis media (OM). Retrospective cohort study of 51 patients with ICCs from OM, drawn from all patients presenting with OM to the emergency room of a large inner-city tertiary care hospital over a 22-year period. 80% of cases were secondary to COM of which the incidence of ICC was 0.8%; 20% were due to AOM. The death occurrence was 7.8%, hearing loss in 90%, and permanent neurological sequelae in 29%. Patients were 61% male. In the majority, onset of ear disease had occurred during childhood. Delay of diagnosis of both the initial infection as well as the secondary ICC was significant. ICCs included brain abscess and meningitis in 78%, and lateral sinus thrombosis, empyema and otitic hydrocephalus in 13%, 8% and 1% of cases, respectively. Twenty-seven neurosurgical procedures and 43 otologic surgery procedures were performed. Two patients were too ill for surgical intervention. ICCs of OM, although uncommon, still occur. These cases require expensive, complex and long-term inpatient treatment and frequently result in hearing loss, neurological sequelae and mortality. It is important to be aware of this potentiality in children with COM, especially, and maintain a high index of suspicion in order to refer for otologic specialty care before such complications occur. Copyright © 2015 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.
Zhao, Juan; Yang, Dejuan; Zheng, Dongyou
Profuse blood loss affects blood coagulation to various degrees. However, whether bleeding speed affects coagulation remains uncertain. This study aimed to evaluate the effect of bleeding speed on coagulation function. A total of 141 patients in the Department of Thoracic Surgery of our hospital were evaluated between January 2007 and February 2014. There are two groups of patients, those who received decortication for chronic encapsulated empyema were called the slow-bleeding group, and those who received thoracoscopic upper lobectomy were called the fast bleeding group; each group was further subdivided into three: group A, 1000 ml ≤ bleeding amount < 1500 ml; group B, 1500 ml ≤ bleeding amount < 1700 ml; group C, 1700 ml ≤ bleeding amount < 2000 ml. Then, coagulation function was assessed in all patients before and during surgery and at 1, 2, and 24 h after surgery, measuring prothrombin time, activated partial thromboplastin time (APTT), fibrinogen, blood pressure, hematocrit, hemoglobin, and platelets. Bleeding duration was overtly longer in the slow-bleeding group than that in quick bleeding individuals (2.3 ± 0.25 h vs. 0.41 ± 0.13 h, P < 0.001). Fibrinogen, hematocrit, hemoglobin, and platelets strikingly decreased, whereas prothrombin time and APTT values significantly increased with bleeding amounts in both quick and slow-bleeding groups. Interestingly, compared with slow-bleeding patients, coagulation indices at each time point and bleeding amounts had significant differences in the quick bleeding group.Increased consumption of coagulation factors in quick bleeding may have greater impact on coagulation function.
Hsieh, Y-C; Chang, L-Y; Huang, Y-C; Lin, H-C; Huang, L-M; Hsueh, P-R
Levofloxacin susceptibility testing was carried out for a total of 2539 Streptococcus pneumoniae isolates obtained from January 2001 to February 2008 at the National Taiwan University Hospital (NTUH) and a further 228 pneumococcal isolates obtained from January 2004 to December 2006 at three other hospitals in different geographical areas in Taiwan. Levofloxacin non-susceptible S. pneumoniae isolates were subsequently analysed for serotype and molecular epidemiology. Rates of levofloxacin non-susceptibility of S. pneumoniae increased significantly from 1.2% in 2001 to 4.2% in 2007 at NTUH. A total of 30 isolates of levofloxacin non-susceptible S. pneumoniae isolates (MIC ≥ 4 mg/L) were available for evaluation of serotype, antimicrobial susceptibility, nucleotide sequence of the quinolone resistance-determining regions of parC, gyrA, parE and gyrB, reserpine effect on quinolone susceptibility and multilocus sequence type. Among these isolates, seven (23.3%) were from children, and two (6.7%; one from a 3- and one from a 93-year-old patient) were from blood. One levofloxacin-resistant isolate (MIC = 8 mg/L) was recovered from a previously healthy child with bacteraemic necrotizing pneumonia complicated by empyema and a haemolytic-uraemic syndrome. All isolates except two had Ser79 and/or Asp83 changes in ParC, and/or Ser81 or Glu85 changes in GyrA. An efflux phenotype concerning levofloxacin was detected in only one (3.3%) isolate. A novel clone (ST3642), genetically related to Spain(9V)-3 and belonging to serotype 11A, was identified. Dissemination of clonal complexes related to Spain(23F)-1, Taiwan(19F)-14, Spain(9V)-3 and Taiwan(23F)-15 has contributed to levofloxacin non-susceptibility among these S. pneumoniae isolates from Taiwan.
Pérez-Rodríguez, Maria Teresa; Sopeña, Bernardo; Méndez-Lage, Susana; Casares, M de los Angeles; Constenla, Lucía; Argibay, Ana; Nodar, Andrés; Villaverde, Iria; Martínez-Vázquez, César; Álvarez-fernández, Maximiliano
Invasive pneumococcal disease (IPD) shows different epidemiological characteristics depending on age and pneumococcus serotype. The aims of the work were to analyze the clinical manifestations and mortality associated with IPD, the serotype isolated and the antibiotic resistance rates in different age groups. Retrospectively, 141 patients with IPD diagnosed between 2002 and 2008 were studied. Patients were classified in 4 age groups: ≤ 2 year-old, 3-14 year-old, 15-64 year-old and ≥ 65 year-old. Pneumonia was the most common manifestation in all age groups (71%). Pneumococcal meningitis was more prevalent in patients ≤ 2 year-old (28 vs. 9%, P=.054) and empyema was more frequent in those between 3-14 year-old (31 vs. 5%, P<.001). Mortality was associated with age ≥ 65 year-old (odds ratio [OR] 7, 95% confidence interval [95% CI] 1.9-28.9), primary bacteremia (OR 7, 95% CI 1.9-28.9) and orotracheal intubation (OR 9, 95% CI 1.9-41.1). The more prevalent serotypes among patients ≤ 2 year-old were 14, 19A and 19F. The serotype 1 was most common in patients between 3-14 year-old and serotype 3 in those ≥ 65 year-old. A higher rate of non-susceptible penicillin strains was observed in pediatric population (42 vs. 19%, P=.007). Age was related to the clinical manifestations, mortality and antibiotic resistance rates. Primary bacteremia was one of the risk factors of mortality. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.
Krenke, Katarzyna; Krawiec, Marta; Kraj, Grażyna; Peradzynska, Joanna; Krauze, Agnieszka; Kulus, Marek
The aim of this study was to evaluate the factors that could predict the development of local complications (parapneumonic effusion/pleural empyema, necrotizing pneumonia, and lung abscess) in children with community-acquired pneumonia (CAP). Demographic, clinical, and laboratory data were prospectively collected and compared in children with noncomplicated and complicated CAP. Two-hundred and three patients aged from 2 months to 17 years were enrolled. There were 141 and 62 children with noncomplicated and complicated CAP, respectively. Significantly longer duration of fever and a higher level of acute phase reactants were demonstrated in complicated when noncomplicated to complicated CAP. Asymmetric chest pain as well as prehospital treatment with ibuprofen and acetaminophen were significantly more common in patients with complicated CAP (P < .001, P = .02 and P = .003, respectively). Preadmission cumulative dose of ibuprofen exceeding 78.3 mg/kg (median dose for the entire group) was associated with 2.5-fold higher odds ratio (OR) for CAP complications [OR 2.54 CI (1.31-4.94); P = .008)]. In contrast, pneumococcal vaccination was associated with lower odds ratio [OR.03 CI (.23-.89); P = .03] for local complications. Some clinical and laboratory data including chest pain, longer duration of fever, higher acute phase reactants, and especially preadmission treatment with ibuprofen or acetaminophen were associated with local complications of CAP. The results of this study highlight the association between the dose of ibuprofen and local CAP complications. © 2016 John Wiley & Sons Ltd.
McCarty, James M; Demetral, Lindsey C; Dabrowski, Lukasz; Kahal, Amandeep K; Bowser, Anna M; Hahn, Julianne E
Coccidioidomycosis, an endemic fungal infection seen throughout the southwestern United States, is not well described in children. We performed a retrospective observational study of all children admitted to Children's Hospital Central California with coccidioidomycosis from 1 January 2010 to 1 September 2011. Thirty-three children, aged 6 months to 17 years, were hospitalized during the study period. These included patients with pneumonia (n = 28), pleural effusion (n = 13), pleural empyema (n = 4), lung abscess (n = 7), pericarditis (n = 2), osteomyelitis (n = 5), meningitis/cerebritis (n = 2), and vocal cord infection (n = 1). Mediastinitis, with radiographic evidence of purulence and necrotic/abscessed lymph nodes in the mediastinum, was present in 7 patients (21%) and tended to occur more often in younger children (median age, 3 years [range, 0.5-11 years] vs 7 years [range, 0.6-17 years] for non-mediastinitis patients; P = .10). Seven patients were admitted to the intensive care unit and 10 required surgical intervention. One patient died of meningitis. Hospitalizations were longer for patients with mediastinitis (median, 130 days [range, 58-200 days] vs 43 days [range, 3-273 days for non-mediastinitis patients]; P < .01) and those with maximum coccidioidal complement fixing antibody titers ≥1:128 (median, 174 days [range, 53-273 days] vs 33 days [range, 3-200 days] for those with maximum titers <1:128; P < .01). Coccidioidomycosis causes a substantial disease burden in the children of central California. Mediastinitis is common and tends to occur in younger children. Patients with mediastinitis or elevated coccidioidal complement fixation titers require longer hospitalizations. Further research is needed on the prevention and treatment of this disease.
Cano, Indalecio; Antón-Pacheco, Juan L; García, Araceli; Rothenberg, Steve
Congenital lung malformations are often discovered on routine prenatal sonography or postnatal imaging. Lesions such as congenital cystic adenomatoid malformation or pulmonary sequestration may be asymptomatic at birth, and their management is controversial. Thoracoscopy in children has been mainly used for lung biopsy and for the treatment of empyema and recurrent pneumothorax. Very few reports of more technically demanding procedures, such as lobectomy, are currently available. This report evaluates the safety and efficacy of video-assisted thoracoscopic (VATS) lobectomy in infants and small children with asymptomatic prenatally diagnosed lung lesions. During 2004, six patients underwent VATS lobectomy without a mini-thoracotomy. Mean age was 10 months (range, 6-19 months). Preoperative diagnosis included congenital cystic adenomatoid malformation (n = 5) and an extralobar pulmonary sequestration. All patients were asymptomatic and surgery was performed electively. Three or four 3-5mm ports were used. Single lung ventilation and controlled low pressure pneumothorax were used in every case. A bipolar sealing device was the preferred mode of vessel ligation and bronchi were closed with interrupted sutures. A chest tube was left in all cases. All the procedures were completed thoracoscopically. Operating times ranged from 70 to 215 min (mean, 130 min). There were five lower lobe and one middle lobe resections. There were no intraoperative complications and chest tubes were left in place 1-4 days. Two patients showed postoperative hemothorax that stopped spontaneously. Hospital stay ranged from 4 to 9 days (mean, 7 days). VATS lobectomy in small infants is a feasible and safe technique. Decreased postoperative pain, a shorter hospital stay, and a better cosmetic result are definite advantages of this minimally invasive procedure. Long-term morbidity due to a major thoracotomy incision is avoided.
Salnikova, Lyubov E; Smelaya, Tamara V; Golubev, Arkadiy M; Rubanovich, Alexander V; Moroz, Viktor V
This study was conducted to establish the possible contribution of functional gene polymorphisms in detoxification/oxidative stress and vascular remodeling pathways to community-acquired pneumonia (CAP) susceptibility in the case-control study (350 CAP patients, 432 control subjects) and to predisposition to the development of CAP complications in the prospective study. All subjects were genotyped for 16 polymorphic variants in the 14 genes of xenobiotics detoxification CYP1A1, AhR, GSTM1, GSTT1, ABCB1, redox-status SOD2, CAT, GCLC, and vascular homeostasis ACE, AGT, AGTR1, NOS3, MTHFR, VEGFα. Risk of pulmonary complications (PC) in the single locus analysis was associated with CYP1A1, GCLC and AGTR1 genes. Extra PC (toxic shock syndrome and myocarditis) were not associated with these genes. We evaluated gene-gene interactions using multi-factor dimensionality reduction, and cumulative gene risk score approaches. The final model which included >5 risk alleles in the CYP1A1 (rs2606345, rs4646903, rs1048943), GCLC, AGT, and AGTR1 genes was associated with pleuritis, empyema, acute respiratory distress syndrome, all PC and acute respiratory failure (ARF). We considered CYP1A1, GCLC, AGT, AGTR1 gene set using Set Distiller mode implemented in GeneDecks for discovering gene-set relations via the degree of sharing descriptors within a given gene set. N-acetylcysteine and oxygen were defined by Set Distiller as the best descriptors for the gene set associated in the present study with PC and ARF. Results of the study are in line with literature data and suggest that genetically determined oxidative stress exacerbation may contribute to the progression of lung inflammation.
Karamchandani-Patel, Gital; Hanson, Eric P; Saltzman, Rushani; Kimball, C Eve; Sorensen, Ricardo U; Orange, Jordan S
Hypomorphic mutations in the nuclear factor-κB (NF-κB) essential modulator (NEMO) gene result in a variable syndrome of somatic and immunologic abnormalities. Clinically relevant genotype-phenotype associations are essential to understanding this complex disease. To study 2 unrelated boys with novel NEMO mutations altering codon 223 for similarity in phenotype in consideration of potential genotype-phenotype associations. Clinical and laboratory features, including cell counts, immunoglobulin quantity and quality, natural killer cell cytotoxicity, and Toll-like and tumor necrosis factor receptor signaling, were evaluated. Because both mutations affected NEMO codon 223 and were novel, consideration was given to new potential genotype-phenotype associations. Both patients were diagnosed as having hypohidrotic ectodermal dysplasia and had severe or recurrent infections. One had recurrent sinopulmonary infections and the other necrotizing soft tissue methicillin-resistant Staphylococcus aureus infection and Streptococcus anginosus subdural empyema with bacteremia. NEMO gene sequence demonstrated a 3-nucleotide deletion (c.667_669delGAG) in one patient and a substitution (667G>A) in the other. These findings predict either the deletion of NEMO glutamic acid 223 or it being replaced with lysine, respectively. Both patients had normal serum IgG levels but poor specific antibodies. Natural killer cell cytotoxicity and Toll-like and tumor necrosis factor receptor signaling were also impaired. Serious bacterial infection did not occur in both patients after immunoglobulin replacement therapy. Two different novel mutations affecting NEMO glutamic acid 223 resulted in clinically relevant similar phenotypes, providing further evidence to support genotype-phenotype correlations in this disease. They suggest NEMO residue 223 is required for ectodermal development and immunity and is apparently dispensable for quantitative IgG production but may be required for specific antibody
Mueller, Nicolas J.; Tarr, Philip E.; Eich, Gerhard; Schulthess, Bettina; Bahlmann, Anna S.; Keller, Peter M.; Bloemberg, Guido V.
We recently described the novel species Streptococcus tigurinus sp. nov. belonging to the Streptococcus mitis group. The type strain AZ_3aT of S. tigurinus was originally isolated from a patient with infective endocarditis. According to its phenotypic and molecular characteristics, S. tigurinus is most closely related to Streptococcus mitis, Streptococcus pneumoniae, Streptococcus pseudopneumoniae, Streptococcus oralis, and Streptococcus infantis. Accurate identification of S. tigurinus is facilitated by 16S rRNA gene analysis. We retrospectively analyzed our 16S rRNA gene molecular database, which contains sequences of all clinical samples obtained in our institute since 2003. We detected 17 16S rRNA gene sequences which were assigned to S. tigurinus, including sequences from the 3 S. tigurinus strains described previously. S. tigurinus originated from normally sterile body sites, such as blood, cerebrospinal fluid, or heart valves, of 14 patients and was initially detected by culture or broad-range 16S rRNA gene PCR, followed by sequencing. The 14 patients had serious invasive infections, i.e., infective endocarditis (n = 6), spondylodiscitis (n = 3), bacteremia (n = 2), meningitis (n = 1), prosthetic joint infection (n = 1), and thoracic empyema (n = 1). To evaluate the presence of Streptococcus tigurinus in the endogenous oral microbial flora, we screened saliva specimens of 31 volunteers. After selective growth, alpha-hemolytic growing colonies were analyzed by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) and subsequent molecular methods. S. tigurinus was not identified among 608 strains analyzed. These data indicate that S. tigurinus is not widely distributed in the oral cavity. In conclusion, S. tigurinus is a novel agent of invasive infections, particularly infective endocarditis. PMID:22760039
Toro, Cristina Moran; Janvier, Jack; Zhang, Kunyan; Fonseca, Kevin; Gregson, Dan; Church, Deirdre; Laupland, Kevin; Rabin, Harvey; Elsayed, Sameer; Conly, John
BACKGROUND: USA300 community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) strains causing necrotizing pneumonia have been reported in association with antecedent viral upper respiratory tract infections (URI). METHODS: A case series of necrotizing pneumonia presenting as a primary or coprimary infection, secondary to CA-MRSA without evidence of antecedent viral URI, is presented. Cases were identified through the infectious diseases consultation service records. Clinical and radiographic data were collected by chart review and electronic records. MRSA strains were isolated from sputum, bronchoalveolar lavage, pleural fluid or blood cultures and confirmed using standard laboratory procedures. MRSA strains were characterized by susceptibility testing, pulsed-field gel electrophoresis, spa typing, agr typing and multilocus sequence typing. Testing for respiratory viruses was performed by appropriate serological testing of banked sera, or nucleic acid testing of nasopharyngeal or bronchoalveloar lavage specimens. RESULTS: Ten patients who presented or copresented with CA necrotizing pneumonia secondary to CA-MRSA from April 2004 to October 2011 were identified. The median length of stay was 22.5 days. Mortality was 20.0%. Classical risk factors for CA-MRSA were identified in seven of 10 (70.0%) cases. Chest tube placement occurred in seven of 10 patients with empyema. None of the patients had historical evidence of antecedent URI. In eight of 10 patients, serological or nucleic acid testing testing revealed no evidence of acute viral coinfection. Eight strains were CMRSA-10 (USA300). The remaining two strains were a USA300 genetically related strain and a USA1100 strain. CONCLUSION: Pneumonia secondary to CA-MRSA can occur in the absence of an antecedent URI. Infections due to CA-MRSA are associated with significant morbidity and mortality. Clinicians need to have an awareness of this clinical entity, particularly in patients who are in risk
Nyale, George Mwamnemo; Anderson, Ronald; Patel, Atulkumar Ramanlal
Background There are few studies that have documented the clinical presentation, complication rate and outcome of cardiothoracic referrals from a Pulmonology Service, particularly in developing countries. Furthermore, the impact of human immunodeficiency virus (HIV) status on such referrals and their outcomes is not well documented. Methods This was a retrospective audit of combined pulmonologist/cardiothoracic consultations, undertaken among the tertiary academic hospitals attached to the University of the Witwatersrand, Johannesburg, South Africa, over a 10 years period (2001–2010) in order to document the clinical features of these referrals and to determine any impact of HIV status on trends in disease presentations, complications and outcome. Results A total of 847 patients were evaluated on whom a variety of surgical procedures was performed, 50.4% being therapeutic, 32.8% diagnostic and 16.9% both therapeutic and diagnostic. HIV status was known in 488 cases. Of these 229 (46.9%) were HIV-seropositive and 259 (53.1%) -seronegative. The main reasons for referral were for infective conditions, including tuberculosis (TB), pleural disease/effusion/empyema, and other bacterial infections, with significantly more of the TB patients being HIV-seropositive (P<0.0001).There was a trend for increasing presentations for TB and pleural conditions, particularly during the last 4–5 years of the audit, coinciding with an increase in the numbers of HIV-positive referrals. HIV status had no impact on the frequency of surgical complications or mortality. Conclusions The audit indicates an increasing referral rate of HIV-seropositive patients to cardiothoracic services in Johannesburg, particularly in association with TB and pleural diseases. However with careful cardiothoracic/pulmonologist evaluation of the cases the frequency of complications and mortality appear to be no different from that of HIV-seronegative cases. PMID:27162782
Girn, H R S; McPherson, S; Nicholson, T; Mavor, A I D; Homer-Vanniasinkam, S; Gough, M J
Acute penetrating thoracic aortic ulcers (PTAU) are associated with vessel rupture, particularly when intramural haematoma (IMH) is present. Although surgical repair is the treatment of choice for PTAU in the aortic arch, definitive treatment of PTAU in other locations of the thoracic aorta remains controversial, particularly in this frail cohort of patients. Recent series of elective and semi-elective endovascular stent-graft repair of PTAU of the descending thoracic aorta show comparable results with the previously advocated best medical management. We report our results from a retrospective, observational study of acute stent-graft repair of symptomatic PTAU. Between 2000 and 2005, 11 patients (seven male, four female; median age 71 years) presented with acute PTAU. CT scans demonstrated an associated IMH in six, a contained leak in three or rupture in four unstable patients. All were covered by a single endovascular stent [Gore (5), Talent (5), Zenith (1); 10 inserted via the groin and one via iliac conduit within 1 week of presentation (five < 24 h). Technical success was 90.90% (10/11) and 3/11 (27%) died within 30 days (two ARDS, one a persistent leak and rupture at 48 h). One patient developed transient paraplegia; three haemothoraces required chest drains, one of which subsequently required empyema drainage. In survivors, CT scans were satisfactory, with no further intervention required at 32.5 (6-66) months of median follow-up. In conclusion, endovascular management of acute PTAU appears effective and durable with mortality rates that are likely to be better than for open surgery. However, haemodynamic compromise at presentation remains a robust denominator of over-all survival.
Petrov, Dmitriy; Uohara, Michael Y; Ichord, Rebecca; Ali, Zarina; Jastrzab, Laura; Lang, Shih-Shan; Billinghurst, Lori
Pediatric cerebral sinovenous thrombosis (CSVT) is an important, though less common subtype of pediatric stroke. It has been linked to several risk factors, including cranial procedures, with few studies highlighting this relationship. The aim of this study was to characterize the diagnosis and treatment of CSVT after cranial surgery. An institutional pediatric stroke research database was used to identify all CSVT cases diagnosed within 30 days of cranial surgery from November 2004 to December 2014. Thirteen subjects were retrospectively analyzed for clinical presentation, surgical details, radiographic characteristics, laboratory study results, treatment, and outcome. Diagnostic testing and treatment adhered to a consensus-based institutional stroke protocol. Cranial vault reconstruction, subdural empyema evacuation, and tumor resection were each observed in three subjects. Eleven (85%) subjects had sinus exposure during surgery, and eight (73%) developed thrombus in a sinus within or adjacent to the operative field. Two (15%) had documented iatrogenic sinus injury. On post-operative testing, ten (77%) subjects had prothrombotic abnormalities. Seven (54%) were treated with anti-coagulation therapy (ACT) starting on a median of post-operative day (POD) 3 (IQR 1-3) for a median of 2.9 months (IQR 2.4-5.4). Median time to imaging evidence of partial or complete recanalization was 2.4 months (IQR 0.7-5.1). No symptomatic hemorrhagic complications were encountered. Pediatric CSVT may be encountered after cranial surgery, and decisions related to anti-coagulation are challenging. The risk of CSVT should be considered in pre-surgical planning and post-operative evaluation of cases with known risk factors. In our study, judicious use of ACT was safe in the post-operative period.
Preece, Stephen R; Nelson, Rendon C; Bashir, Mustafa R; Jaffe, Tracy A; Kim, Charles Y; Haystead, Clare M
The objective of our study was to test the hypothesis that an intercostal approach to imaging-guided percutaneous subdiaphragmatic abscess drainage is as safe as a subcostal approach. A cohort of 258 consecutive patients with one or more subdiaphragmatic abscesses referred for imaging-guided (CT or ultrasound) percutaneous drainage was identified. Demographic characteristics and clinical outcomes were compared between patients who underwent drainage catheter placement via an intercostal approach versus those who underwent drainage catheter placement via a subcostal approach. Percutaneous drainage was performed for 441 abscesses in 258 patients in 409 separate procedures (214 via an intercostal approach, 186 by a subcostal approach, and nine by a combined approach). The total number of pleural complications was significantly higher in the intercostal group (56/214 [26.2%]) than the subcostal group (15/186 [8.1%]; p < 0.001). These complications included a significantly higher pneumothorax rate in the intercostal group than the subcostal group (15/214 [7.0%] vs 0/186 [0%], respectively; p < 0.01) and a higher incidence of new or increased pleural effusions (38/214 [17.8%] vs 14/186 [7.5%]; p < 0.01). The incidence of empyema was low and similar between the two groups (intercostal vs subcostal, 3/214 [1.4%] vs 1/186 [0.5%]; p = 0.63). A few of the complications in the patients who underwent an intercostal-approach drainage were clinically significant. Four of the 15 pneumothoraces required thoracostomy tubes and eight of 38 (21.1%) pleural effusions required thoracentesis, none of which was considered infected. An intercostal approach for imaging-guided percutaneous drainage is associated with a higher risk of pleural complications; however, most of these complications are minor and should not preclude use of the intercostal approach.
Graham, D R; Band, J D; Thornsberry, C; Hollis, D G; Weaver, R E
From 1953 to 1980 the Centers for Disease Control received 933 isolates of bacteria belonging to species of the genus Moraxella, Moraxella-like Moraxella urethralis, now renamed Oligella urethralis, unnamed groups M-5 and M-6, and Kingella kingae. Ordinarily sterile sites were the source of 233 isolates. Moraxella nonliquefaciens, the most common isolate (356 strains), was recovered from upper respiratory or ocular sites in 208 (58%) of the cases. Moraxella osloensis was next most common (199 strains) but was the most frequent blood isolate (44 cases). K. kingae appeared especially invasive, with 58 of 78 isolates from blood, bone, or joint. Of the K. kingae strains, 75% were recovered from children under 6 years, compared with 23% of the other strains from that age group (P less than .01). Of the 74 isolates of group M-5, 53 were from wounds caused by dog bites; no other organism in this series was recovered from such wounds. Sixteen of the 28 M. urethralis isolates were from urine. Cases occurred as single infections, with no evidence of clusters. Of patients with infection of ordinarily sterile sites, 9.3% died; only bacteremia, meningitis, and empyema caused fatalities. Most referring laboratories (98%) had not identified the organisms to species, and only 30% had identified them to correct genus. Susceptibility testing by broth dilution revealed low MICs of penicillin (mean, 0.3; 64% less than 1 micrograms/mL). Moraxella, M. urethralis, M-5, M-6, and Kingella are important but frequently misidentified pathogens for humans; penicillin appears to be the treatment of choice.
Davidson, B R; Neoptolemos, J P; Carr-Locke, D L
Endoscopic sphincterotomy (ES) was attempted in 106 patients with common bile duct (CBD) calculi and gall bladders present, who were considered unfit for surgery on the grounds of age and frailty alone (35%) and/or the presence of major medical problems (65%). Endoscopic sphincterotomy was successful in 105 patients (99%). Early ES related complications occurred in 21 patients (19.8%). Twelve hospital deaths occurred (11.3%), although this was due to biliary causes in only five (4.7%) and one of these was moribund on admission. Complications were more frequent in those in whom initial ES did not clear the common bile duct (30.4%) compared with those in whom this was (11.7%; p = 0.0164). The mortality was also greater in patients in whom there was no ERCP proof of CBD clearance (p = 0.01) unless operated upon. Twelve patients developed gall bladder complications (11.3%) including five with empyema (4.7%). Analysis of clinical, haematological, and biochemical factors together with ERCP findings showed that the only factor which had any value in predicting gall bladder complications was pre-existing cholangitis. The present series was compared with another using ES as a definitive procedure, and with a surgical series. Although there were significant differences in outcome, differences with respect to medical risk factors and the incidence of complications of CBD stones (jaundice, cholangitis, and acute pancreatitis) were striking. Further analysis of these factors may allow a clearer definition of patients most likely to benefit from either ES or surgery.
Davidson, B R; Neoptolemos, J P; Carr-Locke, D L
Endoscopic sphincterotomy (ES) was attempted in 106 patients with common bile duct (CBD) calculi and gall bladders present, who were considered unfit for surgery on the grounds of age and frailty alone (35%) and/or the presence of major medical problems (65%). Endoscopic sphincterotomy was successful in 105 patients (99%). Early ES related complications occurred in 21 patients (19.8%). Twelve hospital deaths occurred (11.3%), although this was due to biliary causes in only five (4.7%) and one of these was moribund on admission. Complications were more frequent in those in whom initial ES did not clear the common bile duct (30.4%) compared with those in whom this was (11.7%; p = 0.0164). The mortality was also greater in patients in whom there was no ERCP proof of CBD clearance (p = 0.01) unless operated upon. Twelve patients developed gall bladder complications (11.3%) including five with empyema (4.7%). Analysis of clinical, haematological, and biochemical factors together with ERCP findings showed that the only factor which had any value in predicting gall bladder complications was pre-existing cholangitis. The present series was compared with another using ES as a definitive procedure, and with a surgical series. Although there were significant differences in outcome, differences with respect to medical risk factors and the incidence of complications of CBD stones (jaundice, cholangitis, and acute pancreatitis) were striking. Further analysis of these factors may allow a clearer definition of patients most likely to benefit from either ES or surgery. PMID:3343004
Dahlberg, Daniel; Ivanovic, Jugoslav; Mariussen, Espen; Hassel, Bjørnar
Brain abscesses frequently cause symptoms such as seizures, delirium, paresis and sensory deficits that could reflect brain edema, increased intracranial pressure, or tissue destruction. However, it is also possible that pus constituents could disturb neuronal function in the surrounding brain tissue. In pus from 16 human brain abscesses, extracellular potassium ([K(+)]o) was 10.6 ± 4.8 mmol/L (mean ± SD; maximum value 22.0 mmol/L). In cerebrospinal fluid (CSF), [K(+)]o was 2.7 ± 0.6 mmol/L (N = 14; difference from pus p < 0.001), which is similar to previous control values for [K(+)]o in CSF and brain parenchyma. Zinc and iron were >40-fold higher in pus than in CSF; calcium, copper, manganese, and chromium were also higher, whereas sodium and magnesium were similar. Pus from 10 extracerebral abscesses (empyemas) also had higher [K(+)]o, zinc, iron, calcium, copper, manganese, and chromium than did CSF. Brain abscess [K(+)]o was significantly higher than serum potassium (3.8 ± 0.5 mmol/L; p = 0.0001), indicating that the elevated abscess [K(+)]o originated from damaged cells (e.g. brain cells and leukocytes), not from serum. High [K(+)]o could depolarize neurons, high levels of zinc could inhibit glutamate and GABA receptors, and high levels of iron and copper could cause oxidative damage, all of which could contribute to neuronal dysfunction in brain abscess patients. Copyright © 2015 Elsevier Ltd. All rights reserved.