Multilevel spinal epidural empyema: series of clinical cases and bibliographic / Empiema epidural espinhal multinível: série de casos clínicos e revisão bibliográfica / Empiema epidural espinal multinivel: serie de casos clínicos y revisión bibliográfica

ABSTRACT: Multilevel spinal epidural empyema (SEE) is a rare and serious infection of the spine with a high rate of morbidity and mortality. Although abscesses or empyema of the spine sector are well studied, this pathology is surprising due to its rarity and diagnostic and therapeutic challenge. It stands out for being more common in adulthood and in males and is associated with predisposing pathologies. The bacteriological agent responsible in most cases is Staphylococcus aureus. Early treatment is essential and is based on two pillars: antibiotic therapy and decompressive surgery. We present two clinical cases with multilevel involvement that evolved favorably both infectiously and neurologically without causing spine instability and we carried out a bibliographic review of the subject. Level of Evidence IV; Case Report.

RESUMO: O empiema epidural espinhal multinível (EEE) e uma infecção rara e grave da coluna vertebral, com alta taxa de morbidade e mortalidade. Embora os abscessos ou empiemas de um setor da coluna vertebral sejam bem estudados, esta patologia surpreende pela sua raridade e desafio diagnóstico e terapêutico. Destaca-se por ser mais comum na idade adulta, no sexo masculino, e estar associada a patologias predisponentes. O agente bacteriológico responsável na maioria dos casos e o Staphylococcus aureus. O tratamento precoce e essencial e baseia-se em dois pilares: antibioticoterapia e cirurgia descompressiva. Apresentamos dois casos clínicos com envolvimento multinível que evoluíram favoravelmente tanto infecciosa quanto neurologicamente sem causar instabilidade da coluna vertebral e realizamos uma revisão bibliográfica do assunto. Nível de Evidencia IV; Estudo de Caso-controle.

RESUMEN: El empiema epidural espinal (EEE) multinivel es una infección rara y grave de la columna vertebral con alta tasa de morbimortalidad. Si bien los abscesos o empiemas de un sector de la columna están bien estudiados, esta patología sorprende por su rareza, reto diagnóstico y terapeutico. Se destaca por ser más frecuente en la edad adulta, en el sexo masculino y se ve asociada a patologías predisponentes. El agente bacteriológico responsable en la mayoría de los casos es el Staphylococcus aureus. El tratamiento precoz es fundamental y está basado en dos pilares: antibioticoterapia y quirúrgico descompresivo Presentamos dos casos clínicos con afectación multinivel que evolucionaron favorablemente tanto en lo infeccioso como en lo neurológico sin provocar una inestabilidad del raquis y realizamos revisión bibliográfica del tema. Nivel de Evidencia IV; Estudio de Caso-control.

Tuberculosis y una Gemella spp: Una combinación indeseable / Tuberculosis and a Gemella spp: An undesirable combination

El género Gemella spp corresponde a cocos gram positivos, anaerobios facultativos, catalasa negativos, no móviles y no formadores de esporas, usualmente comensales de la cavidad oral, que no suelen ser patógenos en pacientes inmunocompetentes. Sin embargo, puede comportarse como germen oportunista en pacientes inmunosuprimidos o con otros factores de riesgo como mala higiene dental, cirugía gastrointestinal, enfermedades metabólicas entre otras, y se asocia con endocarditis, meningitis y en menor medida compromiso pulmonar. La información respecto a la susceptibilidad antimicrobiana es limitada y se asemeja a la de S viridans, por lo que la penicilina y ampicilina son los medicamentos de elección, sin tener claridad en cuanto a duración del tratamiento, usualmente considerando llevar a 4 semanas o hasta el drenaje de la colección. Éste reporte de caso describe una paciente con tuberculosis en tratamiento, que desarrolla una infección invasiva con documentación de empiema y bacteriemia secundaria por Gemella morbillorum, representando la asociación poco común de ésta infección bacteriana con tuberculosis.

Gemella spp. corresponds to gram positive cocci, facultative anaerobes, negative catalase, non mobile and non spore producers, part of colonizing flora of the oral cavity that are not common pathogens in immunocompetent patients. Nevertheless it may behave as an opportunistic germ in immunosuppressed patients or with other risk factors that include bad dental hygiene, bowel surgery, and metabolic diseases among others. It's associated with infections such as endocarditis, meningitis and less frecuently can implicate the lung. The information regarding antimicrobial susceptibility is limited and resembles S viridans, so penicillin and ampicillin are the medications of choice, without being clear about the duration of treatment, usually giving 4 weeks or until collection drain. This case report describes a patient with known tuberculosis diagnosis and under treatment, that develops an invasive infection with empyema and secondary bloodstream infection by Gemella morbillorum, depicting a previously uncommon but described association of this bacterial infection with tuberculosis.

Empiema Necessitatis: reporte de un caso / Empyema Necessitatis: case report / Empiema Necessitatis: reporte de um caso

La formación de un absceso que se inicia en el espacio pleural y se extiende hacia los tejidos adyacentes se conoce como Empiema Necessitatis, es una complicación rara, más aún si es secundaria a traumatismo. El tratamiento temprano es vital y consiste en drenaje del empiema asociado a antibiótico de amplio espectro, hasta obtener cultivos del agente etiológico, con Mycobacterium tuberculosis como etiología más común. A continuación, reportamos el caso de un paciente de 47 años sin antecedentes de importancia, que ingresa inicialmente por politrauma por caída de altura, manejado de forma conservadora. Reingresa 15 días después por fiebre y aparición de masa en torácica. Se confirma, mediante tomografía de tórax contrastada, fistulización de una colección hacia tejidos blandos, por lo que se inicia manejo antibiótico y quirúrgico. Se aisló Staphylococcus aureus sensible. El paciente mejora y egresa para seguir manejo ambulatorio.

The Formation of an abscess in the pleural space that spreads through the adjacent tissues is known as Empyema Necessitatis, which is a rare complication, even more if it is secondary to trauma. An early management is vital and consists of a surgical drainage of empyema associated with broad-spectrum antibiotics until the etiologic agent is identified. Mycobacterium tuberculosis is the most common etiology found. The article presents a report on a medical case of a 47 year-old patient without a significant personal medical history, who was initially admitted for polytrauma due to a fall from his own height. The trauma was treated in a conventional way. After 15 days, is admitted again with fever and a new mass in the wall chest. A CT tomography showed a pus fistulation from the pleural space through the soft tissues of the chest. A drainage was performed and broad-spectrum antibiotics were given until sensitive Staphylococcus aureus was identified. Finally, the patient got better and continued ambulatory management.

A formação de um abscesso que se inicia no espaço pleural e se estende aos tecidos adjacentes se conhece como Empiema Necessitatis, é uma complicação rara, mas ainda assim é secundária ao traumatismo. O tratamento precoce é vital e consiste em drenagem do empiema associado a antibiótico de amplo espectro, até obter cultivos do agente etiológico, com Mycobacterium tuberculosis como etiologia mais comum. A continuação, reportamos o caso de um paciente de 47 anos sem antecedentes de importância, que ingressa inicialmente por politrauma por queda de altura, manejado de forma conservadora. Reingressa 15 dias depois por febre e aparecimento de massa em torácica. Se confirma, mediante tomografia de tórax contrastada, fistulização de uma coleção aos tecidos moles, pelo que se inicia manejo antibiótico e cirúrgico. Se isolou Staphylococcus aureus sensível. O paciente melhora e egressa para seguir manejo ambulatório.

Otomastoiditis crónica supurada complicada con absceso extradural y colecciónsupurada subcutánea (Absceso de Bezold), asociada a hematoma subdural crónico / Chronic suppurative otomastoiditis complicated with extradural abscess and subcutaneous suppurative collection (Bezold's abscess), associated with chronic subdural hematoma

Introducción: Las complicaciones intracraneanas de la otomastoiditis crónica supurada (OMCS) se ven cada vez con menor frecuencia gracias al diagnóstico precoz, acceso a imagenología y uso de antibióticos. La asociación de una OMCS con empiema extradural y hematoma subdural crónico es extremadamente infrecuente y y reportar un caso clinico es el objetivo de este reporte. Caso clínico: Paciente de 28 años, con historia de trauma craneano dos meses antes del ingreso. Consultó por otorrea fétida derecha de 45 días de evolución. Un mes previo a la consulta instala tumoración fluctuante en planos superficiales de región temporoparietal derecha que aumenta de tamaño y se hace dolorosa. Examen neurológico normal. Se realiza tomografía de cráneo que evidencia colección extradural y subdural, asociada a otomastoiditis. Se intervino en conjunto con ORL para evacuación del proceso supurado intracraneano y mastoidectomía, encontrándose en el intraoperatorio que la colección subdural no era infecciosa (empiema), sino que era un hematoma subdural crónico. La evolución fue buena siendo dado de alta asintomático. Reportamos esta asociación lesional muy poco frecuente, cuyo diagnóstico preoperatorio hubiera hecho variar la táctica neuroquirúrgica. Se discuten los hechos clínicos e imagenológicos que podrían haber llevado al diagnóstico correcto.

Introduction: Intracranial complications of chronic suppurative otomastoiditis (OMCS) are seen less and less frequently seen thanks to early diagnosis, access to imaging and access to antibiotics. The association of an OMCS with extradural empyema and chronic subdural hematoma is extremely infrequent. We report a clincal case of OMCS associated with a chronic subdural haematoma. Clinical case: A 28-year-old patient with a history of cranial trauma two months before admission, who consulted for a 46-day history of fetid otorrhea. One month prior to the consultation, he detected a fluctuating tumor in superficial planes of the right temporoparietal region that increased and became painful. He has a normal neurological examination. We performed a cranial CT and we detected an extradural and subdural collection, associated with otomastoiditis. A surgical intervention with a combined team was performed (Othologist and neurosurgeons). The aim of the surgery to evacuate the intracranial process and mastoidectomy. In the intraoperative period, we discovered that the subdural collection was not infectious but a chronic subdural hematoma. The evolution was good being discharged asymptomatic. We report a very rare association (OMCS with chronic subdural haematoma), whose preoperative diagnosis would have changed the neurosurgical tactic. Clinical and imaging facts that could have led to the correct diagnosis are discussed.

Empiema del Muñón Ureteral: Secretos Para un Buen Diagnóstico / Empyema of the Ureteral Stump: Secrets for a Correct Diagnosis

El muñón ureteral es el segmento de uréter remanente posterior a una nefrectomía, que puede, ocasionalmente, dar origen a un cuadro sintomático infeccioso poco frecuente, conocido como empiema del muñón ureteral (EMU). El mismo suele atribuirse a otra patología por desconocimiento médico y no es reconocido hasta que el cuadro clínico avanza significativamente o se realiza la exploración quirúrgica. Los muñones ureterales que se encontraban sanos en la cirugía inicial no suelen desarrollar patología. Por el contrario, los uréteres obstruidos, crónicamente infectados o asociados a litiasis o reflujo distal, son los que se encuentran en riesgo de desarrollar complicaciones futuras. En esta revisión, se repasa la literatura y se presentan casos de pacientes con antecedentes de nefrectomía que por diferentes causas transcurrieron con empiema en el muñón ureteral, con el fin de analizar las posibles causas y factores predisponentes de la patología, describir los hallazgos radiológicos en los diferentes métodos diagnósticos y poder reconocer las posibles complicaciones para su correcto manejo terapéutico. Las infecciones urinarias a repetición son útiles para sospechar la presencia de EMU. Ellas se deben al reflujo urinario o disfunción en el vaciamiento del uréter remanente, con estasis e infección del mismo. Por lo tanto, en pacientes con antecedentes de nefrectomía que presentan dolor abdominal difuso, fiebre y antecedentes de infecciones urinarias a repetición, es necesario sospechar empiema del muñón ureteral para poder realizar un correcto análisis imagenológico y posterior tratamiento.

The ureteral stump is the segment of the ureter that remains after a nephrectomy, and it can occasionally give rise to a rare symptomatic infectious disorder known as an empyema of the ureteral stump. The syndrome is usually attributed to another disease due to the radiologist's or ED physician's unawareness, and diagnosis is delayed until there is significant clinical progression, complimentary images or exploratory surgery is performed. Ureteral stumps that were healthy at the initial surgery, usually do not pose further problems. On the other hand, ureters that are obstructed, chronically infected or associated with nephrolithiasis or distal reflux, are at risk for developing future complications. This review goes over the available literature on the subject and presents cases of patients who underwent a nephrectomy and, for different reasons, developed an empyema of the ureteral stump in order analyze the possible causes and predisposing factors, describing the main radiologic findings in each of the different imaging modalities, and recognize the possible complications and their according therapeutic management. Repeated urinary tract infections are useful for suspecting the presence of an empyema, and are due to vesicoureteral reflux or ureteral dysfunction, with consequent urinary stasis and infection. Thus, patients with a history of nephrectomy presenting with diffuse abdominal pain, fever and repeat urinary infections, should raise the suspicion of empyema of the ureteral stump, leading to a correct imaging analysis and posterior treatment.

Paciente con papilomatosis laringo-traqueo-bronquial recurrente y empiema at necessitates Dificultades de diagnóstico y manejo / Patient with recurrent laryngeal-tracheo-bronchial papillomatosis and empyema at necessitates Difficulties in diagnosis and management

Resumen Paciente masculino de 17 años, con cuadro de PLR desde los 18 meses, al que se le han realizado 85 intervenciones a nivel laringo-traqueal, por lo que requirió traqueostomía permanente desde los cinco años, presentando cuadros de neumonías a repetición con invasión papilomatosa a pulmón de predominio derecho con aislamiento de actinomicetos; desarrolló empiema at neccesitatis del que se aislaron múltiples gérmenes multirresistentes con severo compromiso del parénquima pulmonar por lo que requirió neumonectomía radical derecha en intento de controlar la infección. Fue manejado con anfotericina B deoxicolato, meropenem, tigeciclina y polimixina B a pesar de lo cual presenta empeoramiento del cuadro clínico con posterior choque séptico refractario que lo llevó a la muerte.

Abstract A 17-year-old male patient, with a clinical picture of RRP since18 months of age, who underwent 85 interventions at the laryngo-tracheal level, requiring permanent tracheostomy from the age of 5, presenting recurrent pneumonia with lung papillomatous invasion of right predominance with actinomycete isolation. He developed empyema at neccesitatis from which multiple multiresistant organisms with severe compromise of the pulmonary parenchyma were isolated, which required a right radical pneumonectomy in an attempt to control the infection. He was managed with am-photericin B deoxycholate, meropenem, tigecycline and polymyxin B, despite which he presented worsening of the clinical picture with subsequent refractory septic shock that led to his death.

Manejo del empiema complicado con ventana torácica y sistema de presión negativa / Management of complicated empyema with thoracic window and negative pressure system

Introducción: El empiema torácico se define como derrame pleural purulento. La causa más frecuente es el infeccioso paraneumónico, sin embargo, puede presentarse en escenarios posquirúrgicos o postraumáticos. El empiema sigue una evolución progresiva trifásica y el tratamiento debe enfocarse a la causa de la enfermedad, fase evolutiva, y el estado general del paciente. Algunos casos requieren toracotomía con drenaje abierto tipo ventana torácica para solucionar el padecimiento. Materiales y Método: Estudio observacional, retrospectivo y descriptivo basado en una serie de casos. Se analizaron datos de pacientes consecutivos con empiema intervenidos con toracotomía con drenaje abierto tipo ventana torácica y uso de sistema de presión negativa en un Hospital de 3er Nivel del Sureste de México de octubre 2015 a junio 2017. Resultados: Se analizaron seis casos, la mediana de edad fue 46 años (rango intercuartílico 34-47) y 67% eran hombres. El sistema de presión negativa se colocó en el periodo posquirúrgico con una mediana de 6 días (rango intercuartílico 5-7). El tiempo medio de permanencia fue de 61 días (RIC 43-148). Finalmente, el tiempo de estancia hospitalaria fue de 72 días (RIC 49-87). El 67% de los casos evolucionó con cierre de la ventana torácica y adecuada expansión pulmonar. Conclusiones: En pacientes con empiema crónico, la terapia integral que incluya toracotomía con ventana torácica y el uso de sistema de presión negativa es una estrategia aceptable de tratamiento. Se requieren más estudios que ratifiquen los resultados de forma más objetiva.

Background: Thoracic empyema is defined as a purulent pleural effusion. Its most common origin is parapneumonic, nonetheless, post-surgical or post-traumatic empyema can also occur. Empyema has a progressive three-phase evolution and the treatment must focus to the evolutionary phase, cause of the disease and overall state of the patient. Some cases would undergo through thoracotomy with thoracic window open drainage to solve the disease. Material and Methods: This is an observational, retrospective and descriptive study based on all consecutive patients with empyema who underwent thoracotomy with thoracic window open drainage in a 3rd level hospital in the southeast of Mexico between october 2015 and june 2017. Results: We identified 6 cases. Median of age was 46 years (IQR 34-47) and 67% were male. The negative pressure system was placed in the 6th day of surgery (IQR 5-7). Median time of use was 61 days (IQR 43-148). Finally, the length of hospital stay was 72 days (IQR 49-87). 67% of the cases had chest window closure with adequate lung expansion. Conclusions: when we face a clinical scenario with chronic empyema, an integral therapy that includes thoracic window thoracotomy with a negative pressure system is an acceptable treatment strategy. Subsequent studies are required in order to ratify the results

Management of Complicated Empyema with Thoracic Window and Negative Pressure System

Introduction: the thoracic empyema is defined as a purulent pleural effusion. Its most frequent cause is infectious parapneumonic effusion; however, postsurgical or posttraumatic empyema can also occur. The empyema has a progressive three-phase evolution and its treatment shall focus on the cause of the disease, the evolutionary phase and the general condition of the patient. In order to cure this condition, some cases require thoracotomy with open thoracic window drainage. Materials and Method: observational, retrospective and descriptive study based on a series of cases. We analyzed data from consecutive patients with empyema who underwent thoracotomy with open thoracic window drainage and using a negative pressure system in a third-level care hospital in the southeast of Mexico between October 2015 and June 2017. Results: we analyzed 6 cases. Median of age was 46 years (interquartile range 34-47), and 67% were male. The negative pressure system was placed during the postsurgical period, with a median of 6 days (interquartile range 5-7). The mean permanence time was 61 days (IQR 43-148). Finally, the length of hospital stay was 72 days (IQR 49-87). 67% of the cases had thoracic window closure and adequate lung expansion. Conclusions: in patients with chronic empyema, an integral therapy including thoracic window thoracotomy with a negative pressure system is an acceptable treatment strategy. More studies are required in order to ratify the results more objectively.

Nocardia nova causing empyema necessitatis afterlung re-transplantation: a case report

Abstract: We report herein a case of thoracic infection due to Nocardia nova following lung re-transplantation performed for emphysema related to alpha-1-antitrypsin deficiency. The infection extended from the lung into the pleural space, thoracic wall, and mediastinum, presenting as pericarditis and empyema necessitatis. Nocardia nova was identified by 16S ribosomal deoxyribonucleic acid (rDNA) sequencing and phylogenetic analysis. According to a literature search of PubMed, LILACS and MEDLINE databases, we describe herein the first case of empyema necessitatis caused by N. nova species in a transplanted patient.

Associated factors to empyema in post-traumatic hemotorax / Fatores associados ao empiema em pacientes com hemotórax retido pós-traumático

ABSTRACTObjective:to analyze the associated factors with empyema in patients with post-traumatic retained hemothorax.Methods: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.Results: 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.Conclusion: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.

RESUMOObjetivo:analisar os fatores associados ao empiema em pacientes com hemotórax retido pós-traumático.Métodos:estudo prospectivo observacional. Os dados foram coletados de pacientes submetidos à drenagem pleural de emergência. Foram analisadas: idade, sexo, mecanismo de trauma, lado da lesão torácica, complicações intratorácicas decorrentes do hemotórax retido, laparotomia, lesões específicas, fratura de arcos costais, índices de trauma, dias até o diagnóstico, método diagnóstico do HR, indicação primária da drenagem pleural, volume inicial drenado, dias de permanência do primeiro dreno, procedimento cirúrgico. Obteve-se a incidencia acumulada de empiema, pneumonia e contusão pulmonar e a incidência de empiema em cada categoria das variaìveis analisadas.Resultados:a incidência acumulada de drenagem pleural por trauma foi 1,83% e a de hemotórax retido entre aqueles com derrame pleural foi de 10,63%. Houve 20 casos de empiema (32,8%). A maioria tinha entre 20 e 29 anos, era do sexo masculino e sofreu ferimento por arma de fogo. A incidência de empiema entre pacientes com ferimento por arma de fogo foi inferior aos demais mecanismos; superior entre aqueles com volume drenado entre 300 e 599 ml. O tempo mediano de permanência hospitalar foi maior nos pacientes com empiema.Conclusão:as incidências de derrame pleural e hemotórax retido entre aqueles com DP nessa amostra de baixa gravidade dos pacientes foram, respectivamente, 1,83% e 10,63%. A incidência de empiema revelou-se negativamente associada à ocorrência de ferimento por arma de fogo e positivamente associada a volume drenado entre 300 e 599 ml, bem como, ao tempo mediano de permanência hospitalar.

Cirugía torácica de mínima invasión en el manejo de los empiemas pleurales fase II y III / Minimally-invasive thoracic surgery in handling stages II and III pleural emyemas

Introducción: el empiema es la infección de la cavidad pleural proveniente de focos intra o extra torácicos; hay tres fases en su fsiopatología que se manejan de forma diferente. Los objetivos más importantes son la antibioticoterapia y el drenaje de la colección infectada. En la fase II existe discrepancia de las indicaciones de limpieza quirúrgica y la toracotomía se ha reservado para la fase III. Materiales y métodos: tomamos 66 pacientes intervenidos de limpieza pleural por empiema en el 2011 y 2012 en el Hospital Carlos Andrade Marín. Resultados: el abordaje que más se practicó es la toracotomía, especialmente en la fase III; en cambio los de menor invasión tienen mayor presencia en la fase II. Hay que tomar en cuenta que hay abordajes abiertos y por video en ambas fases. Conclusiones: demostramos que la cirugía de mínima invasión es un procedimiento seguro en los empiemas fase II y debería considerarse como parte del manejo inicial del empiema fase III, representa menor tiempo de hospitalización y consumen menos tiempo de quirófano.

Introduction: empyema is the infection of the pleural cavity from intra or extrathoracic foci; there are three phases in its pathophysiology and are handled differently. The most important objectives are antibiotics with drainage of the infected collection. In phase II there is a discrepancy of surgical cleaning indications; thoracotomy is reserved for phase III. Materials and methods: we took 66 patients who underwent pleural empyema in 2011 and 2012 at the Carlos Andrade Marin Hospital. Results: the most performed procedure was thoracotomy, especially in phase III; however the ones with least invasion had more presence in phase II. It must be considered that open procedures and with video are applied in both phases. Conclusions: we demonstrate that minimally invasive surgery is a safe procedure in phase II empyema and should be considered as part of the initial management of phase III empyema, because it represents shorter hospital stay, and less operating time.

Derrame pleural parapneumônico em crianças: diagnóstico e tratamento / Parapneumonic pleural effusion in children: diagnosis and treatment

O derrame pleural parapneumônico (DPP) tem alta prevalência na população pediátrica, requerindo diagnóstico precoce, tratamento seguro e efetivo, a fim de diminuir o número de complicações e o tempo de hospitalização. Este trabalho visa orientar o reconhecimento, os meios diagnósticos e as opções terapêuticas frente ao paciente com DPP.

Parapneumonic pleural effusion (PPE) has a high prevalence in children, requiring early diagnosis, safe and effective treatment in order to decrease the number of complications and hospitalization time. This study aims to describe the recognition, diagnostic tools and therapeutic options for the pediatric patient with PPE.

Suppurative intracranial processes in 15 domestic ruminants / Processos supurativos intracranianos em 15 ruminantes domésticos

In addition to listeriosis which is relatively common in ruminants, there are three other uncommon suppurative intracranial processes (SIP) identifiable in adult ungulates as brain abscess, basilar empyema and suppurative meningitis. The present paper reports the epidemiological, clinical, laboratorial, pathological and microbiological findings of 15 domestic ruminants with SIP. A total of 15 animals were selected (eight sheep, four cattle and three goats); with the definitive diagnoses of basilar empyema (n=3), brain abscess (n=1), listeriosis (n=5) and suppurative meningitis (n=6). Hematology revealed leukocytosis with inversion of the lymphocyte/ neutrophil ratio in 4 cases. In the majority of animals, cerebrospinal fluid (CSF) presented light yellow coloration and cloudy aspect due to neutrophilic pleocytosis (15 - 997 leukocytes/µL). Microbiological culture of CSF or central nervous system (CNS) fragments resulted on isolation of Trueperella (Arcanobacterium) pyogenes,Listeria monocytogenes,Escherichia coli and Stenotrophomonas sp. In a goat with thalamic abscess, microbiological assay was not performed, but Gram positive bacilli type bacteria were observed in histology. The diagnosis of these outbreaks was based on the association of epidemiological, clinical, pathological and bacteriological findings; reiterating that the infectious component remains an important cause of CNS disease in domestic ruminants and also shows the need for dissemination of information about the most effective preventive measures for the ranchers.

Além da listeriose, que é relativamente comum em ruminantes, existem outros três processos supurativos intracranianos (PSI) identificáveis em ungulados adultos, que não são comuns, como: abscesso cerebral, empiema basilar e meningite supurativa. O presente trabalho tem como objetivo relatar os achados epidemiológicos, clínicos, laboratoriais, patológicos e microbiológicos de 15 ruminantes domésticos com PSI. O total de 15 animais foi selecionado (oito ovinos, quatro bovinos e três caprinos), com o diagnóstico definitivo de empiema basilar (n=3), abscesso cerebral (n=1), listeriose (n=5) e meningite supurativa (n=6). A hematologia revelou leucocitose com inversão da relação linfócito/ neutrófilo em quatro animais. Na maioria dos animais, a análise do líquido cefalorraquidiano (LCR) revelou coloração amarelado clara e aspecto turvo devido à pleocitose neutrofílica (15 - 997 leucócitos/µL). A cultura microbiológica de LCR ou de fragmentos do sistema nervoso central (SNC), permitiu o isolamento de Trueperella (Arcanobacterium) pyogenes,Listeria monocytogenes, Escherichia coli e Stenotrophomonas sp. No caprino com abscesso de tálamo, a cultura microbiológica não foi realizada, mas bactérias Gram positivas tipo bacilos foram observadas na histologia. O diagnóstico desses surtos foi baseado na associação dos achados epidemiológicos, clínicos, patológicos e bacteriológicos; reiterando que o componente infeccioso continua sendo uma causa importante de doença do SNC em ruminantes domésticos e também mostra a necessidade de disseminação da informação sobre as medidas preventivas mais eficazes para os criadores.

Una causa poco frecuente de empiema en un varón inmunocompetente / A Rare Cause of Empyema in an Immunocompetent Male

La coccidiodomicosis es una micosis sistémica endémica de América, producida por los hongos del género Coccidioides, C. immitis y C. posadasii. La mayor parte de las infecciones son benignas y autolimitadas, muy pocas desarrollan una enfermedad pulmonar grave y, un porcentaje mínimo, una enfermedad diseminada. Las infecciones complicadas del espacio pleural se han comunicado en muy pocos casos en la literatura. Se presenta el caso de un paciente inmunocompetente con una forma cavitada extensa asociada a empiema.

Coccidioidomycosis is a systemic mycosis endemic in America, caused by Coccidioides immitis and Coccidioides posadasii. Most of the infections are mild and self-limited; only a few of them develop a serious lung disease and a much smaller proportion cause a systemic disease. A few cases of infections complicating the pleural space infections have been reported in the literature. We present a case of an immunocompetent patient, with a pulmonary Coccidiodiomycosis with extensive cavitary dissease associated to empyema.

Empiema Necessitatis / Empyema necessitatis

Se presenta el caso de un hombre de 73 años, agricultor, quien consulta por cuadro de tres meses de tos húmeda con expectoración verdosa, posteriormente hemoptoica, de predominio matutino, asociado a dolor lumbar izquierdo. Se documentó en imágenes empiema que se comunica con región lumbar izquierda, constituyendo así un cuadro de empiema necessitatis con presentación poco usual como lo es el drenaje hacia espacio paravertebral. (Acta Med Colomb 2013; 38: 28-31).

We present the case of a 73-year-old farmer, who consults for a 3 months clinical picture of wet cough with greenish sputum, subsequently hemoptoic predominantly in the mornings, associated with left lumbar pain. We documented in images empyema communicating with the left lumbar region, constituting an empyema necessitatis picture with unusual presentation as is the drainage to the paravertebral space. (Acta Med Colomb 2013; 38: 28-31).

Empiema cerebral por Escherichia coli en un lactante de 5 meses: reporte de caso y revisión del tema / Brain empyema due to Escherichia coli in a 5 month-old infant: a case report and literature review

Introducción: el empiema cerebral en pediatría es una rara infección intracraneal que puede ser secundaria a una meningitis, sinusitis, o por mecanismos como trauma craneal, cirugía neurológica o como resultado de la diseminación hematógena desde un sitio remoto. Objetivo: describir un caso de empiema cerebral causado por Escherichia coli en un lactante. Metodología: presentar un caso clínico, con aislamiento de Escherichia coli fuera del periodo gris de la meningitis. Se realiza una revisión acerca de los factores de riesgo, la etiología y tratamiento del empiema cerebral en niños. Resultados: masculino de 5 meses, sin inmunodeficiencia, cráneo con plagiocefalia; antecedente de otitis de 3 semanas de evolución previo a su ingreso al hospital. El paciente manifestó fiebre, crisis convulsivas y deterioro rostro-caudal. El líquido cefalorraquídeo con pleocitosis e hipoglucorraquia. Las imágenes tomográficas revelaron la presencia de empiema cerebral. Se logró el aislamiento de Escherichia coli en el cultivo, requirió drenaje quirúrgico y antibioticoterapia sistémica por 4 semanas. Conclusiones: el empiema cerebral por Escherichia coli en lactantes después del periodo gris es muy raro. Su tratamiento consiste en la evacuación quirúrgica oportuna, la erradicación del foco infeccioso primario y la administración apropiada de antimicrobianos sistémicos.

Introduction: Brain empyema in children is a rare intracranial infection that may result from meningitis, sinusitis, or mechanisms such as head trauma, neurological surgery or hematogenous spread from a remote site. Objective: To describe a case of brain empyema caused by Escherichia coli in an infant. Methodology: A case report is presented with isolation of Escherichia coli arising after the overlap period of meningitis (1-3 months). A literature review of the risk factors, etiology and treatment of brain empyema in children is conducted. Results: The case report is about a 5 month-old male infant with no history of immunodeficiency, plagiocephalic, and with a 3 week-long history of otitis prior to admission. The patient had fever, seizures and rostro-caudal deterioration, cerebrospinal fluid pleocytosis and hypoglycorrhachia. The tomographic images revealed brain empyema. It was posible to isolate Escherichia coli from culture and surgical drainage was required plus systemic antibiotic therapy for 4 weeks. Conclusions: Brain empyema caused by Escherichia coli in infants after the overlap period are very rare. Treatment consists in prompt surgical evacuation, eradication of the primary infection and proper administration of systemic antimicrobials.

Derrame pleural parapneumônico: uma análise descritiva de pacientes pediátricos e proposta de protocolo deatendimeto / Parapneumonic effusion: a descriptive analysis of pediatric patients and managment protocol proposal

Realizar a análise descritiva de pacientes internados com diagnóstico de derrame pleural parapneumônico.

To perform a descriptive analysis on the hospitalized patients diagnosed with parapneumonic effusion.

Costo-efectividad de la vacunación universal antineumocócica en Uruguay / Cost-effectiveness of universal pneumococcal vaccination in Uruguay

OBJETIVO: Evaluar la relación costo-efectividad del programa de vacunación universal con la vacuna antineumocócica conjugada heptavalente (VCN7) en niños menores de 5 años en Uruguay. MÉTODOS: Se desarrolló un modelo Markov simulando una cohorte de 48 000 niños nacidos en 2007 y su evolución hasta los 76 años de edad. El caso base usó un esquema de tres dosis con una duración estimada de protección de cinco años. La presunción de eficacia y efectividad de la vacuna se realizó acorde con estudios realizados en Estados Unidos con ajuste a la prevalencia-incidencia de serotipos en Uruguay. Los resultados se expresaron como costo incremental por año de vida ganado (AVG) y por año de vida [ganado] ajustado por calidad (AVAC). RESULTADOS: Para el caso base, el costo incremental fue de US$ 7 334,6 por AVG y US$ 4 655,8 por AVAC, previniéndose 8 muertes y 4 882 casos de otitis, 56 bacteriemias-sepsis, 429 neumonías y 7 meningitis. El modelo muestra sensibilidad a variaciones en eficacia, costo de la vacuna y tasa de mortalidad por neumonía. CONCLUSIONES: El programa de vacunación universal con VCN7 en Uruguay es altamente costo-efectivo y, en consecuencia, recomendable para otros países con carga de enfermedad neumocócica y cobertura de serotipos similares a Uruguay.

OBJECTIVE: Evaluate the cost-effectiveness ratio of the program for universal vaccination with heptavalent pneumococcal conjugate vaccine (PCV7) in children under 5 years of age in Uruguay. METHODS: A Markov model was developed that simulated a cohort of 48 000 children born in 2007 and their progress to age 76. The baseline case used a regimen of three doses with estimated protection for five years. The presumption of vaccine efficacy and effectiveness was based on studies conducted in the United States with adjustment for serotype prevalence-incidence in Uruguay. The results were expressed as the incremental cost per life year gained (LYG) and quality-adjusted life year (QALY) [gained]. RESULTS: For the baseline case, the incremental cost was US $7334.60 for each LYG and US $4655.80 for each QALY. Eight deaths and 4 882 cases of otitis, 56 cases of bacteremia-sepsis, 429 cases of pneumonia, and 7 cases of meningitis were prevented. The model shows sensitivity to variations in vaccine cost, efficacy, and pneumonia-related mortality. CONCLUSIONS: The universal vaccination program with PCV7 in Uruguay is highly cost-effective. Therefore, it is recommended for other countries with burden of pneumococcal disease and serotype coverage similar to those of Uruguay.

Infecciones diferentes a la peritonitis bacteriana espontánea en pacientes con cirrosis / Infections other than spontaneous bacterial peritonitis in patients with cirrhossis

Patients with cirrhosis are regularly infected with a plethora of bacteria, fungi and mycobacteria. A high index of suspicion of infection and a low threshold for culturing, ascitic fluid, blood, urine, pleural fluid, spinal fluid, joint fluid, etc will lead to a rapid diagnosis of infection and perhaps prolong survival of these very fragile patients.