Nontuberculous mycobacterial empyema in an immunocompetent child.

Nontuberculous mycobacterium (NTM) species are mycobacterial species other than those belonging to the Mycobacterium Tuberculosis complex and Mycobacterium leprae. There are very few reports of NTM in immunocompetent children causing empyema. In this article, we report a 9-year-old immunocompetent girl who presented with Mycobacterium avium-intracellulare empyema.

Mycobacterium avium complex empyema in a patient with interferon gamma autoantibodies.

Interferon gamma (IFN-γ) autoantibodies are a relatively recently discovered clinical entity, which have been shown to be associated with disseminated non-tuberculous mycobacterial (NTM) infections and other opportunistic infections. Interestingly, isolated NTM infections (without disseminated NTM infection) have not been shown to be a good predictor of the presence of IFN-γ autoantibodies. This case describes an isolated NTM empyema in a patient with IFN-γ autoantibodies and makes the argument that the development of an NTM empyema in a patient with no known immunodeficiency should prompt consideration for IFN-γ testing. Additionally, this case underscores the importance for clinicians to recognize that an unusual infection without the typical cause of impairment in immunity should prompt a more thorough investigation of the patient's immune system.

Invasive Trichosporon infection in solid organ transplant patients: a report of two cases identified using IGS1 ribosomal DNA sequencing and a review of the literature.

Trichosporon species are rare etiologic agents of invasive fungal infection in solid organ transplant (SOT) recipients. We report 2 well-documented cases of Trichosporon inkin invasive infection in SOT patients. We also conducted a detailed literature review of Trichosporon species infections in this susceptible population. We gathered a total of 13 cases of Trichosporon species infections. Any type of organ transplantation can be complicated by Trichosporon infection. Bloodstream infections and disseminated infections were the most common clinical presentations. Liver recipients with bloodstream or disseminated infections had poor prognoses. Although the most common species was formerly called Trichosporon beigelii, this species name should no longer be used because of the changes in the taxonomy of this genus resulting from the advent of molecular approaches, which were also used to identify the strains isolated from our patients. Antifungal susceptibility testing highlights the possibility of multidrug resistance. Indeed, Trichosporon has to be considered in cases of breakthrough infection or treatment failure under echinocandins or amphotericin therapy. Voriconazole seems to be the best treatment option.

The increasing incidence of empyema.

PURPOSE OF REVIEW: The aim of this review is to highlight recent changes concerning the incidence of empyema. In this article we have focused on community-acquired empyema RECENT FINDINGS: The incidence of empyema seems to have been increasing both in children and adults worldwide in the past decades, mainly in healthy young adults and in older patients. The bacteriology of pleural infection is changing as well. In children, the most common microorganism that causes empyema continues to be Streptococcus pneumoniae. Interestingly, the widespread use of the seven valent conjugate vaccine has produced a replacement phenomenon with the emergence of some pneumococcal serotypes such as serotypes 1, 3 and 19A, which have a higher propensity to cause empyema. Moreover increases in the incidence of empyema due to Staphylococcus aureus have also been observed. In adults, increases in the rate of empyema due to Streptococcus milleri group and S. aureus have been reported. SUMMARY: Continued surveillance in the epidemiology of empyema is needed. Progress in new strategies of prevention, such as a new generation of conjugate pneumococcal vaccines and protein-based vaccines, could become an important step in the control of this important complication.

A bedside assay to detect streptococcus pneumoniae in children with empyema.

BACKGROUND: Empyema is a complication of pneumonia, commonly caused by Streptococcus pneumoniae. AIMS: To validate the utility of an immunochromatographic test for the detection of S. pneumoniae antigen in the pleural fluid of children with empyema. METHODS: Empyema patients had blood and pleural fluid cultured, and polymerase chain reaction (PCR) to detect the S. pneumoniae autolysin gene, lytA, in pleural fluid. Pleural fluid was tested using the Binax NOW S. pneumoniae antigen detection assay and compared with lytA PCR results and/or culture in blood or pleural fluid. RESULTS: S. pneumoniae was detected by PCR in pleural fluid of 68 of 137 (49.6%) patients, by culture in 11 of 135 (8.1%) pleural specimens and 16 of 120 (13.3%) blood specimens. Pleural fluid Binax NOW testing from 130 patients demonstrated a sensitivity of 83.8% and specificity of 93.5% (positive predictive value of 93.4% and negative predictive value of 84.1%). CONCLUSIONS: In pediatric empyema, high predictive values of pleural fluid Binax NOW S. pneumoniae antigen test suggest that this test may help rationalize antibiotic choice in these patients.

Effects of the TREM-1 pathway modulation during empyema in rats.

BACKGROUND: The activation of triggering receptor expressed on myeloid cells-1 (TREM-1) in the presence of microbial components amplifies the inflammatory response. The aim of the present study was to investigate the effect of the modulation of the TREM-1 pathway during empyema in rats. METHODS: Adult male Wistar rats were subjected to empyema induced by intrapleural injection of Pseudomonas aeruginosa and Staphylococcus aureus. The animals were treated with LP17 (a synthetic TREM-1 inhibitor), a control peptide, or a vehicle (normal saline). Differential cell count, flow cytometry and histological examination were performed to evaluate local inflammatory alterations. Concentrations of tumor necrosis factor-alpha, interleukin-1beta, and interleukin-6 in both pleural effusion and serum were measured by enzyme-linked immunosorbent assay. RESULTS: Although differential counts of each type of leukocytes in pleural effusion were not affected by LP17, a marked reduction in neutrophil numbers was seen in LP17 treated rats due to the reduction of both pleural effusion volume and total cell numbers. LP17 administration impaired concentration elevation in tumor necrosis factor-alpha, interleukin-1beta, and interleukin-6 in both pleural effusion and serum. It was found that survival rate in LP17 treated rats was much higher than that in control rats. CONCLUSION: The modulation of the TREM-1 pathway by the use of LP17 appears to be beneficial during empyema in rats in attenuating pleural and systemic inflammatory responses.

Influence of pneumococcal vaccine on the incidence of empyema.

PURPOSE OF REVIEW: The aim of this review is to highlight recent reports (2009) concerning empyema and the heptavalent pneumococcal conjugate vaccine. RECENT FINDINGS: Streptococcus pneumoniae remains the most common cause of complicated pneumonia worldwide. Moreover, the incidence of empyema is increasing in many parts of the world and nonvaccine pneumococcal serotypes have been related with this increase. The introduction of heptavalent pneumococcal conjugate vaccine has been associated with the replacement phenomenon in the nasopharynx. Replacement implies that nonvaccine serotypes acquire an ecological advantage for colonizing the nasopharynx and, consequently, increase the carriage status and, in a second step, the disease. Pneumonia with or without empyema has been the main clinical presentation related with the emergence of nonvaccine serotypes. The replacement phenomenon could be multifactorial because other factors apart from heptavalent pneumococcal conjugate vaccine can also contribute to this event. SUMMARY: A new generation of conjugate vaccines that include new serotypes and a wider spectrum of coverage, and the protein-based vaccines that may prevent invasion and preserve colonization, should help us to achieve a positive long-term impact of pneumococcal vaccination.

Elevated levels of thymus and activation-regulated chemokine (TARC) in pleural effusion samples from patients infested with Paragonimus westermani.

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.

Immunoreactivity in lung cancer.

Lung cancer has been associated with suppression of the cellular immune system. Recent experimental evidence suggests that recognition of HLA class I molecules by cytolytic T lymphocytes is important for tumor resistance. Augmentation of this interaction may soon play a role in cancer therapy.

Recruitment of inflammatory cells to the pleural space. Chemotactic cytokines, IL-8, and monocyte chemotactic peptide-1 in human pleural fluids.

Pleural effusions secondary to various diseases are associated with the presence of different inflammatory cells. The role of selective chemotactic cytokines in the recruitment of phagocytes to the pleural space is unclear. IL-8 and monocyte chemotactic peptide-1 (MCP-1) are recently described cytokines that are chemotactic for neutrophils and monocytes, respectively. We prospectively studied 63 patients, using strictly defined criteria for their selection. IL-8 concentrations were elevated in both empyema fluid (9.15 +/- 0.89 ng/ml) and parapneumonic effusions (4.7 +/- 0.697 ng/ml) when compared with pleural effusions secondary to other diseases. IL-8 levels were higher in empyema fluid than in parapneumonic effusions (p = 0.01). There was a significant correlation between IL-8 levels and the total numbers of neutrophils in empyema fluids (r = 0.80). Chemotactic activity for neutrophils was elevated in empyema fluid and the addition of IL-8 neutralizing serum decreased bioactivity by 32.22%. Malignant pleural effusions had the highest levels of MCP-1 (12.0 +/- 3.7 ng/ml) when compared with others. Cytology-positive pleural fluids (n = 10) had a higher level of MCP-1 than cytology-negative effusions (p = < 0.05). Malignant pleural fluid MCP-1 levels correlated (r = 0.70) with the absolute number of monocytes in the pleural fluid. Neutralization of monocyte chemotactic activity of malignant pleural fluid by specific neutralizing serum caused a 70.3% inhibition of bioactivity. Immunohistochemical staining of malignant pleural fluid localized antigenic MCP-1 to malignant cells. We conclude that both IL-8 and MCP-1 play major but not exclusive roles in the recruitment of neutrophils and monocytes from the vascular compartment to the pleural space.

[Dynamics of immunologic indicators in children with severe forms of suppurative-septic diseases after the exchange-substitute plasmapheresis]. / Dinamika immunologicheskikh pokazatelei u detei s tiazhelymi formami gnoino-septicheskikh zabolevanii pod vliianiem obmeno- zamestitel'nogo plazmafereza.

Time course of the immunity system parameters was followed in children suffering from grave endotoxicosis forms treated by discrete plasmapheresis (DPA) as the emergency therapeutic measure. T, T-active, B lymphocytes, O cells, immunoglobulins A, G, M were analyzed, as were the counts of phagocytizing leukocytes and circulating immune complexes. The infectious process was found to lead to a temporary relative secondary immunodeficiency. DPA with perfusion of hyperimmune plasma resulted in rapid correction of all component of the immunity system, paralleled by normalization of the general clinical status of the patients, and prevented chronic transformation of the process.

[Interaction of opportunistic bacteria and factors in the body's anti-infective resistance against a background of antibacterial therapy of children with acute pneumonia]. / Vzaimodeistvie uslovno-patogennykh bakterii i faktorov antiinfektsionnoi rezistentnosti organizma na fone antibakterial'noi terapii detei s ostroi pnevmoniei.

The aim of this investigation was the complex analysis of the dynamics of microflora at the focus of inflammation, the factors of the anti-infective resistance of the body and the clinical course of acute pneumonia in groups of children subjected to different kinds of antibacterial therapy (corresponding and not corresponding to the antibioticogram of the causative agent) or in the absence of antibacterial therapy, i.e. in groups 1, 2 and 3 respectively. As a result, differences in the change of microflora at the focus of inflammation were revealed. They were manifested, in particular, by the possibility of the development of microflora consisting of multiresistant strains as early as on day 7 of hospitalization. Different dynamics of the anti-infective resistance factors corresponded to changes in microflora at the focus of inflammation. No negative effect of antibiotics of the penicillin series and gentamicin on the levels of immunoglobulins, complement and on phagocytic activity was revealed.

Yersinia enterocolitica causing spinal osteomyelitis and empyema in a nonimmunocompromised host.

We have reported a case of spinal osteomyelitis and empyema caused by Yersinia enterocolitica. Because this patient was in otherwise good health without evidence of liver disease, the extent of her illness was remarkable. This unique report of Y enterocolitica infection of the spine not only illustrates the organism's capacity for hematogenous spread in nonimmunocompromised patient, but documents survival in the face of widely disseminated multisystemic disease. Furthermore, the management of this patient was unusual in that operation was required. The astute clinician should consider the possibility of spinal involvement in a patient with Yersinia colitis and neck pain and should also recognize the possibility of serious and widespread infection in an otherwise low-risk patient. In a patient with widespread disease, focal collections of fluid may necessitate surgical management.

[Immunological indicators as the criteria of prognosis and treatment of infectious complications in patients operated on for chronic nonspecific diseases of the lungs and pleura]. / Immunologicheskie pokazateli kak kriterii prognoza i lecheniia infektsionnykh oslozhnenii u bol'nykh, operirovannykh po povodu khronicheskikh nespetsificheskikh zabolevanii legkikh i plevry.

A correlation of clinical specific features of the postoperative period and dynamics of immunological indices in patients operated upon for chronic nonspecific diseases of lungs and pleura was established. Pyo-inflammatory complications were three times more often in decreased amount of T-lymphocytes after operation. HBO-therapy has an immunostimulating effect in the form of increased total and active T rosette-forming lymphocytes, causes more rapid elimination of purulent intoxication, purification of the pleural cavity from the purulent discharge and makes the period of treatment at the hospital shorter.

Branhamella catarrhalis pneumonia and immunoglobulin abnormalities: a new association.

A case of Branhamella catarrhalis pneumonia in a patient with multiple myeloma is reported. With the inclusion of this case, 5 of 17 (29.4%) reported cases of Branhamella pneumonia or empyema have occurred in patients with underlying diseases associated with immunoglobulin abnormalities. This strong clinical association suggests that qualitatively and quantitatively normal immunoglobulins are important host defense mechanisms in preventing infection with this pathogen. The sputum Gram stain demonstrating kidney-shaped gram-negative diplococci may be an early clue to the diagnosis, as well as an initial guide to empiric therapy, and may help the laboratory isolate and identify this pathogen, which, because of its morphologic resemblance to Neisseria, is frequently reported as "normal flora".

[Characteristics of nonspecific resistance in children with lung diseases due to opportunistic microflora]. / Kharakteristika pokazatelei nespetsificheskoi rezistentnosti u detei s zabolevaniiami legkikh, vyzvannymi uslovno-patogennoi mikrofloroi.

Acute destructive pneumonia in children was found to be complicated by acute pleural empyema (APE) on days 3-21 of the disease. The time of the development of this complication depended on the state of the nonspecific resistance of the body: the greater was the degree of deficiency as manifested by cell-mediated and humoral immunity indices, the earlier developed APE. Staphylococci and Pseudomonas aeruginosa infected the pleural cavity of children under the conditions of essentially decreased phagocytic activity, phagocytic index, C'H50 and one of the classes of immunoglobulin. The reaction of the body to staphylococci and P. aeruginosa took its course after the type of primary or secondary immune response, depending on the time of infection.