Complicated pneumococcal pneumonia with pleural effusion or empyema in the 13-valent pneumococcal conjugate vaccine era.

AIM: The aim was to analyze the epidemiological, microbiological and clinical characteristics of patients with complicated pneumococcal pneumonia with pleural effusion (PE) or empyema. METHOD: Prospective study in three Catalan hospitals in persons aged <18 years diagnosed with complicated pneumonia with PE or empyema with isolation of Streptococcus pneumoniae in blood or pleural fluid by culture or real-time PCR between January 2012 and June 2016. Patients were divided into <2 years and 2-17 years age groups. Epidemiological, microbiological, and clinical data of patients were compared annually in both groups. PCV13 vaccination coverage increased from 48.2% in 2012 to 74.5% in 2015. RESULTS: We included 143 patients. The incidence of pneumococcal pneumonia was 6.83 cases × 10-5 persons/year in cases with PE or empyema and 2.09 cases × 10-5 person-years in cases without (rate ratio [RR]: 3.27; 2.25-4.86; P < 0.001). Empyema was more frequent than PE (79.7% vs 20.3%, P < 0.005). Of 143 cases studied, 93 (65.0%, P < 0.001) were diagnosed by real-time-PCR, 43 (30.1%) by culture and RT-PCR and 7 (4.9%) by culture only. PCV13 serotypes were more frequent in complicated than in uncomplicated pneumonia (116/142, 81.7% vs 27/45, 60.0%; P = 0.003), especially serotype 1 (41/142, 28.9% vs 6/45, 13.3%, P : 0.036). From 2012 to 2015 there was a significant reduction in serotype 1 (16/43, 37.2% vs 3/27, 11.1%, P = 0.026), and a trend to an increase in non-PCV13 serotypes (6/43, 14% vs 9/27, 33.3%, P = 0.054). CONCLUSIONS: A directly proportional relationship was observed between the reduction in pneumonia complicated with PE or empyema and a significant reduction in PCV13 serotypes, especially serotype 1, coinciding with increased PCV13 coverage.

Alteplase and DNase for the treatment of pleural empyema in rats.

BACKGROUND AND OBJECTIVES: Adjunctive intrapleural fibrinolytic is an option to treat empyema at fibrinopurulent stage, but there is controversy about which should be use. Our objective is to evaluate the action of alteplase and/or desoxyribonuclease at physical and chemical properties in vitro pus derived from an experimental induced empyema in rats. METHODS: Streptococcus pneumoniae was introduced into the pleural cavity by thoracentesis through pleural pressure monitor. Animals were euthanized after 24 h, with macroscopic thoracic evaluation and measurement of amount of intrapleural liquid that was posteriorly stored at -80 °C. Selected samples were randomly distributed into four groups, then thawed at room temperature before exposure to one of the following: G1 = alteplase (n = 12), G2 = DNase (n = 12), G3 = alteplase + DNase (n = 12), or G4 = saline (n = 6). The mean molecular size in the fluid portion of the empyema was evaluated using dynamic light scattering; viscosity of the empyema fluid was measured using the drip method. RESULTS: Macroscopic showed purulent liquid, with fibrin and septation, with mean volume of 4.16 ml (0.5-8 ml). All samples were culture-positive for Streptococcus pneumoniae. Comparing with control, all experimental groups presented reduction of larger than 135 nm molecular size, but there was only significant difference with alteplase (p = 0,02). Viscosity reduced at all experimental groups, but increased at control. DNase group presented negative median (-5 mPa/s) of viscosity, and differed significantly from that observed in the control group (p = 0.04). CONCLUSIONS: Alteplase, DNase and alteplase + DNase changed significantly physical and chemical properties of experimental empyema at fibrinopurulent phase: alteplase reduced molecular size larger than 135 nm and DNase reduced viscosity.

Clinical, functional, and radiological outcome in children with pleural empyema.

INTRODUCTION: Few studies have prospectively evaluated recovery process and long-term consequences of pleural space infections. OBJECTIVE: To evaluate clinical, pulmonary, and diaphragmatic function and radiological outcome in patients hospitalized with pleural empyema. MATERIAL AND METHODS: Previously healthy patients from 6 to 16 years were enrolled. Demographic, clinical, and treatment data were registered. At hospital discharge, and every 30 days or until normalization, patients underwent a clinical evaluation, diaphragmatic ultrasound, and lung function testing. Chest radiographs were performed at subsequent visits only if abnormalities persisted. RESULTS: Thirty patients were included. Nineteen (63%) were male, with an age of (mean ± SD) 9.7 ± 3.2 years, and body mass index (mean ± SD) 18.6 ± 3. Twelve patients (40%) were treated with chest tube drainage only, 12 (40%) exclusively with surgery, and 6 (20%) completed treatment with surgery due to an ineffective chest tube drainage. At hospital discharge, 26 (87%) of patients had abnormal breath sounds at the site of infection, 28 (93%) had a spirometric restrictive pattern, 19 (63%) diaphragmatic motion impairment, and 29 (97%) presented radiological involvement of pleural space, mainly pleural thickening. All patients had recovered diaphragmatic motion and were asymptomatic at 90- and 120-day follow-up control, respectively. Then, with a great individual variability, radiological findings, and lung function returned to normal at 60 days (range 30-180) and 90 days (range 30-180) after hospital discharge, respectively. CONCLUSION: Patients with pleural empyema had a complete and progressive recovery, with initial clinical and diaphragmatic motion normalization followed by radiological and lung function recovery.

Prospective evaluation of lung function in children with parapneumonic empyema.

RATIONALE: Prospective studies that evaluated the outcome of childhood empyema are limited. OBJECTIVE: To compare the outcome of pulmonary function in children with empyema. PATIENTS AND METHODS: Children discharged with a diagnosis of empyema underwent a longitudinal study including measurement of pulmonary function and radiographic imaging. RESULTS: The population consisted of 39 patients, 24 males, and 15 females; with a median age of 4.6 years. Etiology was defined in 20/39 patients, and predominant microorganism was Streptococcus pneumoniae (19/20 isolates). Chest tube drainage with or without fibrinolytic agents was the primary intervention in 25 children. Video-assisted thoracoscopic surgery was performed in 14 and 5 children as primary and secondary intervention, respectively. Thirty-five children completed the lung function follow-up. At first follow-up visit, 5 out of 17 children able to perform spirometry (initially collaborating children) had normal tests, and 12 had mild-to-moderate defects of lung function that returned to normal over 2-57 months. Eighteen children unable to perform spirometry at first follow-up visit (initially non-collaborating children) had normal tests when they were evaluated 5-78 months postdischarge. At the end of the follow-up, all patients had normal lung function. Time to normalize did not differ between groups receiving different treatments (initially collaborating children, P = 0.064; initially non-collaborating children P = 0.223). Three previously healthy children had recurrent cough, and all children had normal chest radiographs aside from pleural thickening. CONCLUSIONS: The respiratory outcome in children with empyema is generally good and is not influenced by the type of intervention.

Factors Affecting Postoperative Lung Expansion in Patients with Pyogenic Empyema.

BACKGROUND: In patients with parapneumonic empyema, decortication is usually preferred to ensure functional lung re-expansion. However, there could be patients exhibiting incomplete postoperative lung expansion and inadequate drainage despite decortication. Therefore, we evaluated factors affecting postoperative lung expansion in patients undergoing decortication. METHODS: A total of 221 patients with pyogenic empyema who underwent video-assisted thoracoscopic surgery (VATS) between January and October 2016 in our hospital were reviewed in terms of surgical success. The following factors were evaluated: age; the time between identification of a localized effusion and surgical referral; chest tube drainage durations; any underlying morbidity preoperative blood culture data; and the thickness of the visceral pleura. RESULTS: Several factors that significantly prolonged the postoperative time to lung expansion were evident in patients with diabetes mellitus (DM) and bacteremia; postoperative chest tube drainage was significantly longer in those with DM (p = 0.009) and bacteremia (p = 0.01); and postoperative hospitalization time was significantly longer in patients with bacteremia (p = 0.01). The thickness of the visceral pleura was strongly correlated with postoperative chest tube drainage duration and postoperative hospitalization time (Pearson correlation coefficient, r = 0.245, p = 0.00). CONCLUSIONS: In patients with DM, bacteremia, or thickened pleura, the time to lung expansion after operation was longer. Therefore, stricter pre- and post-operative control of blood-sugar levels and adequate antibiotics are required to facilitate postoperative lung re-expansion. In patients with thickened pleurae, prolonged chest tube placement is unavoidable.

Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial.

BACKGROUND: A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown. METHODS/DESIGN: This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children's hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality. DISCUSSION: This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.

[WAYS OF THE SURGICAL MISTAKES OVERCOME IN THE PAIN ABDOMINAL AND THORACIC SYNDROMS].

Experience of differential diagnosis of pleural diseases, accompanied by pleuroabdominal pain syndrome, simulating «an acute abdomen¼, was summarized. In a pleural exudate syndrome such a course was noted in 17 (3%) patients, of them 7 (1.23%) were operated on; and in a syndrome of spontaneous pneumothorax ­ in 3 (1.7%), 1 (0.4%) was operated. Diagnostic algorithm was proposed.

Frequency of Hepatic Hydrothorax and its Association with Child Pugh Class in Liver Cirrhosis Patients.

OBJECTIVE: To determine the frequency of hepatic hydrothorax and its association with Child Pugh Class in patients with liver cirrhosis. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, (Ward- 7), from June 2012 to May 2013. METHODOLOGY: All patients with established diagnosis of decompensated chronic liver disease were included. Detailed history, thorough physical examination, routine laboratory investigations, chest X-ray and abdominal ultrasound were carried out in all patients to find out the presence of pleural effusion and ascites, respectively. Fifty milliliters of pleural fluid was aspirated in all patients with pleural effusion using the transthoracic approach, taking ultrasound guidance, wherever required. Fluid was sent for microscopic, biochemical, and microbial analysis. SBEM defined if pleural fluid with polymorphonuclear (PMN) cell count > 500 cells/mm3 or positive culture with PMN cell count > 250 cells/mm3 with exclusion of a parapneumonic effusion. RESULTS: Two hundred and six patients met the inclusion criteria, with mean age of 41.25 ±13.59 years. Among them, 149 (72.3%) were males and 57 (27.7%) females. Twenty-three (11.2%) had hydrothorax; right sided involvement was in 18 (78.3%) subjects, 3 (13%) had left sided while bilateral pleural effusion was found in 2 (8.7%) cases. SBEM was found in 07 (30.43%) cases. Mean serum albumin 3.125 ±0.71 gram/dl. There was association between serum albumin levels and hydrothorax. Asignificant association of hydrothorax with Child Pugh scoring system (p=0.018), but not with serum albumin (p=0.15). CONCLUSION: The frequency of hepatic hydrothorax has a significant association with hepatic function as assessed by Child Pugh scoring system, but not with serum albumin.

OPEN WINDOW THORACOSTOMY, STILL AN OPTION IN THE MANAGEMENT OF CHRONIC EMPYEMA: EXPERIENCE FROM AYDER REFERRAL HOSPITAL.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Effect of decortication and pleurectomy in chronic empyema patients.

BACKGROUND: Fibrosis that occurs in the chronic phase of pleural empyema restricts lung movement and impairs pulmonary function. It also leads to asymmetry of the chest wall. We evaluated the efficacy of decortication and pleurectomy in improving these adverse consequences. METHODS: Data of 50 patients (42 males, mean age 49.1 ± 19.46 years) with chronic empyema who underwent lung decortication via a posterolateral thoracotomy between 2004 and 2014 were reviewed in this study. All patients had pulmonary function tests before and after surgery. Computed tomography was used to determine transverse and anteroposterior diameters of the chest before and after surgery. RESULTS: The patients were followed up for 11.5 ± 4.5 months. Mean forced expiratory volume in 1 s was 62.5% ± 13.61% before surgery vs. 77.3% ± 13.31% after surgery (p < 0.001). Mean forced vital capacity was 60.6% ± 14.38% before surgery vs. 78.5% ± 12.64% after surgery (p < 0.001). The improvement in patients with reduced chest wall diameters was significant (p < 0.001). Improvements in pulmonary function tests and chest wall diameters were not significantly different between patients with tuberculosis (n = 10) and those with other diseases (n = 40; p < 0.05). CONCLUSION: Decortication and pleurectomy via a posterolateral thoracotomy significantly improves pulmonary function and chest wall diameters in patients with chronic empyema due to tuberculosis or other diseases.

CT differentiation of tuberculous and non-tuberculous pleural infection, with emphasis on pulmonary changes.

OBJECTIVE: To determine whether pulmonary changes on computed tomography (CT) are helpful in differentiating between pleural tuberculosis (TB) and non-tuberculous pleural infection MATERIALS AND METHODS: We retrospectively reviewed CT scans of patients with pleural tuberculous and non-tuberculous empyema, focusing on pulmonary changes such as consolidation, ground glass opacity, interlobular septal thickening, cavitation, abscess and presence and distribution of micronodules. We also assessed the presence of loss of overlying pleural integrity, peripheral bronchopleural fistula and lymphadenopathy. RESULTS: We evaluated 65 patients with pleural TB and 43 with empyema. CT findings of pleural TB differed significantly from those of empyema with interlobular septal thickening (P = 0.022) and micronodules with subpleural, peribronchovascular and septal distribution (P < 0.001). Subpleural abscess was more frequently seen in empyema, accompanying loss of overlying pleural integrity and peripheral bronchopleural fistula (P < 0.001), but there was no statistical difference between the two groups in prevalence of consolidation, ground glass opacity, cavitation, centrilobular nodules or lymphadenopathy. CONCLUSION: Interlobular septal thickening and micronodules with perilymphatic distribution are characteristic CT findings of pleural TB but not empyema. Presence of subpleural abscess and loss of pleural integrity or peripheral bronchopleural fistula are highly suggestive of empyema.

Impact of fibrinolytics on the outcome of empyema in South African children.

BACKGROUND: Childhood pneumonia is common in all countries, and empyema is one of the commonest complications. The role of routine intrapleural fibrinolytics in the management of childhood empyema is not well established in low- and middle-income countries. METHODS: We did a prospective observational study of children sequentially hospitalised with empyema between December 2006 and December 2011 in South Africa (SA). Intrapleural tissue plasminogen activator (TPA), administered according to a standard protocol, was introduced in September 2009. Outcomes in children treated with TPA after 2009 were compared with the historical cohort not treated with TPA who met the treatment criteria. RESULTS: One hundred and forty-two children with empyema, median age 17 months (interquartile range 8-43), were admitted during the study period. Excluding children who did not have a chest tube inserted and those in whom fibrinolysis was contraindicated, there were 99 patients, 52 of whom received fibrinolytics. Clinical characteristics and empyema aetiology were similar in those who received fibrinolysis and those who did not. Eighteen children (38.3%) not treated with TPA required surgery v. 5 (9.6%) treated with TPA (relative risk 0.25; 95% confidence interval 0.1-0.6). The median duration of hospitalisation was similar in both groups. Complications occurred rarely and with a similar incidence in both groups. In-hospital mortality was low, with two deaths in each group. CONCLUSION: Intrapleural TPA resulted in a four-fold reduction in surgery. Fibrinolytics should be used for management of empyema in children in SA.

The clinical features of respiratory infections caused by the Streptococcus anginosus group.

BACKGROUND: The Streptococcus anginosus group (SAG) play important roles in respiratory infections. It is ordinarily difficult to distinguish them from contaminations as the causative pathogens of respiratory infections because they are often cultured in respiratory specimens. Therefore, it is important to understand the clinical characteristics and laboratory findings of respiratory infections caused by the SAG members. The aim of this study is to clarify the role of the SAG bacteria in respiratory infections. METHODS: A total of 30 patients who were diagnosed with respiratory infections which were caused by the SAG bacteria between January 2005 and February 2015 were retrospectively evaluated. RESULTS: Respiratory infections caused by the SAG were mostly seen in male patients with comorbid diseases and were typically complicated with pleural effusion. Pleural effusion was observed in 22 (73.3%) patients. Empyema was observed in half of the 22 patients with pleural effusion. S. intermedius, S. constellatus and S. anginosus were detected in 16 (53.3 %), 11 (36.7 %) and 3 (10.0 %) patients, respectively. Six patients had mixed-infections. The duration from the onset of symptoms to the hospital visit was significantly longer in "lung abscess" patients than in "pneumonia" patients among the 24 patients with single infections, but not among the six patients with mixed-infection. The peripheral white blood cell counts of the "pneumonia" patients were higher than those of the "lung abscess" patients and S. intermedius was identified significantly more frequently in patients with pulmonary and pleural infections (pneumonia and lung abscess) than in patients with bacterial pleurisy only. In addition, the patients in whom S. intermedius was cultured were significantly older than those in whom S. constellatus was cultured. CONCLUSIONS: Respiratory infections caused by the SAG bacteria tended to be observed more frequently in male patients with comorbid diseases and to more frequently involve purulent formation. In addition, S. intermedius was mainly identified in elderly patients with having pulmonary infection complicated with pleural effusion, and the aspiration of oral secretions may be a risk factor in the formation of empyema thoracis associated with pneumonia due to S. intermedius.

Paradoxical respiratory sinus arrhythmia due to a large thoracic empyema in an ambulatory patient.

We report a case of paradoxical respiratory sinus arrhythmia (PRSA) caused by a retro-cardiac empyema in an ambulatory patient. The case describes the dynamics and deleterious impact of PRSA on cardio-respiratory cycle, its electrocardiographic, radiologic and echocardiographic findings. Furthermore, it discusses a probable mechanism of paradoxical respiratory sinus arrhythmia in the setting of a retrocardiac mass and suggests a need for physicians to check for the changes in ventilation perfusion mismatch and rise in physiological dead space in such patients. In conclusion, to the best of our knowledge, this is the first documented report of paradoxical respiratory sinus arrhythmia in an ambulatory, non-anesthetized spontaneously breathing patient.

Unilateral empyema impacts the assessment of regional lung ventilation by electrical impedance tomography.

Several studies have shown the ability of electrical impedance tomography (EIT) to assess regional ventilation distribution in human lungs. Fluid accumulation in the pleural space as in empyema, typically occurring on one chest side, may influence the distribution of ventilation and the corresponding EIT findings. The aim of our study was to examine this effect on the assessment of regional ventilation by EIT. Six patients suffering from unilateral empyema and intubated with a double-lumen endotracheal tube were studied. EIT data were acquired during volume-controlled ventilation with bilateral (tidal volume (V(T)): 800 ml) and unilateral ventilation (V(T): 400 ml) of the right and left lungs. Mean tidal amplitudes of the EIT signal were calculated in all image pixels. The sums of these values, expressed as relative impedance change (rel. ΔZ), were then determined in whole images and functionally defined regions-of-interest (ROI). The sums of rel. ΔZ calculated during the two cases of one-lung ventilation either on the affected or unaffected side were significantly smaller than during bilateral ventilation. However, in contrast to previous findings in patients with no pleural pathology, very low values of rel. ΔZ were found when the lung on the affected side was ventilated. ROI-based analysis rendered higher values than the whole-image analysis in this case, nonetheless, the values were significantly smaller than when the unaffected side was ventilated in spite of identical VT. In conclusion, our results indicate that the presence of empyema may affect the quantitative evaluation of regional lung ventilation by EIT.

[The treatment of Aspergillus empyema using open thoraco-myoplasty with the preservation of lung function -- case report]. / Aspergillus empyema kezelése nyitott thoracostomiával és izomplasztikával, a tüdo funkciójának megorzésével -- esetismertetés.

CASE REPORT: Invasive aspergillosis is a life threatening complication in immune-compromised patients causing lung tissue destruction. Aspergillus empyema requires aggressive multimodality treatment. MATERIAL AND METHOD: We present a case of Aspergillus empyema treated by thoracic and plastic surgery preserving the lung function in an 18 year-old male patient suffering dermatomyositis and treated with steroids for a long time. After open window thoracostomy (OWT) we used pedicled musculus latissimus dorsi (MLD) flap and mobilised the anterior serratus muscle to close the pleural cavity. CONCLUSION: The intrathoracic use of muscle flaps after OWT in case of chronic Aspergillus empyema can preserve the underlying lung tissue. Cooperation of thoracic and plastic surgeons - as in the cases presented - provides an excellent opportunity to treat successfully of otherwise hopeless patients.

[The surgical treatment of the pleural empyem].

The treatment results of the 286 patients with pleural empyem after thoracic injuries (n=107) and closed trauma of the pleural cavity (n=179) were retrospectively analyzed. The frequency of pleural empyem was 1.39% by injuries and 1.34% by the closed thoracic trauma. 15 (14%) patients of the first group developed the bronchopleural fistula, whereas the complication was observed in 32 (17.9%) patients of the second group. The adequate pleural drainage with intrapleural enzyme therapy in acute inflammation period allowed recovery in 78% and 71.9% of patients, respectively. Early videothoracoscopic sanation of the pleural cavity shortened the recovery time in more then 1.5 times. The chronization of the empyem was more often observed after the closed thoracic trauma - 14.5% rather than 6.5% after the open thoracic injury. The lethality rate by pleural empyem was 14% after the open injuries and 15.6% after the closed trauma.