Accidental Detection of Tuberculous Empyema at Health Check-Up.

BACKGROUND: Patients with tuberculous empyema (TE) can have a serious impact on lung function as their disease progresses, and, if left untreated, can cause damage to other parts of the body such as the thorax and spine, causing pain and inconvenience to the patient. Early diagnosis and the search for appropriate treatment are key to improving the survival rate of the disease. METHODS: We report a case of a young patient with an unexpected finding of right pleural effusion on physical examination, who was eventually diagnosed with TE using next-generation sequencing of pleural tissue. We analyzed the literature to improve clinicians' understanding of TE and how to properly diagnose and treat the disease. RESULTS: Laboratory results of the pleural effusion suggested a possible Mycobacterium tuberculosis infection, but pathogen-related tests were negative, and the diagnosis was eventually successfully confirmed by thoracoscopic pleural biopsy. CONCLUSIONS: The diagnosis of TE should be considered in young patients with pleural thickening of the empyema. Adenosine deaminase may provide diagnostic direction in patients with unexplained thorax abscess. Pleural biopsy, although an invasive procedure, is an essential diagnostic tool in some cases.

Clinicopathological outcome in 27 children with tuberculous empyema in Shandong Provincial Chest Hospital, Jinan, China.

The literature on childhood tuberculous empyema (TE) is limited. The aim of this study was to examine the clinicopathological characteristics and outcome of paediatric TE and methods of prompt diagnosis and treatment. Between January 2014 and April 2019, 27 consecutive patients with TE aged ≤15 years [mean (SD) 12.2 (3.3), range 6-15] were retrospectively reviewed. The following were reviewed: baseline demographics, symptoms, laboratory and pathological examination, radiographical findings, microbiological data, anti-tuberculous and surgical treatment and clinical outcome. Acid-fast bacillus (AFB) smear, culture, TB real-time (RT) polymerase chain reaction (PCR) and T-SPOT.TB assay were reviewed. Six (60%) of 10 patients were TB-RT-PCR-positive in pus or purulent fluid. Twenty-three of 24 (95.8%) were T-SPOT.TB-positive. Decortication by surgical thoracotomy or thoracoscopy was performed in 22 (81.5%) patients. None of the 27 patients had specific complications such as pyopneumothorax or bronchopleural fistula and all were successfully treated. In childhood TE, aggressive surgical management is associated with a favourable outcome.Abbreviations: AFB, acid-fast bacilli; E, ethambutol; EPTB, extra-pulmonary TB; H, isoniazid; HIC, high-income countries; LMIC, low- and middle-income countries; MTB, Mycobacterium tuberculosis; PCR, polymerase chain reaction; PTB, pulmonary TB; R, rifampicin; RT, real time; TB, tuberculosis; TE, tuberculous empyema; Z, pyrazinamide.

Risk factors associated with postoperative respiratory failure in tuberculous empyema patients.

ABSTRACT: Our objective was to identify independent risk factors for predicting which patients in the Chinese population would likely develop respiratory failure.A descriptive analysis was conducted of demographic and clinical data of patients with tuberculous empyema (TE) admitted to the Beijing Chest Hospital, Capital Medical University between January 2001 and January 2020. Risk factors associated with postsurgical respiratory failure in TE patients were identified based on results of analyses based on univariable and multivariable logistic regression models.A total of 139 TE patients who underwent surgical treatment in the Beijing Chest Hospital, Capital Medical University from January 2001 to January 2020 were enrolled in this study. Cases included 109 male and 30 female patients, with an overall mean age (range 17-73) of 39.3 years. Of 139 TE patients, 26 (18.7%) experienced respiratory failure after surgery. Among significant risk factors for postsurgical respiratory failure, intraoperative blood loss volume greater than 1000 mL had the highest odds ratio value of 6.452. In addition, a pathologic preoperative pulmonary function test result showing a high partial pressure of carbon dioxide level was an independent risk factor for respiratory failure. Moreover, the presence of tuberculosis lesions in the contralateral lung was another significant risk factor for respiratory failure, as determined using multivariate analysis.Respiratory failure is a predominant complication experienced by TE patients undergoing surgery. High intraoperative blood loss, high preoperative high partial pressure of carbon dioxide level, and tuberculosis lesion(s) in the contralateral lung of TE patients were associated with increased risk of postoperative respiratory failure.

Chronic tuberculous empyema in an 8-year-old boy.

Mycobacterium tuberculosis (MTB) as a causative organism of empyema thoracis is rare, especially in children. An 8-year-old boy with tuberculous empyema and no history of contact with tuberculosis presented with minimal symptoms other than mild deformity of the chest wall. He had been vaccinated with bacillus Calmette-Guérin. A chest CT scan demonstrated intrathoracic lymphadenopathy, thickened and calcified pleural rind and rib thickening adjacent to the empyema. The diagnosis was confirmed by post-operative histopathological examination, positive acid-fast stains and DNA PCR. In countries with a high burden of tuberculosis, MTB should be considered in the differential diagnosis of empyema despite minimal symptoms.

Loculated empyema due to tuberculosis in a child.

A 9-year-old girl from black ethnic origin presented with a history of fever, cough, loss of weight and right-sided chest wall pain for 2 weeks. Chest X-ray demonstrated an effusion, which was shown to be loculated on chest CT scan. She was not responding to medical treatment and at thoracotomy loculated pus was drained. Mycobacterium tuberculosis (TB) was cultured from the pus. TB is a rare cause of loculated empyema with an overlapping clinical and radiological picture with pyogenic infections.

Mixing It Up: Coadministration of tPA/DNase in Complicated Parapneumonic Pleural Effusions and Empyema.

BACKGROUND: A recent randomized controlled trial showed 12 serial doses of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is safe and effective in managing complicated parapneumonic pleural effusions and empyema (CPEE). However, this regimen is laborious, requiring trained personnel to open/close the chest tube 8 times daily for 3 days. We present our observational data using a simplified regimen of coadministered tPA/DNase. MATERIALS AND METHODS: This is a retrospective observational study of patients who received coadministered tPA/DNase for CPEE from January 2012 to April 2015 at the University of Texas Medical Branch. Patient demographics, pleural fluid, radiologic and treatment characteristics, and outcomes were collected. Data are presented as proportions and percentages. Our primary outcome was successful treatment without need of surgery and discharge home alive. Secondary outcomes were dose and length of treatment and hospital stay, treatment complications, and 90-day mortality. RESULTS: The study included 39 patients. All pleural effusions were loculated, 59% macroscopically purulent, 50% had a positive organism in Gram stain, and 40% were culture positive. A median of 6 (interquartile range, 3.5 to 6) doses were coadministered mainly via small bore chest tube (≤14 Fr in 79%) with a median of 14.5 (interquartile range, 9.5 to 21.5) hospital days. Overall, 85% were successfully treated without need for surgery. Treatment failures occurred in 15%: 3/39 (7%) received surgery; 3/39 (7%) died. Only 1 (2.5%) complication of hemorrhagic pleural effusion resolved after discontinuation of intrapleural treatment. CONCLUSIONS: Our study shows intrapleural coadministration of tPA/DNase was effective and safe in management of CPEE.

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.

Unusual cause of chest pain: empyema necessitans and tubercular osteomyelitis of the rib in an immunocompetent man.

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.

Therapeutic drug monitoring and the conservative management of chronic tuberculous empyema: case report and review of the literature.

BACKGROUND: 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. CASE PRESENTATION: 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. CONCLUSION: 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 TDM increase the chances that conservative management of CTE will be successful.

Outcomes of Video-Assisted Thoracic Surgical Decortication in 274 Patients with Tuberculous Empyema.

OBJECTIVE: The present work aimed to retrospectively assess the outcomes associated with decortication by video-assisted thoracic surgery (VATS) in patients with tuberculous empyema. METHODS: Patients (n = 274) who underwent decortication by VATS for surgical management of pleural empyema between January 2000 to 2010 were included. Pre-, intra-, and postoperative characteristics were observed for all patients, which were followed up for 12 months to evaluate surgical outcomes such as postoperative complications and disease recurrence. RESULTS: No patients required conversion to thoracotomy, and no death or postoperative bleeding was reported. The mean operation time was 104.5 ± 20.4 min, with 271.5 ± 41.3 ml intraoperative blood loss and median length of hospital stay of 7.2 ± 3 .4 days. Of the 274 patients, 262 were followed up for 12 months; 26 (9.9%) patients showed complications, including incomplete lung re-expansion (11 patients) and persistent air leak (6 patients). While early disease recurrence was observed in 3 (1.1%) patients after surgery, late recurrence was reported for 6 (2.3%) individuals. Interestingly, the complication rate was much higher in patients with chronic empyema (15/34, 44.1%) than in subjects with acute empyema (11/228, 4.8%). CONCLUSIONS: Decortication by VATS decreases postsurgical complications, and results in decreased disease recurrence. This study demonstrated improved outcomes by decortication by VATS, even in patients with stage III tuberculous empyema.

Evaluation of extra pulmonary tuberculosis in Bangladeshi patients.

This is a retrospective study of 200 cases of Extra Pulmonary Tuberculosis (EPTB) and this study was conducted from January 2010 to July 2011 at Sheheed Ziaur Rahman Medical College Hospital and TB clinic, Bogra, Bangladesh. Data were collected from the Hospital records on demographics, clinical, laboratory and treatment out come status. The incidence of EPTB was high in 16-45 years age group (55%), mean age was 35.67±14.6 years and predominated in Female patients (60%). Extra pulmonary Tuberculosis (EPTB) still constitutes an important clinical problem in Bangladesh. The objective of this study was to evaluate the demography and features of patients with EPTB in our high burden tuberculosis country. Lymph nodes are the most common site of involvement (50%) followed by tubercular pleural effusion (15%) and virtually every site of the body can be affected by tuberculosis. Since the clinical presentation of EPTB is atypical, tissue samples for the confirmation of diagnosis can sometimes be difficult procedure and conventional diagnostic method have a poor yield, so the diagnosis is often delayed. EPTB constitutes about 15-20% of all cases of TB patients and it is more common in low socio-economic group (60%) Biopsy and/ or surgery, FNAC is required to procure tissue samples and pus and/or aspirated fluids are required for diagnosis and for managing complications. The EPTB usually responds to standard anti tubercular drug regimen.

[Tuberculous spondylitis of vertebra with fracture, paraparesis and pleural empyema complications--case report].

INTRODUCTION: 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. CASE REPORT: 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. CONCLUSION: Tuberculous spondylitis occurs relatively frequently in clinical practice. Early diagnosis and adequate therapy of this disease can prevent the occurrence of its serious complications.

Empyema necessitans caused by Mycobacterium tuberculosis in an immunocompetent patient.

A 22-year-old man, a recent immigrant from Mexico, was admitted to a Wisconsin hospital because of a swelling of the chest wall and right axilla. Originally, it was thought to be a skin infection with Staphylococcus aureus. When the treatment was unsuccessful, the patient returned to the hospital and the abscesses were found to have been caused by Mycobacterium tuberculosis. Furthermore, there were pleural collections and it was thought that he had a manifestation called empyema necessitans, an extension of purulent pleural liquid through adjacent tissues to form an abscess on the thoracic wall.