Pleural fluid nucleic acid testing enhances pneumococcal surveillance in children.

BACKGROUND AND OBJECTIVE: National surveillance of invasive pneumococcal disease (IPD) includes serotyping Streptococcus pneumoniae (SP) isolates from sterile site cultures. PCR is more sensitive and can identify more SP serotypes (STs) in culture-negative samples. The aim of this study was to determine whether enhanced surveillance of childhood empyema, using PCR, provides additional serotype information compared with conventional surveillance. METHODS: Pleural fluid (PF) from children with empyema were cultured and tested by PCR to identify SP, targeting the autolysin gene (lytA). Multiplex PCR-based reverse line blot assay was used to identify SP STs. Corresponding IPD surveillance and serotype data were obtained from the National Notifiable Diseases Surveillance System (NNDSS). RESULTS: Eighty-nine children with empyema, aged ≤16 years, were recruited between April 2008 and March 2009, inclusive. SP was isolated from 5/84 (5.9%) PF cultures and by PCR in 43/79 (54.4%) PF samples. Serotypes were unidentifiable in 15 samples. The frequency of six serotypes (or serotype pairs) identified in 28 samples, including one with two serotypes, were: ST1, n = 4/29 (13.8%); ST3, n = 9/29 (31.0%); ST19A, n = 12/29 (41.4%); ST7F/7A, n = 1/29 (3.4%); ST9V/9A, n = 1/29 (3.4%); ST22F/22A, n = 2/29 (6.9%). Over the same period, 361 IPD patients, aged 16 years or less, were notified to NNDSS. Among 331 serotypeable NNDSS isolates (71.5% from blood), the frequencies of ST1 and 3 were significantly lower than in PF samples: ST1, n = 8/331 (2.4%; P < 0.05); ST3, n = 13/331 (3.9%; P < 0.0001). CONCLUSIONS: The use of PCR to identify and serotype SP in culture-negative specimens provides additive information.

Cytological-energy analysis of pleural effusions with predominance of neutrophils.

BACKGROUND: The predominance of neutrophils in pleural effusions of patients with different serious impairments of the pleural cavity organs is often found. The aim of this study was to identify the type of injury using the cytological-energy analysis of pleural effusions. METHODS: We analysed 635 samples of pleural effusions with predominance of neutrophils. We compared the values of the coefficient of energy balance (KEB), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) catalytic activities in the following subgroups of patients: with transudative effusions, purulent pneumonia, chest empyema and after chest surgery with and without purulent complications. Statistical analysis was performed using the ANOVA Kruskal-Wallis test (p < 0.05 was considered as significant). RESULTS: We found the lowest KEB values in pleural effusions of patients with chest empyema and their gradual increases in patients with purulent pneumonia and with transudative effusions. We observed the highest LDH and AST enzymes activity in patients with chest empyema and their gradual decrease in patients with purulent pneumonia and with transudative effusions. LDH and AST enzymes activity was significantly higher in pleural effusions of patients after chest surgery with purulent complications compared with non-purulent cases. CONCLUSION: The most intensive inflammation and the most extensive tissue destruction in the pleural cavity were found in patients with chest empyema. Significantly better parameters were observed in patients with purulent pneumonia. The absence of serious inflammation and the absence of tissue destruction were typical for patients with transudative effusions. Finally, our results confirmed an anticipated higher tissue destruction in patients after chest surgery. Significantly worse injury was found in surgical patients with purulent complications compared with non-purulent ones. The reviews of this paper are available via the supplemental material section.

Epstein-Barr virus-positive pyothorax-associated lymphoma expresses CCL17 and CCL22 chemokines that attract CCR4-expressing regulatory T cells.

Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphomas associated with chronic inflammation (DLBCL-CI) develop in patients with chronic inflammation but without any predisposing immunodeficiency. Given the expression of the EBV latent genes, DLBCL-CI should have mechanisms for evasion of host antitumor immunity. EBV-positive pyothorax-associated lymphoma (PAL) is a prototype of DLBCL-CI and may provide a valuable model for the study of immune evasion by DLBCL-CI. This study demonstrates that PAL cell lines express and secrete CCL17 and/or CCL22 chemokines, the ligands of C-C motif chemokine receptor 4 (CCR4), in contrast to EBV-negative DLBCL cell lines. Accordingly, culture supernatants of PAL cell lines efficiently attracted CCR4-positive regulatory T (Treg) cells in human peripheral blood mononuclear cells. PAL cells injected into mice also attracted CCR4-expressing Treg cells. Furthermore, this study confirmed that CCR4-expressing Treg cells were abundantly present in primary PAL tissues. Collectively, these findings provide new insight into the mechanisms of immune evasion by PAL, and further studies are warranted on whether such mechanisms eventually lead to the development of DLBCL-CI.

Likely False-Positive Pneumococcal Antigen Test BinaxNOW Due to Parvimonas micra: A Four-Case Series.

We retrospectively report four cases from two hospitals of nonpneumococcal pleural empyema with a likely false-positive result on the pneumococcal antigen test BinaxNOW (PATB) (Alere) performed in pleural fluid samples in patients with aspiration pneumonia risk factors. To determine whether the positive reaction was due to cross-reactivity, we separately tested the isolates from the pleural fluid samples, along with collection and reference strains. All patients had polymicrobial aerobic and anaerobic positive cultures, including Parvimonas micra in every case. In all cases, 16S rDNA polymerase chain reaction sequencing yielded Fusobacterium nucleatum. Samples for culture and specific polymerase chain reaction were negative for Streptococcus pneumoniae. We found that the false-positive PATB finding was likely due to P micra, a previously unknown cross-reactivity. In case of aspiration pneumonia risk factors, a positive PATB result must be interpreted with caution because there can be a false positivity due to anaerobic infection or co-infection.

Accuracy of complement activation product levels to detect infected pleural effusion in rats.

BACKGROUND: Pleural empyema is a well-known complication of pneumonia. If treatment is delayed, empyema may increase morbidity and mortality in affected patients. Therefore, the identification of empyema biomarkers in parapneumonic pleural effusion is desirable. Previous research has suggested complement activation products as candidate empyema markers. OBJECTIVE: To compare the levels of complement activation products C3a, C5a, and C5b9 in pleural effusion induced by Staphylococcus aureus (SA), Streptococcus pneumoniae (SP), or turpentine (control). METHODS: Thirty-nine male Wistar rats (mean weight 414 g; 290-546 g) were allocated as follows: 17 animals in the SA group, 12 in the SP group, and 10 in the control group. Bacteria or turpentine were injected into the pleural space. After 12 hr, intrapleural fluid was collected using ultrasound-guided thoracentesis. Levels of complement activation products were determined using ELISA kits. RESULTS: Two SA and one SP animals died before 12 hr. Mean levels were as follows: C3a: 1066.82 µg/ml (937.29-1196.35 µg/ml) in SA, 1188.28 µg/ml (1095.65-1280.92 µg/ml) in SP, and 679.13 µg/ml (601.29-756.98 µg/ml) in controls (P < 0.001); C5a: 55.727 ng/ml (41.22-70.23 ng/ml) in SA, 520.107 ng/ml (278.92-761.3 ng/ml) in SP, and 5.268 ng/ml (1.68-8.85 ng/ml) in controls (P < 0.001); C5b9: 15.02 ng/ml (13.1-16.94 ng/ml) in SA, 16.63 ng/ml (14.37-18.9 ng/ml) in SP, and 14.05 ng/ml (9.8-18.29 ng/ml) in controls (P = 0.692). ROC analysis revealed an area under the curve of 0.987 (95% CI: 0.953-1) for C3a; 1 (1-1) for C5a; and 0.757 for C5b9 (0.523-0.990). CONCLUSIONS: In the present rat model, complement activation fragments C3a and C5a accurately detected infected pleural effusion. Pediatr Pulmonol. 2017;52:757-762. © 2017 Wiley Periodicals, Inc.

Rheumatoid pleural effusion.

OBJECTIVES: To describe the clinical and laboratory features of rheumatoid pleural effusion (RPE) and the diagnostic and therapeutic approaches to this condition. METHODS: The review is based on a MEDLINE (PubMed) search of the English literature from 1964 to 2005, using the keywords "rheumatoid arthritis" (RA), "pulmonary complication", "pleural effusion", and "empyema". RESULTS: Pleural effusion is common in middle-aged men with RA and positive rheumatoid factor (RF). It has features of an exudate and a high RF titer. Underlying lung pathology is common. Generally RPE is small and resolves spontaneously but symptomatic RPE may require thoracocentesis. Rarely, RPE has features of a sterile empyematous exudate with high lipids and lactate dehydrogenase, and very low glucose and pH levels. This type of effusion eventually leads to fibrothorax and lung restriction. Superimposed infective empyema often complicates RPE. Oral, parenteral, and intrapleural corticosteroids, pleurodesis and decortication, have been used for the treatment of sterile RPE. Infected empyema is treated with drainage and antibiotics. CONCLUSIONS: RPE may evolve into a sterile empyematous exudate with the development of fibrothorax. Symptomatic effusions or suspicion of other causes of exudate (infection, malignancy) require thoracocentesis. The "rheumatoid" nature of the pleural exudate in patients without arthritis mandates a pleural biopsy to exclude tuberculosis or malignancy. The optimal therapy of RPE has yet to be established. The role of cytokines in the course of RPE and the possible usefulness of cytokine blockade in the treatment of this RA complication require further evaluation.

Pleural empyema caused by Salmonella enteritidis in a patient with non-Hodgkin lymphoma.

INTRODUCTION: Extraintestinal manifestations of nontyphoidal salmonellosis are usually seen in patients with cellular immunodeficiency. Pleural empyema caused by nontyphoidal Salmonella is very rare clinical presentation of salmonellosis and there are just a few cases described in a literature. We presented a very rare case of pleural empyema caused by Salmonella enteritidis in a patient with non-Hodgkin limphoma. CASE REPORT: A 60-year-old male with low grade B-cell lymphoma, mucosa associated lymphoid tissue (MALT) type in IV clinical degree, manifested with infiltration of stomach, bronchus, pleura and peritoneum was admitted to the hospital. Initially the patient was presented with non-specific symptoms and signs, suggesting poor general condition. During the hospitalization his pleural fluid became purulent and changes in blood counts were registered with the increase of leukocytes, especially neutrophils. A large number of leukocytes was found by microscopic evaluation of pleural fluid and Salmonella enteritidis was isolated by its culture. There were no pathogenic bacteria in stool culture and hemoculture remained sterile. Toxins A and B of Clostridium difficile were not detected in stool. The patient was treated by ciprofloxacin and cefrtiaxone for 14 days with drainage of the purulent content, what was followed by the resolution and organization of the pleural fluid. After the stabilization of his general condition, chemotherapy with cyclophosphamide, vincristine, prednisone (COP) was introduced, with complete response. CONCLUSION: Although rare, pleural empyema caused by nontyphoidal Salmonella should be considered in patients with severe immunosuppression, because appropriate antimicrobial therapy with surgical measures are very important for the outcome in these patients.

Role of an immunosuppressive cytokine, interleukin-10, in the development of pyothorax-associated lymphoma.

Malignant lymphoma frequently develops in the pleural cavity of the patients with long-standing pyothorax. Thus, the term pyothorax-associated lymphoma (PAL) has been proposed for this type of tumor. Most of PALs are diffuse lymphoma of B cell type and contain Epstein-Barr virus (EBV) DNA. We have established two lymphoma cell lines from the biopsy specimens of PAL cases, OPL-1 and OPL-2. Both cell lines contain EBV DNA, but only OPL-1 expresses Epstein-Barr virus nuclear antigen 2 (EBNA2) that works as a target molecule for cell-mediated immune response. In this study, we examined the expression of immunosuppressive factors in OPLs. Only OPL-1, not OPL-2, expressed interleukin-10 (IL-10) mRNA and secreted IL-10 into culture supernatant. Both OPL-1 and OPL-2 expressed transforming growth factor (TGF) beta 1 mRNA, however, neither expressed latent TGF beta binding protein (LTBP) mRNA at detectable level by Northern blot analysis. Because TGF beta expresses its functions in cooperation with LTBP, the biological functions of TGF beta 1 could be negligible. Neither cell lines expressed EBV BCRF1 mRNA at detectable level, a viral gene product which is partly homologous to human IL-10 and shares biological activities of IL-10. Since OPL-1 shows weaker proliferative activity than OPL-2 and expresses viral antigens, the production of an immunosuppressive cytokine, IL-10, might contribute to the development of overt lymphoma. The present study suggested that immunosuppressive cytokine plays a role in lymphomagenesis of immunocompetent patients.

Complementing the patient: a complement component deficiency in a patient with recurrent infections and glomerulonephritis.

We present a case showing the investigation of a 7-year-old girl with empyema and glomerulonephritis whose "immunological" defect was a single complement component (C2) deficiency which prevented her from activating her classical complement pathway. A defect in complement function should be suspected in any patient with severe or recurring pyogenic infections. Investigations of "? immune deficiency" should always include tests to assess the patency of the patient's complement system.

[Cytokines in complex treatment of posttraumatic empyema of the pleura].

Results of treatment of 114 patients with posttraumatic empyema of the pleura (EP) after closed injury of the thorax (62), stab-incised (43) and missile (9) wounds are presented. In complex treatment of 25 patients one of cytokines - recombinant interleukin-1v (betaleukin) -- was administered intravenously (10 patients) and intrapleurally (15 patients). Control group consisted of 35 similar patients treated with traditional methods including drainage and sanitation of empyema's cavity with protheolytic enzymes, antibacterial and detoxication therapy. Comparative analysis has demonstrated that patients of the study group showed fast normalization of immunogram's parameters, decrease of duration of purulent process (51+/-4 days, on the average, in the control group and 28+/-3 days in the study group) due to fast obliteration of purulent cavity, and decrease of rate of chronic forms of EP (from 20 to 4%) which required surgical treatment.

Adverse reactions of biological therapy for psoriasis.

AIM: To detect in patients with psoriasis the adverse effects during TNF-a inhibitor therapy. MATERIAL AND METHODS: Fifty-seven patients with psoriasis, aged between 12 and 75 years were analyzed. They were treated with different TNF-α antagonists, the maximum treatment duration being 59 months. All patients were followed monthly after the initiation of therapy by clinical checkup, then every 3 months during the first 6 months of treatment by laboratory screening, and then every 6 month. Chest x-ray and tuberculin intradermal skin test were performed annually or as needed. All symptoms reported by patients were recorded, the treating doctor deciding the need for additional investigations or specialist consult. RESULTS: Of the total of 57 patients with psoriasis on biological therapy, 9 patients developed diseases requiring temporary or permanent discontinuation of therapy. The recorded adverse reactions were: infectious (pulmonary tuberculosis, pulmonary empyema), oncologic (rectal cancer, renal cancer), dermatologic (vesiculobullous erythema multiforme major, nodular hypodermtis, secondary erythroderma, and hives) disorders. CONCLUSIONS: Despite its adverse reactions, biological therapy is safe and is a necessary tool in the treatment of moderate and severe forms of psoriasis unresponsive to other treatments.

Modelling staphylococcal pneumonia in a human 3D lung tissue model system delineates toxin-mediated pathology.

Staphylococcus aureus necrotizing pneumonia is recognized as a toxin-mediated disease, yet the tissue-destructive events remain elusive, partly as a result of lack of mechanistic studies in human lung tissue. In this study, a three-dimensional (3D) tissue model composed of human lung epithelial cells and fibroblasts was used to delineate the role of specific staphylococcal exotoxins in tissue pathology associated with severe pneumonia. To this end, the models were exposed to the mixture of exotoxins produced by S. aureus strains isolated from patients with varying severity of lung infection, namely necrotizing pneumonia or lung empyema, or to purified toxins. The necrotizing pneumonia strains secreted high levels of α-toxin and Panton-Valentine leukocidin (PVL), and triggered high cytotoxicity, inflammation, necrosis and loss of E-cadherin from the lung epithelium. In contrast, the lung empyema strain produced moderate levels of PVL, but negligible amounts of α-toxin, and triggered limited tissue damage. α-toxin had a direct damaging effect on the epithelium, as verified using toxin-deficient mutants and pure α-toxin. Moreover, PVL contributed to pathology through the lysis of neutrophils. A combination of α-toxin and PVL resulted in the most severe epithelial injury. In addition, toxin-induced release of pro-inflammatory mediators from lung tissue models resulted in enhanced neutrophil migration. Using a collection of 31 strains from patients with staphylococcal pneumonia revealed that strains producing high levels of α-toxin and PVL were cytotoxic and associated with fatal outcome. Also, the strains that produced the highest toxin levels induced significantly greater epithelial disruption. Of importance, toxin-mediated lung epithelium destruction could be inhibited by polyspecific intravenous immunoglobulin containing antibodies against α-toxin and PVL. This study introduces a novel model system for study of staphylococcal pneumonia in a human setting. The results reveal that the combination and levels of α-toxin and PVL correlate with tissue pathology and clinical outcome associated with pneumonia.

Pyothorax-associated lymphoma. An unusual case with biphenotypic character of T and B cells.

Pyothorax-associated lymphoma is known to develop in patients who received an artificial pneumothorax for pulmonary tuberculosis some 30 to 40 years previously. Such patients exhibit large, immunoblastic lymphoma cells and often have a B-cell phenotype. We present a patient with an artificial pneumothorax and such a late developing lymphoma but with the unique finding of aberrant T- and B-cell phenotypes. Southern blot hybridization using immunoglobulin gene JH and T-cell receptor beta chain receptors revealed germline configurations. Lymphomas developing in immunocompromised patients, such as those with acquired immunodeficiency syndrome, may show such unusual phenotypes. The unusual phenotypes found in this patient provide evidence that his pyothorax-associated lymphoma was related to an immunocompromised state.

Effect of intrapleural streptokinase administration on antistreptokinase antibody level in patients with loculated pleural effusions.

BACKGROUND: Streptokinase is widely used IV for the treatment of myocardial infarction and intrapleurally for the treatment of loculated pleural effusions. IV administration of streptokinase is known to cause the production of antistreptokinase antibodies. OBJECTIVE: The aim of this study was to evaluate whether the intrapleural administration of streptokinase results in a similar elevation of the serum antistreptokinase antibody level. METHODS: During 1 year, venous blood samples were taken from 16 consecutive patients (10 men and 6 women; age range, 22 to 60 years) requiring intrapleural streptokinase administration (250,000 IU once a day, for 2 to 6 days). Blood samples were taken before treatment, on day 5, and day 14. Antistreptokinase antibodies were measured using enzyme-linked immunosorbent assay (ELISA) and were expressed in arbitrary ELISA units. Four patients with myocardial infarction treated with IV streptokinase (1,500,000 IU) were included as control subjects for the method. RESULTS: Before treatment, the median antistreptokinase antibody level in patients with loculated pleural effusions was 729 ELISA units (range, 196 to 13,529 ELISA units) and increased to 9,240 ELISA units (range, 1,456 to 77,389 ELISA units) by day 14 (p < 0.0001). In the control group, the median pretreatment level was 119 ELISA units, and by day 14 it had increased to 20,495 ELISA units. Four patients who developed an elevated body temperature after intrapleural administration of streptokinase had a significantly higher pretreatment antistreptokinase antibody level compared to other patients. CONCLUSIONS: The intrapleural administration of streptokinase results in the elevation of the serum antistreptokinase antibody level, which is similar to the case with IV administration. An increased pretreatment antistreptokinase antibody level does not influence the result of intrapleural fibrinolysis but can cause an elevation of body temperature after the administration of streptokinase.

Elevated soluble CD26 levels in patients with tuberculous pleurisy.

SETTING: Several reports have shown that tuberculous infection elicits a Th1-like immune response with increased levels of IFN-gamma. Recently, expression of CD26 on CD4+ lymphocytes has been shown to correlate with the production of Th1-like cytokines. We therefore hypothesized that CD26 expression might increase in tuberculous pleural effusion, and might thus be a possible marker for detecting tuberculous pleurisy. OBJECTIVE AND DESIGN: To test this hypothesis, we measured soluble CD26 levels in the serum and pleural fluid of patients with tuberculous pleurisy (TB; n = 13), carcinomatous pleurisy (CA, n = 17), empyema (EM, n = 6), and congestive heart failure (HF, n = 10). RESULTS: The pleural CD26 levels, but not the serum CD26 levels, in patients with tuberculous pleurisy were significantly higher than those in other groups, and were correlated with levels of adenosine deaminase and interferon-gamma in the tuberculous pleural effusion. Furthermore, when the cut-off value for p-CD26 was set at 544.5 ng/ml, the positive rate for the TB group was significantly higher than that for the CA, EM and HF groups (P < 0.05). CONCLUSION: These results suggest that elevation of soluble CD26 in pleural fluid is implicated in Th1-like immune response, and may be a useful marker for tuberculous pleurisy.

Surgical treatment of parapneumonic empyema.

The management of parapneumonic empyema remains controversial. We present the management of 20 children with empyema who were referred to The Royal Brompton Hospital, over a 5-year period from January 1990 to December 1994. Prior to referral, only 12 of the 20 patients had undergone thoracocentesis, all confirming the diagnosis of empyema. Six of these 12 patients then underwent closed chest tube drainage. There was a 2 to 32 day (median, 8 days) delay from initial hospital presentation to referral. Following referral 13 of the 20 patients were assessed as having persistence of clinical symptoms and radiological appearances making recovery with continued conservative management unlikely. These patients had a thoracotomy with decortication within 2 days. The remaining 7 were initially treated with closed chest tube drainage, but 5 subsequently required decortication. All patients made an uneventful postoperative recovery and were discharged within 3-11 days (mean. 6.8 days) Four patients were subsequently found to have a significant underlying immunological defect We conclude that there is a lack of agreement regarding the initial management of parapneumonic empyema. In our experience, decortication gives excellent results in those children not responding to medical treatment within 7-0 days. In experienced hands this technique is safe with rapid resolution. All patients who present with empyema should be screened for immunological abnormalities.

IL-8 in pleural effusion.

Interleukin-8 (IL-8) is a recently described potent chemotactic factor that may be involved in the pathogenesis of pleural effusions. To understand the actual mechanisms mediating the inflammatory response, changes in cellular components and IL-8 level in pleural fluid of different aetiologies were evaluated. Thirty-four patients (19 male, 15 female) with a mean age of 46 +/- 22 years (range 16-92) were included in the study. Of these, 13 had tuberculous pleural effusion, seven had empyema/parapneumonic pleural effusion, and 14 had malignant pleural effusion (seven adenocarcinoma, three ovarian carcinoma, two lymphoma, one chronic myeloid leukaemia, and one small cell carcinoma) with positive cytology. Differential cell counts in the pleural fluid were obtained using cytocentrifuge preparations. The concentrations of IL-8 in pleural fluid were measured by the ELISA method. Interleukin-8 was detected in all 34 pleural fluid samples. The serum IL-8 level was analysed only in the empyema/parapneumonic pleural effusion group. The mean IL-8 levels of tuberculous, empyema/parapneumonic, and malignant pleural effusions were 1420 +/- 1049 pg ml-1, 4737 +/- 2297 pg ml-1, and 1574 +/- 1079 pg ml-1, respectively. The IL-8 levels in the empyema/parapneumonic group were significantly raised over malignant and tuberculous groups (P < 0.02). The mean pleural fluid neutrophil counts in tuberculous, empyema/parapneumonic and malignant pleural effusions were 315 +/- 575 cells mm-3, 11,136 +/- 12,452 cells mm-3, and 635 +/- 847 cells mm-3, respectively (P < 0.003). There was a significant positive correlation between pleural IL-8 levels and neutrophil counts (r = 0.46, P < 0.006). The levels of IL-8 in paired samples of serum and pleural fluid in the empyema/parapneumonic effusion group were compared, and the concentration of IL-8 was higher in the pleural effusion than serum (means, 4737 +/- 2297 pg ml-1 and 130.0 +/- 62.5 pg ml-1, respectively, P < 0.03). There was a significant negative correlation between IL-8 concentrations in serum and pleural fluid (r = -0.80, P < 0.03). This data suggests that production of IL-8 in pleural effusion may play a key role in initiation and maintenance of inflammatory reactions, especially in empyema/parapneumonic pleural effusions. It may offer the basis for introduction of novel anti-inflammatory agents in treatment.

Pyothorax caused by Nocardia otitidiscaviarum in a patient with rheumatoid vasculitis.

We report a case of pyothorax caused by Nocardia (N.) otitidiscaviarum infection in a 69-year-old man with rheumatoid vasculitis, who was regularly treated with prednisolone in our hospital. Initially, the patient responded poorly to intravenous imipenem/cilastatin (IPM/CS), minocyclin (MINO), and oral trimethoprim-sulfamethoxazole (TMP-SMX), but later improved after treatment with levofloxacin (LVFX) and gentamicin sulfate (GM) according to in vitro susceptibility tests. To our knowledge, this is the first description of pyothorax caused by N. otitidiscaviarum infection. It is a rare disease, but recognition of the disease in immunocompromised patients and the prompt initiation of appropriate treatments based on isolation of the pathogen and susceptibility testing can lead to a successful outcome.