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.

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.

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.

Early pleural decortication for thoracic empyema in immunosuppressed patients.

Patients with empyema and impaired immune response often remain in a toxic condition after tube thoracostomy because the infection is not localized and walled off satisfactorily. Consequently, the reported mortality rate is extremely high. Despite the expectation of a high mortality rate from thoracotomy and débridement in this category of critically ill patients, we were forced to perform pleural decortication in eight patients after lesser procedures had failed. They were immunodeficient because of (1) high-dose steroids (HDS) for sagittal sinus thrombosis, (2) HDS for systemic lupus erythematosus, (3) HDS for chronic myelogenous leukemia and myelofibrosis, (4) HDS for multiple myeloma, (5) hemolytic anemia with pulmonary infiltrates, (6) chemotherapy for Hodgkin's disease, (7) diabetes mellitus with Kimmelstiel-Wilson disease, and (8) diabetes mellitus with chronic glomerulonephritis. Six of the eight patients survived and were discharged with completely healed incisions 3 to 6 weeks after operation. This compares well with the survival rates reported by others. Although risky, the over-all survival rate may be better with thoracotomy and decortication than with prolonged tube drainage and open drainage in immunodeficient patients with empyema, and the period of morbidity is shortened considerably.

Postpneumonectomy empyema. The cloud with a silver lining?

I have reviewed the literature concerning the effect of postoperative sepsis on survival following resection for carcinoma of the bronchus and added to this my experience over a 12 year period. Surgeons agree that because of its morbidity and the morbidity of measures necessary for its treatment, postoperative empyema is to be avoided, but many still hope that some compensation might be afforded the unfortunate sufferer by improvement in long-term survival. I have not found this to be the case and I feel that statistical evidence favors this view.

Empyema following lung cancer resection: risk factors and prognostic value on survival.

A retrospective evaluation of 199 consecutive patients undergoing resection for lung cancer revealed a significantly shorter long-term survival for those in whom empyema developed postoperatively. The overall five-year survival for the empyema group was 24% compared with 35% in the control group (patients without empyema), and the median survival was 15 months for the control group. These differences in survival were not found among patients with Stage I lung cancer. Pneumonectomy proved to be the main risk factor for the occurrence of empyema after operation, but a minor risk factor was the anatomical extent of disease. this correlation may be explained by major surgical contamination or manipulation as well as by lower immunological host reaction, all related to the extent of the tumor. A lower immunological defense could also explain the worse outcome for patients with Stage II or III lung cancer in whom empyema developed postoperatively.

Pathogenesis of sinus empyema.

The crucial event in the pathogenesis of sinus empyema is the ostial obstruction. On the basis of recent reports, some consequences of the obstruction on the local bacterial-host interrelationship have been outlined. The anaerobic gas environment of the empyema is one quality important to the selection of bacteria but probably also to the efficiency of the antibacterial activity of the granulocytes. Release of proteolytic enzymes from neutrophilic granulocytes in the sealed sinus may jeopardize the bacterial engulfment due to proteolytic degradation of opsonins. A longstanding exposure of the sinus mucosa to uninhibited proteolytic enzymes may explain the irreversible lesion of the mucosa in chronic sinusitis.

[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.

[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.

[Clinico-immunologic shifts in pleural empyema in patients of different age]. / Kliniko-immunologicheskie sdvigi pri empieme plevry u bol'nykh raznogo vozrasta

In 218 patients the causes of pleural empyema, the state of immunological indices and treatment have been studied in relation to patient's age. It is demonstrated that the most inadequate protection potential, conditioned by an insufficient specific resistance, is observed in children and patients over 50 years of age. The treatment of pleural empyema is usually started with a puncture method of administering antibiotics, enzymes and general analeptic drugs. In children due to a rapidly progressing intoxication and pulmonary insufficiency thoracocentesis was employed in 55.5%, in patients aged from 16 to 50 years pleurectomy and other operative procedures were accomplished. In patients over 50 years of age a puncture method and thoracocentesis were applied, surgery being used only in 10.4 per cent.

[Pleural empyema after closed mitral commissurotomy]. / Empiema plevry posle zakrytoi mitral'noi komissurotomii.

Risk factors, causes and results of the treatment of 63 patients with pleura empyema after closed commissurotomy were studied. The incidence of this complication was 0,77% per 8147 operations. Among the direct causes of empyemas there were infected blood (47,6%) and exudate (41,3%) in the pleural cavity of abscessing infarction-pneumonia (9,5%). Open drainage was found to be the most effective method of the treatment. 81% of the patients recovered. Lethality was 19%, mainly due to pyo-septic complications.

[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.

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.

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.