A case report of tuberculous empyema: A tricky disease.

Extrapulmonary tuberculosis (TB) can rarely be transmitted to others. The disease mostly affects adults and immunocompromised individuals. A 26-year-old male presented with weight loss and occasional chest pain with a deep breath, but he was otherwise normal. The patient had a history of severe dry coughs, night sweats, fever, confusion, and dizziness for >3 weeks. The patient was initially misdiagnosed with an allergic cough and was treated with anti-allergic medications. Due to small and sticky effusion, the thoracentesis procedure failed, and the patient was referred to a thoracic surgeon for an open decortication. Pleural biopsy (PB) was negative for acid-fast bacilli, but the report showed necrotizing granulomatous inflammation. The patient was started on anti-TB treatment according to the WHO guidelines. The patient gained about 6% of the body weight at the end of the intensive phase and about 15% of the body weight at the end of the continuation phase. His chest pain subsided. Chest radiography showed improvement. The patient recovered, and no relapse occurred. This study recommends that a patient with dry coughs, night sweat, and fever for >3 weeks should be followed up with a chest X-ray for at least the next 3 months.

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.

Endoscopic Bronchial Occlusion with Silicon Spigots for the Treatment of an Alveolar-pleural Fistula during Anti-tuberculosis Therapy for Tuberculous Empyema.

A prolonged air leak caused by pulmonary tuberculosis is difficult to treat, and little is known about optimal treatment strategies. We herein report the case of a 60-year-old man who demonstrated tuberculous empyema with a fistula. An air leak from a tuberculous cavity in his left upper lobe persisted for approximately 4 months; surgical repair could not be performed due to a poor physical status and undernourishment. However, the air leak was successfully treated with endobronchial occlusion using two silicone spigots in left B3b and B4, without any adverse effects or aggravation of the infection.

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.

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.

Treatment of a tuberculous empyema with simultaneous oral and intrapleural antituberculosis drugs.

A 71-year-old man was diagnosed with an uncomplicated tuberculous (TB) empyema. Differential penetration of anti-TB drugs, believed to explain the phenomenon of acquired drug resistance in TB empyema, was confirmed by measurement of serum and pleural fluid anti-TB drug concentrations. Simultaneous oral and intrapleural anti-TB drugs were administered and a cure was achieved. The present case is discussed in the context of the literature on acquired drug resistance in TB empyema. It is argued that high-end doses of oral drugs or combined oral plus intrapleural drugs, along with tube thoracostomy or intermittent thoracentesis, will cure uncomplicated TB empyema without threatening to induce drug resistance or having to resort to surgery.

Tuberculose pleural / Tuberculous pleural effusions

O derrame pleural tuberculoso pode ser devido a uma manifestação da forma primária da doença ou da reativação de uma infecção latente pelo M. tuberculosis. Os avanços nos métodos laboratoriais contribuíram sobremaneira para um melhor diagnóstico e para a compreensão da fisiopatologia desta doença. No entanto, embora o derrame pleural predominante linfocítico seja indicativo de tuberculose em nosso meio, uma rotina de abordagem diagnóstica deve ser instituída a fim de orientar o tratamento precoce e evitar seqüelas.

Tuberculous pleural effusion is a common manifestation of the primary form of the disease or consequence of the reactivation of a latent infection due to the M. tuberculosis. Advances in the laboratory methods have contributed to better diagnose and understand the pathophysiology of the effusion secondary to tuberculosis. However, although a predominant lymphocytic pleural effusion is suspicious of tuberculosis, a diagnostic routine shall be instituted to orient treatment and prevent undesirable sequels.

Predictors of successful closure of open window thoracostomy for postpneumonectomy empyema.

BACKGROUND: Although the open window thoracostomy (OWT) represents the ideal method for drainage of postpneumonectomy empyema (PPE), several controversies exist concerning its closure. METHODS: Between January 1993 and December 2003, an OWT was created in 31 patients (29 male and 2 female) with PPE. The median age was 61 years (range, 32 to 76). In 26 patients (84%) a bronchial stump fistula developed. The OWT closure was correlated with characteristics of PPE and the timing of OWT. RESULTS: In 15 patients (48%), the OWT could be closed by obliteration of pleural cavity with antibiotic solution (3 patients) or intrathoracic muscle transposition (12 patients). A successful closure was observed in 13 of the 15 patients (87%). All patients closed by Clagett's procedure remained empyema free. Recurrent cancer (n = 4), poor functional status (n = 3), refusal of further operation (n = 2), and persistent tuberculous empyema (n = 2) were common causes of failure of OWT closure. Univariate analysis revealed that the timing of empyema development after surgery (p = 0.02) and the timing of OWT (p = 0.03) were significant predictors of thoracostomy closure. CONCLUSIONS: Late onset of PPE and immediate OWT creation are significant predictors of OWT closure. Smaller dimensions of the pleural cavity appeared to increase the likelihood of closure. When the pleural cavity shows healthy granulation tissue and no bronchopleural fistula, the Clagett's procedure is safe and effective to obliterate the pleural cavity. Obliteration by muscle flap transposition can be reserved for patients with persistent or recurrent bronchopleural fistula.

Pleural tuberculosis.

Pleural effusions in tuberculosis are commonly seen in young adults as an immunological phenomenon occurring soon after primary infection. However, the epidemiology and demographics of tuberculous pleurisy are changing due to the impact of HIV co-infection and the increasing number of pleural effusions seen as part of re-activation disease. Pleural biopsy for histology and culture is the mainstay of diagnosis with closed needle biopsy adequate in the majority of cases. Techniques such as PCR of biopsy specimens and the role of pleural fluid ADA are still being evaluated as a diagnostic aid. Tuberculous empyema is less commonly seen in the western world and the diagnostic yield from pleural fluid here is greater than in "primary" effusions. Treatment with appropriate antituberculous chemotherapy is generally successful though there is currently insufficient evidence to recommend the routine use of corticosteroids in this condition.

Endobronchial tuberculosis complicated with Staphylococcus aureus pneumonia and empyema in a child.

Childhood tuberculosis might have unusual clinical presentation. A seven-year-old female patient was admitted with fever and pleural effusion. Her pneumonia resolved following 21-day treatment period. An atelectatic appearance remained on the right middle zone in her chest X-ray. Tuberculin skin test showed 13 mm induration. Triple drug antituberculosis treatment was started. Since atelectasis persisted on her follow-up radiograph one month later, bronchoscopy was performed which revealed a hemorrhagic polypoid mass occluding the right upper lobe anterior segment orifice. Surgical removal was performed by right upper lobectomy. The pathological diagnosis was necrotizing granulomatous infection suggesting tuberculosis. The patient has been well on follow-up after completing a nine-month course of antituberculous treatment.

[Tuberculous pyothorax. 28 cases]. / Le pyothorax tuberculeux. 28 cas.

OBJECTIVES: Despite the efforts in the fight against tuberculosis (Tb) and the decrease in its incidence, severe forms persist. Tubercular pyothorax (TP), which was a frequent complication, is still difficult to treat. We studied the epidemiological, diagnostic, therapeutic and progressive aspects of this particular localization. METHODS: Retrospective study collecting all the TP reported between 1990 and 1999 in the department of pneumology in Ariana. The inclusion criterion was any patient presenting with pleural-parietal empyema of tubercular origin. We excluded patients presenting with negative bacilliferous pyothorax cultures. RESULTS: Twenty-eight cases of TP were retained among 875 cases of tuberculosis, i.e., 3.2%. The mean age of patients was of 44 years (range: 15-75) and they were moderate smokers: 27 PA. Infectious fever concomitant to a pleural syndrome was the typical clinical manifestation. In some patients empyema (3 cases) or cutaneous fistula (2 cases) were the circumstances in which the disease was discovered. Thoracic imaging is a very useful tool: standard radiography, tomodensitometry and magnetic resonance imaging permit analysis of the pleural wall and cavity. In 9 cases, pneumothorax was concomitant. A co-infection with pyogenic germs was present in 4 patients. Treatment of TP is triple; it associates specific poly-chemotherapy, thoracic draining and respiratory physiotherapy. The progression was satisfactory in the recent forms concomitant to a bacilliferous pulmonary Tb. Complications such as pleural-pulmonary after effects are inherent to the severe forms. Surgery was necessary for 9 patients (5 drainages, 2 rib resections and 2 decortications). CONCLUSION: TP is a menace for functional prognosis. Treatment is double: early, curative and effective, and preventive of Tb and its risk factors.

Tuberculous empyema.

The clinical courses of 35 tuberculous empyema patients were investigated retrospectively from November 1990 through November 1995. Most patients had nonspecific symptoms and signs but with far-advanced pulmonary parenchymal lesions in their chest roentgenographs. The effusions showed neutrophilic leukocytosis with a 60% positive culture rate for Mycobacterium tuberculosis. Multidrug resistant strains were found in 7 out of 18 cultures. All patients received chemotherapy and eight of them underwent additional surgical management. Twenty-two (62.9%) patients had been treated successfully and one patient is still under treatment. The remaining 12 patients either died during treatment or defaulted; and four (11.4%) of them had died of tuberculosis. We conclude that the treatment outcome of tuberculous empyema is less satisfactory than that of pulmonary tuberculosis, however, modern multidrug chemotherapy with repeated drainage and opportune surgical interventions could be in prospect of successful treatment of tuberculous empyema.

Chronic tuberculous empyema with bronchopleural fistula resulting in treatment failure and progressive drug resistance.

We treated five patients with a past history of tuberculous pleural infection that led to chronic, quiescent, loculated empyema. Reactivation of TB was associated with formation of BPF and recovery of drug-susceptible Mycobacterium tuberculosis from sputum. All patients had recurrence of positive sputum cultures that yielded tubercle bacilli resistant to drugs they were receiving. The lungs demonstrated gross thickening with calcification of both visceral and parietal pleura. Two patients underwent retreatment chemotherapy followed by decortication-empyemectomy and lung resection surgery; both are now culture-negative for TB. One patient received retreatment chemotherapy but refused surgery; he remains clinically stable with negative sputum cultures. Two other patients' organisms became drug-resistant and they remain sputum-culture positive. We believe that thick, calcified pleural walls limit penetration of drugs into the infected empyema space, resulting in suboptimal drug concentrations and drug resistance. Intensified chemotherapy and surgical intervention should be considered in these cases.