Mycobacterium abscessus subsp. abscessus empyema complicated with subcutaneous abscess.

There have been no case reports of thoracic subcutaneous abscess after surgery for Mycobacterium abscessus complex associated empyema. We herein report a case of Mycobacterium abscessus subsp. abscessus (M. abscessus subsp. abscessus) induced subcutaneous abscesses following surgical treatment for concurrent M. abscessus subsp. abscessus -associated empyema and pneumothorax. A 75-year-old woman had M. abscessus subsp. abscessus -associated empyema and pneumothorax. She underwent surgical treatment of decortication and fistulectomy and suffered from M. abscessus subsp. abscessus -associated subcutaneous abscesses after thoracentesis/drainage. A multidisciplinary approach combined with surgical care, thermal therapy, and multidrug chemotherapy contributed to a successful result. An early multidisciplinary approach is believed to be important in cases of M. abscessus subsp. abscessus -associated empyema and subcutaneous abscess.

Pneumocystis jirovecii-related spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in a liver transplant recipient: a case report.

BACKGROUND: Pneumocystis pneumonia (PCP) is a common opportunistic infection caused by Pneumocystis jirovecii. Its incidence at 2 years or more after liver transplant (LT) is < 0.1%. PCP-related spontaneous pneumothorax and/or pneumomediastinum is rare in patients without the human immunodeficiency virus, with an incidence of 0.4-4%. CASE PRESENTATION: A 65-year-old woman who had split-graft deceased-donor LT for primary biliary cirrhosis developed fever, dyspnea and dry coughing at 25 months after transplant. Her immunosuppressants included tacrolimus, mycophenolate mofetil, and prednisolone. PCP infection was confirmed by molecular detection of Pneumocystis jirovecii,in bronchoalveolar lavage. On day-10 trimethoprim-sulphamethoxazole, her chest X-ray showed subcutaneous emphysema bilaterally, right pneumothorax and pneumomediastinum. Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum and subcutaneous emphysema. She was managed with 7-day right-sided chest drain and a 21-day course of trimethoprim-sulphamethoxazole before discharge. CONCLUSION: Longer period of PCP prophylaxis should be considered in patients who have a higher risk compared to general LT patients. High index of clinical suspicion, prompt diagnosis and treatment with ongoing patient reassessment to detect and exclude rare, potentially fatal but treatable complications are essential, especially when clinical deterioration has developed.

Tetratrichomonas in pyopneumothorax.

Pleural trichomonosis is clinically rare, and very few cases of trichomonal empyema have been reported so far. A rare case of an 81-year-old woman with pyopeumothorax presenting with recurrent fever and macroscopic pyuria was present. Microscopic examination of the pleural effusion showed mobile flagellated protozoa which molecular methods identified as Tetratrichomonas. In addition, Streptococcus anginosus was discovered in pleural fluid cultures. Treatment with imipenem/cilastatin and metronidazole successfully eliminated the pathogens and led to relief of clinical symptoms. In the context of a review of the relevant literature, the clinical application of molecular methods in the diagnosis of pleural trichomonosis is underlined.

Subacute invasive pulmonary aspergillosis as a rare cause of pneumothorax in immunocompetent patient: brief report.

Subacute invasive pulmonary aspergillosis (IPA) represents a form of chronic pulmonary aspergillosis which affects immunocompetent individuals or mildly immunocompromised persons with underlying pulmonary disease. Pneumothorax can be a rare complication of subacute IPA due to a leakage of air from an air-filled lung cavitation into the pleural space. Herein, we report rare and unusual case of pneumothorax in a patient with pulmonary cavity infection. A 40-year-old woman was admitted to thoracic surgery due to complete pneumothorax of the left lung. She was active smoker with untreated chronic obstructive pulmonary disease (COPD). After thoracic drainage multiple cavity forms in the both lungs were noticed. Galactomannan antigen was positive in bronchoalveolar lavage as well as culture of Aspergillus fumigatus. Antifungal treatment by voriconazole was started and continued during 6 months with a favorable outcome. This case highlights that subacute IPA is a diagnose that should be considered in patients with end-stage COPD, low body mass index, or patient who developed pneumothorax. The results of our case show that voriconazole is a safe and effective treatment as primary or salvage therapy in subacute forms of IPA, irrespective of the immunological status of the patients.

Spontaneous pneumothorax in paracoccidioidomycosis patients from an endemic area in Midwestern Brazil.

Paracoccidioidomycosis (PCM) is the most important systemic mycosis in Latin America. About 80% of PCM patients are present with its chronic form. The lungs are affected in most patients with the chronic form; however, pleural involvement has rarely been reported. We describe nine cases of PCM that presented with lung involvement and spontaneous pneumothorax. All patients, except one whose condition was not investigated, were smokers. PCM was diagnosed during the pneumothorax episode in three patients, and from 3 to 16 years before the pneumothorax episode in six patients. A total of six patients underwent chest drainage and one died as a direct result of the pneumothorax. We suggest that pneumothorax, although rare, should be considered in PCM patients who present with suddenly worsening dyspnoea. PCM should also be investigated in cases of pneumothorax in adult men from mycosis-endemic areas.

Successful rescue combination of extracorporeal membrane oxygenation, high-frequency oscillatory ventilation and prone positioning for the management of severe methicillin-resistant Staphylococcus aureus pneumonia complicated by pneumothorax: a case report and literature review.

BACKGROUND: To describe the experience of combination therapy with extracorporeal membrane oxygenation(ECMO), high-frequency oscillatory ventilation(HFOV) and prone positioning in treating severe respiratory failure caused by community acquired methicillin resistant Staphylococcus aureus(CA-MRSA). CASE PRESENTATION: A 30-year-old female presented with fever and dyspnea for 3 days. She was diagnosed CA-MRSA pneumonia complicated by severe respiratory failure, pneumothorax and neutropenia. Venovenous ECMO was applied within 8 h of the pneumothorax diagnosis. For amelioration of ventilator-induced lung injury, HFOV and prone positioning were combined with ECMO. The patient's condition improved considerably. ECMO was weaned on day 19, and she was discharged on day 48 with good lung recovery. CONCLUSIONS: To the best of our knowledge, this was the first case in which ECMO was combined with HFOV and prone positioning to treat severe necrotic CA-MRSA pneumonia complicated with pneumothorax. This combination therapy may provide safe respiratory support, may minimize the risk of barotrauma, and provide better drainage of secretions in patients with necrotizing pneumonia.

Extracorporeal membrane oxygenation as treatment for acute respiratory failure and subsequent pneumothorax caused by Pneumocystis jirovecii pneumonia in a kidney transplant recipient.

Acute respiratory failure (ARF) accompanied by pneumothorax caused by Pneumocystis jirovecii pneumonia (PJP) is often fatal. We present our experience using extracorporeal membrane oxygenation as treatment for ARF and subsequent pneumothorax caused by PJP in a kidney transplant recipient.

Clinical characteristics and prevalence of pneumothorax in patients with pulmonary Mycobacterium avium complex disease.

Pneumothorax in patients with pulmonary Mycobacterium avium complex (MAC) disease is considered to be a rare complication, and little is known about its clinical course. In this study, we aimed to define the clinical features, outcome, and prevalence of pneumothorax in patients with pulmonary MAC disease. A retrospective review of medical records identified eight men and ten women (mean age, 75 years) with active pulmonary MAC disease complicated by pneumothorax between 2003 and 2010 in our institution. None of the patients was positive for HIV infection. Pneumothorax occurred in the right lung in 12 patients and in the left in six. All but one patient had MAC disease in both lungs, and 12 patients had widespread lesions covering a total area larger than one lung field. Seven of the 18 patients (39 %) were forced to undergo surgery following unsuccessful thoracic drainage. Five patients experienced recurrence during the study period and two others eventually developed chronic pneumothorax. The complication rate of pneumothorax was calculated on the bases of the total number of patients with active pulmonary MAC disease during the same period. The overall complication rate of pneumothorax was as high as 2.4 % (18 of 746 patients with MAC disease). In conclusion, the incidence of pneumothorax in patients with active pulmonary MAC disease was unexpectedly high, especially in patients who were elderly and had advanced MAC disease. This condition is often difficult to treat and can recur easily.

[Pyopneumothorax caused by Salmonella choleraesuis: a case report and review of the literature].

OBJECTIVE: To improve understanding of the clinical features, diagnosis and treatment of pyopneumothorax caused by Salmonella choleraesuis. METHODS: One case of pyopneumothorax caused by Salmonella choleraesuis diagnosed and treated in our hospital in 2010 was reported and the related literatures were reviewed. As of May 2011, the literature review was carried out with "Salmonella choleraesuis" and "thoracic empyema" as the search terms in Wanfang Med Online and Pubmed Database. RESULTS: A 43-year-old Chinese woman presenting with fever and chest pain for 4 days was admitted to our hospital. A CT scan of the chest revealed a massive shadow with mixed density in the right hemithorax, from the top of thorax to diaphragmatic surface, and there was air inside or surrounding the mass irregularly but without an air-fluid level. Blood culture and bronchial secretion culture by bronchoscope both showed some serotypes of Salmonella strains. At first intravenous antibiotic therapy (piperacillin-tazobactam, ceftazidime, and then imipenem-cilastatin) was ineffective. Open chest surgery was performed, and chest tube placed. Salmonella choleraesuis was isolated from the drained pleural fluid. Chest tube drainage remained in place for more than 6 weeks, and with prolonged antibiotic therapy, which contributed to a good outcome. Literature review found no related reports in Wanfang Med Online, while 3 literatures were found in Pubmed, including 2 of case report and 1 of retrospective study. Among 973 patients with empyema thoracis in the retrospective study, 12 of these patients, including 9 men and 3 women, were infected with Salmonella species. The median age was 49 years, and 10 patients were immunocompromised, including malignancy, liver cirrhosis, and diabetes mellitus. Seven patients were infected with Salmonella choleraesuis, and 4 (57%) of them died. CONCLUSIONS: Pyopneumothorax or thoracic empyema is a rare complication of Salmonella choleraesuis infection. Higher rates of death were noted in this disease. Salmonella choleraesuis infection is even more serious in adult patients with underlying diseases. Early diagnosis, appropriate antimicrobial drug therapy, and aggressive drainage are necessary to improve the outcome of patients with pyopneumothorax or thoracic empyema due to Salmonella choleraesuis.

Interventional radiology of pleural diseases.

Image-guided pleural procedures are important in both the diagnosis and management of pleural disease. Pleural aspiration, biopsy and drainage are all proven to be safer and more efficacious using image guidance. The aim of this article is to review common image-guided pleural techniques and the evidence base for their application in clinical practice.

Tuberculosis-associated secondary pneumothorax: a retrospective study of 53 patients.

BACKGROUND: Pneumothorax is a well known complication of pulmonary tuberculosis (TB), particularly in patients with advanced TB. METHODS: At our national TB-referral hospital, we compared the medical records of 53 TB patients with pneumothorax and 106 TB patients without pneumothorax, seen in 2003 to 2008. We analyzed data on demographics; TB type (smear-positive, smear-negative, extrapulmonary); patient type (new patient, relapse, treatment default, treatment failure); clinical and radiological manifestations; surgeries; and outcomes. RESULTS: Of the 53 pneumothorax patients, 34 (64%) were male. The pneumothorax group's mean age was 34 y (range 14-76 y). Thirty-six (68%) of the pneumothorax patients were new TB cases (ie, TB undiagnosed before they presented with pneumothorax). Pneumothorax was not significantly associated with sex, smoking, or drug use. Pneumothorax was significantly more common in patients < 30 years old (P < .001). In terms of radiological manifestations, 20 pneumothorax patients (38%) had cavitary lesions, and pulmonary infiltration and effusion were present in 19 (36%) and 17 (32%) patients, respectively. Cavitary lesion was significantly more common among the pneumothorax patients (P = .006). Overall, 47 (89%) of the pneumothorax patients were relieved with chest-tube insertion; the other pneumothorax patients were only observed. CONCLUSIONS: In patients < 30 years old or with cavitary lesions, worsening of the patient's respiratory condition should prompt consideration of pneumothorax.

[Spontaneous pneumothorax due to pulmonary coccidioidomycosis]. / Neumotórax espontáneo secundario a coccidioidomicosis pulmonar.

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis. It is endemic in northern Mexico and the southwest part of the United States. Radiologic manifestations are varied. Rupture of a coccidioidal pulmonary cavity with subsequent pneumothorax is a rare clinical event, even in endemic areas. We present a case with a brief review of this rare condition.

Radiological diagnosis and follow-up of pulmonary tuberculosis.

Mycobacterium tuberculosis, the causal organism of tuberculosis (TB), is one of the oldest and still one of the deadliest pathogens known to man. Approximately 1 in 10 people with primary pulmonary tuberculosis (PTB) present clinically; of untreated cases, approximately 1 in 10 reactivate usually at a time of relative immunodeficiency. The spectrum of radiologic manifestations of PTB can pose a variety of diagnostic and management challenges. PTB infection often leaves long term sequelae of infection, particularly granulomatous nodules, cavitation, and fibrosis; distinguishing dormant disease from reactivation is not always clear-cut. The radiologic presentation of primary PTB infection tends to differ from that of post-primary PTB, but there is significant overlap in the appearances. Primary PTB typically presents with consolidation and regional lymphadenopathy, whereas post-primary PTB more often results in cavitation. The pathology and therefore the radiology of TB infection will be altered based on the efficacy of the immune response and will therefore vary depending on the immune competency. Clinically, in the presence of infection, the main questions are whether M tuberculosis is the infecting organism and, if treated, does the radiology indicate response to treatment. In order to interpret the radiology of TB one needs to be aware of the spectrum of presentation, the expected reaction to treatment, and the myriad of non-pulmonary sites of infection that may prove to be more clinically significant than the pulmonary infection.

Scedosporium apiospermum infection presenting as a pneumothorax and cavitary lung lesions in a patient with acquired immune deficiency syndrome.

The Scedosporium genus consists of filamentous fungi that inhabit soil, sewage, manure, and polluted waters, and contains two medically important species: Scedosporium apiospermum and Scedosporium prolificans. Scedosporiosis is caused by inhalation or traumatic subcutaneous implantation of the organism, and may have varied clinical presentations. A variety of pulmonary manifestations can occur, but to our knowledge, pneumothorax as initial presentation has not been reported. Treatment may be difficult, as the disease occurs more commonly in immunocompromised patients, and the organism may demonstrate resistance to various antifungal agents. We describe successful treatment of extensive pulmonary disease due to S apiospermum in a patient with acquired immune deficiency syndrome (AIDS).

Disparate effects of methicillin-resistant Staphylococcus aureus infection on renal function in IgA-dominant infection-associated glomerulonephritis and menstrual toxic shock syndrome: a case report and literature review.

The sudden outbreak of severe acute respiratory syndrome coronavirus 2 pneumonia posed a significant challenge to medical professionals because treatment of critically ill patients requires the efforts of a multidisciplinary team. To highlight this principle, we examined acute kidney injury (AKI) in IgA-dominant infection-associated glomerulonephritis (GN) and menstrual toxic shock syndrome (mTSS). Both GN and mTSS are rare diseases caused by staphylococcal infection, and renal function is frequently impaired. The resulting AKIs are disparate pathological entities driven by distinct immune mechanisms. We begin by describing the case of a diabetic man with pyopneumothorax following methicillin-resistant Staphylococcus aureus (MRSA). He had endocapillary proliferative GN with in situ IgA-dominant immune-complex formation in the mesangium accompanied by complement C3 deposition in the glomerular capillary wall. By contrast, acute tubular necrosis was observed in a case of mTSS; the patient's immune response was stimulated differently by MRSA enterotoxin and exotoxin resulting in aberrant IgA deposition, complement activation, and insufficient antibody production. As a multidisciplinary communication covering the fields of nephrology, immunology, and pathology, this report may help clinicians to understand these distinct renal lesions and make optimal therapeutic decisions expeditiously.

Recurrent bilateral pneumothoraces: a rare complication of miliary tuberculosis.

Pneumothorax as a complication of adult cavitary pulmonary tuberculosis is well known and not at all rare, but its occurrence as a complication of miliary tuberculosis is extremely rare. We report a 22-year-old woman who had nonproductive cough and fever for 3 days. Chest radiography showed diffuse, symmetrical miliary nodulation throughout both lung fields. The patient was treated for a presumed diagnosis of miliary tuberculosis with standard antituberculous regimen. Bilateral pneumothorax occurred simultaneously during hospitalization and chest tube thoracostomy was performed. Three days later, recurrent right pneumothorax developed. Video-assisted thoracoscopic surgery (VATS) lung biopsy of the right lung was performed and pathology showed granulomatous interstitial pneumonia with acid-fast positive bacilli. Lung tissue culture was positive for Mycobacterium tuberculosis. In the following 2 months, bilateral pneumothorax recurred twice and chemical pleurodesis with minocycline was performed on both sides, but air leakage persisted. VATS pleurodesis was performed on both sides successfully without recurrence of pneumothorax on either side. Our experience highlights the fact that pneumothorax should be suspected in an adult with miliary tuberculosis who suddenly develops acute respiratory distress. Recurrent pneumothorax can be managed, apart from medical therapy of miliary tuberculosis, with surgical intervention.

Bilateral Pneumothoraces: A Rare Complication of Septic Pulmonary Emboli in Intravenous Drug Abusers.

BACKGROUND Right-sided infective endocarditis is a classic complication of intravenous drug abuse. Without timely bactericidal antibiotics, the disease process can progress to septic pulmonary emboli. Rarely, a pneumothorax can occur as a result of the emboli, and progressive persistent valvular disease may require a valve replacement. Tricuspid valve replacement has a high morbidity rate even in stable patients. CASE REPORT We present a case of tricuspid valve replacement in a 39-year-old man with peripheral intravenous drug abuse who had bilateral pneumothoraces secondary to septic pulmonary emboli originating on large tricuspid valve infected vegetations. The patient died 21 days after the valve replacement. CONCLUSIONS Tricuspid valve replacement is an especially dangerous procedure in intravenous drug abusers who present with bilateral pneumothoraces and advanced cardiopulmonary pathology.

Pleural coccidioidomycosis presenting as spontaneous pneumothorax.

Coccidioides is a fungus endemic to Southwestern USA and Northern Mexico which can be asymptomatic or result in a well-defined clinical syndrome of community-acquired pneumonia. On rare occasion, coccidioidomycosis may have atypical presentations as in our patient, a 25-year-old man admitted with a 2-month history of progressive dyspnoea and cough. He was found to have a large right-sided pneumothorax with exudative pleural effusion which did not resolve following thoracentesis. Decortication was performed which revealed a dense rind of inflammatory tissue covering all lobes of his right lung. Histopathology demonstrated hyphae resembling Aspergillus, but culture and serology confirmed Coccidioides immitis Following several months of antifungal therapy, he achieved complete clinical recovery with near-complete resolution of radiographic findings.

Clinical Features of Nontuberculous Mycobacterial Pleurisy: A Review of 12 Cases.

Objective The incidence of pulmonary nontuberculous mycobacterial (NTM) infections has increased in recent decades. Nevertheless, NTM pleurisy is still a rare disease. The objective of the present study was to elucidate the clinical features and outcomes of NTM pleurisy. Methods A retrospective study was undertaken of consecutive patients whose pleural effusion culture yielded NTM, from 2002 to 2016 at a respiratory hospital in Japan. The clinical features, treatment, and outcomes of these patients were analyzed. Result The 12 patients with NTM pleurisy were predominantly male, with a median age of 69 years (range, 48-93 years). They included eight patients with a history of smoking and six patients with immunosuppressive comorbidities such as malignancy, diabetes mellitus, and conditions requiring steroid administration. Fibrocavitary disease was the most common radiographic feature of these patients, and Mycobacterium avium complex was the most common pathogen. Pneumothorax was complicated in 11 patients. Surgery was performed on seven patients, in addition to thoracic drainage for the treatment of pleurisy and pneumothorax. Three patients died of respiratory failure. Conclusion Pneumothorax is a frequent complication of NTM pleurisy, often making the condition difficult to treat. Surgery at an appropriate time should therefore considered for refractory cases.