Management of patients with empyema.

Empyema is the term used to describe an accumulation of pus in a body cavity such as the pleural space as a result of bacterial infection. The condition is serious because it is difficult for the immune system to resolve infection in this area. Empyema can be avoided by the use of appropriate antibiotic therapy and good aseptic technique when dealing with any situation that breaches the chest wall. Treatment of this condition may be medical but if the condition does not resolve, surgical intervention is required. The nursing role involves providing support, education and long-term management for patients with empyema.

Characterization of a new mouse model of empyema and the mechanisms of pleural invasion by Streptococcus pneumoniae.

Although empyema affects more than 65,000 people each year in the United States and in the United Kingdom, there are limited data on the pathogenesis of pleural infection. We investigated the pathogenesis of empyema using animal and cell culture models of Streptococcus pneumoniae infection. The pathological processes during the development of empyema associated with murine pneumonia due to S. pneumoniae (strain D39) were investigated. Lungs were examined using histology, and pleural fluid and blood bacterial colony-forming units, cytokine levels, and cellular infiltrate were determined over time. Bacterial migration across mesothelial monolayers was investigated using cell culture techniques, flow cytometry, and confocal microscopy. After intranasal inoculation with 10(7) S. pneumoniae D39 strain, mice developed pneumonia associated with rapid bacterial invasion of the pleural space; raised intrapleural IL-8, VEGF, MCP-1, and TNF-α levels; and caused significant intrapleural neutrophilia followed by the development of fibrinous pleural adhesions. Bacterial clearance from the pleural space was poor, and in vitro assays demonstrated that S. pneumoniae crossed mesothelial layers by translocation through cells rather than by a paracellular route. This study describes key events during the development of S. pneumoniae empyema using a novel murine model of pneumonia-associated empyema that closely mimics human disease. The model allows for future assessment of molecular mechanisms involved in the development of empyema and evaluation of potential new therapies. The data suggest that transmigration of bacteria through mesothelial cells could be important in empyema development. Furthermore, upon entry the pleural cavity offers a protected compartment for the bacteria.

A 71-Year-Old Man With Diffuse Waxing and Waning Multifocal Lung Lesions, Empyema, and Episodic Fevers Reveals a Rare Diagnosis.

CASE PRESENTATION: A 71-year-old man with history of gastroesophageal reflux disease, chronic sinusitis, arthritis, hypothyroidism, and anemia of chronic disease initially sought treatment with a recurrent left pleural effusion along with other abnormal lung findings on chest CT scan. Before his referral, he was being managed for 3 years at his local hospital for waxing and waning fevers, fatigue, productive cough, chills, and night sweats. He did not report any hemoptysis or chest pain, but reported weight loss of 13 kgs in 15 months. During those 3 years, he was treated with multiple courses of antibiotics and steroids with temporary relief of symptoms. At that time, his chronic sinusitis was suspected to be the cause of his symptoms and he underwent balloon sinuplasty. He was receiving daily sublingual immunotherapy for inhaled respiratory allergens for the previous year after showing positive test results for 17 inhaled allergens. The patient had no other known immunologic workup before our evaluation.

Transmigration of fibrino-purulent inflammation and malignant cells into an artificial dura substitute (Neuro-Patch): report of two cases.

PURPOSE: The objective of this work was to present possible, though rare, complications of Neuro-Patch implantation after brain surgery. METHODS: Two patients, aged 62 and 63 years, who had a partial dural substitution with an artificial polyurethane graft after neurosurgical resection of a gross tumour, are presented. RESULTS: In the two patients, the a-vital tissue was infiltrated by either inflammatory or neoplastic tissue respectively. CONCLUSIONS: This report demonstrates a new pathological point of view in using synthetic materials for the reconstruction of dural defects.

Ventilation induced pneumothorax following resolved empyema.

We report a case of pneumothorax as a result of positive pressure ventilation in a child previously treated for empyema. Three months following discharge for successful treatment of empyema our patient received a general anesthetic for an elective MRI of the brain for investigation of nystagmus. During recovery from the anesthetic he developed respiratory distress and was found to have a loculated pneumothorax. We propose that pleural fragility in childhood empyema possibly persists even after clinical resolution and in this case for up to 3 months. The complication of pneumothorax should be considered in all patients receiving positive pressure ventilation following resolved empyema.

Management of empyema in children.

The incidence of empyema complicating community-acquired pneumonia is increasing and causes significant childhood morbidity. Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world. Newer molecular techniques utilizing the polymerase chain reaction have led to an increase in identification of causative bacteria, previously not isolated by conventional culture techniques. This remains an important epidemiological tool, and may help in guiding correct antibiotic use in the future. There are many treatment options, however, and the care a child currently receives is dependent on local practice, which is largely determined by availability of medical personnel and their preferences. Although there are many reported case series comparing treatment options, only two randomized controlled studies exist to guide treatment in children. There is an urgent need for this to be addressed, particularly with the introduction of relatively new surgical techniques such as video-assisted thorascopic surgery.

Evarts Ambrose Graham, empyema, and the dawn of clinical understanding of negative intrapleural pressure.

The concept of negative intrapleural pressure is fairly new. Although the phenomenon had already been described, Wirz provided the first definitive analysis of its significance to the mechanics of breathing in 1923. By contrast, empyema has been known since antiquity; from the time of Hippocrates, treatment has consisted of open drainage. Open drainage was often successful and did not result in pneumothorax, because most cases of empyema were associated with adhesions and thickened visceral pleura that prevented the lung from collapsing. The epidemic of group A streptococcal pneumonia in military camps in 1917-1918 was associated with the rapid and early accumulation of empyema fluid and was the catalyst for renewed study of empyema. Use of open drainage to manage this illness resulted in a high immediate mortality rate, probably because patients developed pneumothorax. The work of Evarts Graham and the Empyema Commission married physiological understanding of pleural mechanics with rational clinical treatment and paved the way for further advances in thoracic surgery.

Reappraisal of empyema thoracis. Surgical intervention when the duration of illness is unknown.

The timing of surgical treatment of empyema remains controversial. Traditionally, thoracotomy is performed either within three weeks of diagnosis or delayed until presumed pleurodesis occurs. Often, these patients are moribund and the duration of illness impossible to determine. We report our surgical results in seven patients with a deteriorating clinical course and multiple loculations which persisted after tube thoracostomy and would not have responded to multiple thoracostomies. Five patients required decortication. One required lobectomy for an abscess which developed on the contralateral side six weeks after discharge. There were no deaths or recurrences of empyema. Average times from surgery to tube removal and to discharge were six to 12 days, respectively. We conclude that one can safely and cost-effectively treat these patients surgically even when the duration of illness and presence of pleurodesis are unknown, and that the postoperative course will be uncomplicated.

Effect of hemothorax on experimental empyema thoracis in the guinea pig.

An experimental model for empyema thoracis in the Duncan-Harley guinea pig is introduced. Empyema thoracis development and early death (less than 14 days after bacterial inoculation) were noted after various concentrations and species were inoculated into the pleural space with a piece of umbilical tape, which was used as a cofactor. The effect of concomitant hemothorax was also tested. Group I (N = 90) had intrapleural inoculation of umbilical tape and various concentrations (10(4), 10(6), 10(8) organisms/ml) of various bacterial species, which included Staphylococcus aureus (N = 30), Escherichia coli (N = 30), and Bacteroides fragilis (N = 30). Group II (N = 90) had intrapleural inoculation of umbilical tape, 1 ml of autologous blood, and the same varying concentrations and species of bacteria as Group I. The observation period was 14 days, during which time early deaths were noted. Fifty-eight percent of the staphylococcal group of animals, 37% of the E. coli group of animals, and none of the B. fragilis group of animals developed empyema. Animals with empyema developed significant weight loss (p less than 0.05) and roentgenographic evidence of empyema, which was supported by postmortem pleural reaction and pneumonia scores (p less than 0.05). Higher concentrations of inoculated bacteria produced a higher incidence of empyema in the S. aureus and E. coli groups (p less than 0.05), but concomitant hemothorax did not increase the already high incidence of empyema and early death in the E. coli group. Empyema caused by B. fragilis did not develop, even with cofactors of umbilical tape and blood. Anaerobic infections in this model may require the presence of other aerobic or facultative organisms, the presence of necrotic lung, prior malnutrition, or a combination thereof.

Surgical treatment of chronic empyema. A new one-stage operation.

The operative results in a series of 92 patients with chronic empyema were reviewed. Of these, 46 had empyema with an underlying fistula, and 46 had empyema without fistulization. Twenty-one underwent decortication, 65 were treated by our technique, and six were treated by a modification of the Eloesser technique. These techniques were employed with priority given in the order just cited. Our technique involves decortication of the visceral peel and obliteration of the dead space by collapsing of the parietal wall without rib resection. Cure was obtained with decortication alone in 20 of 21 patients. Sixty of 65 patients treated by our technique were cured without deformation of the thoracic cage. In all patients treated by the modified Eloesser technique, obliteration of the empyema cavity was achieved secondarily by thoracoplasty combined with a pedicled muscle flap. Postoperative pulmonary function studies demonstrated a significant improvement in vital capacity and forced expiratory volume in 1 second in patients treated by decortication or by our technique. With the modified Eloesser technique, in contract, pulmonary function tended to decline.

Acalculous cholecystitis and septicemia caused by non-O1 Vibrio cholerae: first reported case and review of biliary infections with Vibrio cholerae.

The first case of septicemic acute acalculous cholecystitis caused by non-O1 Vibrio cholerae is described in a healthy traveler, and biliary tract infections from V. cholerae are reviewed. Immediately after a vacation in Cancun, Mexico, a 55-year-old man developed acute cholecystitis. Blood and bile cultures grew non-O1 V. cholerae. At surgery, the gallbladder was acalculous, inflamed, distended, and nearly ruptured. Pathogenetic factors may have included diarrhea prophylaxis with bismuth subsalicylate, distension of the gallbladder from illness-induced fasting, and bacterial toxins in the gallbladder. The patient received i.v. cephapirin, followed by oral cephradine for a total of 10 days, and he made a quick and complete recovery. V. cholerae should be considered in the differential diagnosis of persons from endemic areas who present with cholecystitis or acute jaundice.

Acute empyema in children treated by open thoracotomy and decortication.

Acute nontuberculous empyema treated conventionally by thoracentesis, thoracostomy drainage, and antibiotics has an unacceptably high rate of morbidity and mortality. Early open thoracotomy to eliminate the empyema with decortication of the fibrinous peel and reexpansion of the lung has proven safe and effective for 25 years. The goals of treatment of acute nontuberculous empyema are: (1) to save life, (2) to eliminate the empyema, (3) to reexpand the trapped lung, (4) to restore mobility of the chest wall and diaphragm, (5) to return respiratory function to normal, (6) to eliminate complications or chronicity, and (7) to reduce the duration of hospital stay. Our studies confirm the normal values to be expected in patients who have had complete recovery from the acute empyema, and we lay to rest any concern that decortication might, in time, limit pulmonary function. We present the cases of 21 children who had acute and mature empyemas that were treated by open thoracotomy and decortication, with an average follow-up of 18 years, among whom there were no deaths or complications.

Infratentorial empyema: analysis of 22 cases.

OBJECTIVE: Infratentorial empyema is an uncommon form of intracranial suppuration that is usually secondary to neglected otogenic infection. The diagnosis is frequently delayed and often confused with that of meningitis. The associated mortality is distressingly high, yet it has, as a clinical entity, received scant attention in the literature. We present a 13-year experience of this condition. PATIENTS AND METHODS: From a retrospective analysis of 3865 patients with intracranial suppuration during a 13-year period, 22 patients with infratentorial empyema were identified. The inpatient notes for these patients were analyzed with reference to clinical, radiological, bacteriological, operative, and outcome data. RESULTS: Twenty-two patients with infratentorial empyema accounted for 0.6% of admissions caused by intracranial suppuration during the study period. Of these 22 empyemas, 13 were subdural and 9 epidural. Hydrocephalus was present in 17 (77.3%). Except for two epidural empyemas that did not warrant neurosurgical intervention, all patients underwent standard surgical management (wide posterior fossa craniectomy). Nineteen underwent mastoidectomy because the source of infection was otogenic. Concomitant and persistent hydrocephalus was treated aggressively. Five patients died (mortality rate of 22.7%). All fatalities had subdural empyemas, and all three patients with cerebellopontine angle extension of subdural purulent collections died. CONCLUSION: Although rare, infratentorial empyema, especially when subdural, is a lethal disease. Cerebellopontine angle extension of pus was a particularly ominous sign in our experience. Early surgical drainage via wide posterior fossa craniectomy, aggressive treatment of associated hydrocephalus, eradication of the primary source of sepsis, and, finally, intravenous high dosage of appropriate antibiotics form the mainstay of treatment.

Diagnosis and treatment of amebic "empyema": report of eighty-eight cases.

To prevent pleural soilage, early diagnosis and adequate treatment of amebic abscess of the liver are mandatory. Therapy includes administration of amebicidal drugs, drainage of the chest cavity, and treatment of associated respiratory, circulatory, and systemic derangements.

Deficient phagocytosis secondary to breakdown of opsonic factors in infected exudates.

Pleural empyema, a clinical entity characterized by the simultaneous presence of large number of PMNLs and viable bacteria, is a biological paradox which has not been fully explained yet. Our preliminary studies suggest that receptor and bactericidal functions of PMNL isolated from purulent exudates, can be close to normal in this condition. Supernatants of these empyemas however have been shown to be low in heat labile opsonic activity and complement hemolytic activity. These observations have been extended by the demonstration of breakdown of IgG, C3 and factor B in infected pleural effusions as opposed to pleural fluids obtained under other conditions. The breakdown of Ig and C3 seems to be enzymatic and to occur, at least for C3, even in the absence of Ca and Mg ions: thus, direct cleavage of C3, possibly by PMNL enzymes, has to be postulated to explain these results. Present work in our laboratory is trying to explore this possibility.

Pulmonary function tests in normal Indian children and changes in respiratory disorders.

To document the normal values of pulmonary function tests in children and changes occurring in their values with various respiratory disorders, a study was carried over a period of one year in 95 healthy controls (39 females and 56 males) of 8-13 years of age and 51 cases with respiratory disorders (bronchial asthma-31, pneumonia-10, empyema-10) of matched age, sex and height distribution. The lung functions studied were FVC, FEV1, FEV1/FVC, PEFR and FEF25-75%. In children with bronchial asthma, the FEV1/FVC%, PEFR and FEF25-75% were reduced in accordance with the severity of the disease. A typical restrictive pattern of equivalent decrease in FVC and FEV1 along with insignificant lowering of flow rates, i.e., PEFR and FEF25-75% was observed in pneumonia whereas in patients of empyema a combined pattern of significantly decreased FVC and FEV1 along with mildly reduced FEV1/FVC%, PEFR and FEF 25 75% was observed.

[Empyema and subdural effusion after meningitis. 2 cases of unusual location]. / Lémpyème et l'épanchement sous-duraux post-méningitiques. Deux observations à localisation rare

A 12-year old child and a 2-month old infant developed, in the wane of a purulent meningitis, the former, an infratentorial subdural empyema, the latter, a large, encapsulated, haemoorhagic, aseptic subdural effusion, in the right parieto-temporo-occipital region. In both cases, signs of intracranial hypertension dominated the clinical picture. Neuroradiological investigations permitted diagnosis and localisation of the expansive processes, whose subdural position was recognized at operation and confirmed by histopathological examination. According to the literature, purulent meningitis is a rare cause of subdural empyema, except in infants; the solely infratentorial location is also unusual. Sterile subdural effusion is a more common complication of purulent meningitis in infancy, but the unilateral posterior supratentorial location is also a peculiar feature. Subdural collections after memingitis may be aseptic and possibly haemorrhagic, or septic and purulent; these different modes of presentation correspond perhaps to different degrees or stages of subdural pathological changes in the neighbourhood of leptomeningeal infection.

[Development of new therapeutic method for empyema].

OBJECTIVES: We have investigated whether polylactic acid (PLA) sponge and fibroblast-growth-factor (FGF) released slowly from gelatin beads can induce fibrotic tissue in postpneumonectomy dead space. METHODS: Left pneumonectomy was performed in white Japanese rabbits. In the control group (N = 5), left chest was closed without any treatment. In the PLA sponge group (N = 5), PLA sponge and FGF (100 micrograms) released from gelatin beads were introduced into the left chest cavity. RESULTS: In the control group, herniation of the heart and right lung were observed without fibrotic material in the left chest cavity. In the PLA sponge group, dense fibrotic material was observed by chest CT scan 1 month after the operation. Pathological examinations revealed that PLA sponge and FGF did promote the organization of the fibrotic materials. CONCLUSIONS: Fibrotic materials can be induced in the postpneumonectomy dead space by PLA sponge and FGF released slowly from a gelatin sponge. New therapeutic method may be introduced near future by this concept, reduction of dead space with newly developed own fibrotic materials.

[Postoperative changes of maximum inspiratory and expiratory pressures in 3 pneumonia cases occurring after surgery for empyema].

We examined preoperative and postoperative maximum inspiratory (MIP) and expiratory (MEP) pressures in 3 cases who died of postoperative pneumonia occurring more than one month after open drainage thoracotomy for empyema. All cases showed reduction of MIP and MEP to less than 20 cmH2O one month after surgery, then suffered of pneumonia. On the other hand, the other 3 cases with empyema who underwent open drainage thoracotomy and recovered without complication showed recovery of MIP and MEP one month after surgery. In conclusion, for the cases that underwent thoracic surgery, postoperative MIP and MEP are the index of respiratory condition such as deep diaphragmatic breathing and ability of efficient coughing, and can be an early prediction of late onset pneumonia after thoracic surgery.

[Lung function after recovery from empyema treated by closed chest tube drainage]. / Czynnosc ukladu oddechowego po przebytym ropniaku oplucnej leczonym zamknietym saczkowaniem jamy oplucnel.

In 32 patients 8 years after recovery from unilateral empyema treated by chest tube drainage the pulmonary function was studied. The most frequently occurring abnormalities were diminished dynamic lung compliance, diffusion capacity and perfusion evaluated by scintigraphy. Restrictive patterns were observed only in 2 patients. The greatest abnormalities were observed in patients with extensive empyema, in patients with delay in drainage and with residual radiological changes after recovery.