Ceftazidime-avibactam and intrapleural amikacin therapy for extensively drug-resistant Pseudomonas aeruginosa thoracic empyema: A case report.

INTRODUCTION: Thoracic empyema and concomitant bronchopleural fistula are serious complications of pneumonia. The treatment of empyema caused by extensively drug-resistant Pseudomonas aeruginosa (XDR-PA) has become increasingly challenging. PATIENTS CONCERNS AND IMPORTANT CLINICAL FINDINGS: A 57-year-old woman with controlled schizophrenia developed hospital-associated bacterial pneumonia secondary to P. aeruginosa on day 13 of hospitalization for brain meningioma surgery. DIAGNOSIS: Chest radiography and computed tomography revealed right-sided necrotizing pneumonia with pneumothorax, a focal soft tissue defect over the right lower chest wall, and a mild right-sided encapsulated pleural effusion with consolidation. XDR-PA was isolated on empyema cultures. INTERVENTIONS: The patient was treated with intrapleural amikacin as a bridge to video-assisted thoracoscopic surgery, followed by novel ceftazidime-avibactam therapy. OUTCOMES: On the 104th day of admission, the patient underwent chest wall debridement and closure. The patient was discharged on day 111. Twenty-eight days after discharge, there were no observable sequelae of empyema. CONCLUSION: Although the minimum inhibitory concentration of ceftazidime-avibactam for XDR-PA is relatively high (8 mg/L), this report emphasizes the efficacy of ceftazidime-avibactam treatment for XDR-PA empyema, as well as the importance of source control.

Efficacy, safety, and optimal timing of single-trocar video-assisted flexible thoracoscopic debridement under local anesthesia for complicated parapneumonic empyema.

OBJECTIVE: Thoracoscopic debridement under local anesthesia is a useful approach for complicated parapneumonic effusion or empyema (CPE) and is a less invasive procedure than video-assisted thoracoscopic surgery under general anesthesia. There are various methods of thoracoscopic debridement under local anesthesia, although the optimal timing of treatment is unknown. The objective of this study was to verify the efficacy and safety of our video-assisted flexible thoracoscopic debridement (VAFTS-D) procedure under local anesthesia, and to investigate the clinical features associated with the success of VAFTS-D. METHODS: The study included 71 consecutive patients with CPE who underwent VAFTS-D. The primary outcome was success of VAFTS-D. We retrospectively analyzed the efficacy and safety of VAFTS-D from the clinical data obtained from hospital medical records, and used univariate logistic analyses to identify potential predictors of the outcome. RESULTS: VAFTS-D was considered successful in 62 of 71 patients (87.3%). Two of the remaining nine patients died and the other seven patients required subsequent operation under general anesthesia. Complications due to VAFTS-D occurred in six patients (8.5%). Duration of empyema < 10 days (P = 0.024) and negative bacterial culture in pleural effusion (P = 0.029) were independently associated with the success of VAFTS-D by univariate logistic regression analysis. CONCLUSION: VAFTS-D might be an acceptable first-line procedure in patients with suspected CPE. VAFTS-D should be performed as early as possible for a successful outcome, and to obtain useful information on the pleural cavity.

[Antibiotic strategy in pleural empyema in children: Consensus by the DELPHI method]. / Stratégie antibiotique dans les pleurésies en pédiatrie : consensus par méthode DELPHI.

INTRODUCTION: The evolution of the microbial epidemiology of pleuropulmonary infections complicating community-acquired pneumonia has resulted in a change in empirical or targeted antibiotic therapy in children in the post Prevenar 13 era. The three main pathogens involved in pleural empyema in children are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus. METHODS: A questionnaire according to the DELPHI method was sent to experts in the field (paediatric pulmonologists and infectious disease specialists) in France with the purpose of reaching a consensus on the conservative antibiotic treatment of pleural empyema in children. Two rounds were completed as part of this DELPHI process. RESULTS: Our work has shown that in the absence of clinical signs of severity, the prescription of an intravenous monotherapy is consensual but there is no agreement on the choice of drug to use. A consensus was also reached on treatment adjustment based on the results of blood cultures, the non-systematic use of a combination therapy, the need for continued oral therapy and the lack of impact of pleural drainage on infection control. On the other hand, after the second round of DELPHI, there was no consensus on the duration of intravenous antibiotic therapy and on the treatment of severe pleural empyema, especially when caused by Staphylococci. CONCLUSIONS: The result of this work highlights the needed for new French recommendations based on the evolution of microbial epidemiology in the post PCV13 era.

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.

Combined serum biomarkers in the noninvasive diagnosis of complicated parapneumonic effusions and empyema.

BACKGROUND: We previously demonstrated that the pleural levels of proteins (neutrophil gelatinase-associated lipocalin/NGAL, calprotectin, bactericidal permeability-increasing/BPI, azurocidin 1/AZU-1) were valuable markers for identifying complicated PPE (CPPE). Herein, this study was performed to evaluate whether these proteins are useful as serological markers for identifying CPPE and empyema. METHODS: A total of 137 participates were enrolled in this study. The levels of NGAL, calprotectin, BPI and AZU-1 were measured in serum and pleural fluid by enzyme-linked immunosorbent assay. We also characterized the diagnostic values of these markers between different groups. RESULTS: The serum levels of NGAL, calprotectin, and BPI in PPE patients were significantly higher than those in transudates, noninfectious exudates, and healthy controls. The area under the curve (AUC) values of NGAL, calprotectin, and BPI for distinguishing PPE from transudates or noninfectious exudates were around 0.861 to 0.953. In PPE group, serum NGAL and calprotectin levels were significantly elevated in patients with CPPE and empyema than in those with UPPE, whereas the serum BPI levels were similar between these two groups. In CPPE and empyema patients, the serum NGAL showed a positive correlation with the pleural fluid NGAL (r = 0.417, p <  0.01). When combined with serum CRP, the sensitivity and specificity of serum calprotectin for identifying CPPE and empyema were the highest at 73.52% and 80.55%, respectively. CONCLUSIONS: We concluded that serum calprotectin and NGAL were adjuvant serological markers for CPPE and empyema diagnosis. Patients present with pneumonia and pleural effusion signs in the chest x-ray and the combination of serum calprotectin and CRP constitutes a more highly sensitive and specific assay for identifying CPPE and empyema.

Human pleural fluid is a potent growth medium for Streptococcus pneumoniae.

Empyema is defined by the presence of bacteria and/or pus in pleural effusions. However, the biology of bacteria within human pleural fluid has not been studied. Streptococcus pneumoniae is the most common cause of pediatric and frequent cause of adult empyema. We investigated whether S. pneumoniae can proliferate within human pleural fluid and if growth is affected by the cellular content of the fluid and/or characteristics of pneumococcal surface proteins. Invasive S. pneumoniae isolates (n = 24) and reference strain recovered from human blood or empyema were inoculated (1.5×106CFU/mL) into sterile human malignant pleural fluid samples (n = 11). All S. pneumoniae (n = 25) strains proliferated rapidly, increasing by a median of 3009 (IQR 1063-9846) from baseline at 24hrs in all pleural effusions tested. Proliferation was greater than in commercial pneumococcal culture media and concentrations were maintained for 48hrs without autolysis. A similar magnitude of proliferation was observed in pleural fluid before and after removal of its cellular content, p = 0.728. S. pneumoniae (D39 strain) wild-type, and derivatives (n = 12), each with mutation(s) in a different gene required for full virulence were inoculated into human pleural fluid (n = 8). S. pneumoniae with pneumococcal surface antigen A (ΔpsaA) mutation failed to grow (2207-fold lower than wild-type), p<0.001, however growth was restored with manganese supplementation. Growth of other common respiratory pathogens (n = 14) across pleural fluid samples (n = 7) was variable and inconsistent, with some strains failing to grow. We establish for the first time that pleural fluid is a potent growth medium for S. pneumoniae and proliferation is dependent on the PsaA surface protein and manganese.

Population-based cohort study examining the association between splenectomy and empyema in adults in Taiwan.

OBJECTIVE: This study aimed to investigate the association between splenectomy and empyema in Taiwan. METHODS: A population-based cohort study was conducted using the hospitalisation dataset of the Taiwan National Health Insurance Program. A total of 13 193 subjects aged 20-84 years who were newly diagnosed with splenectomy from 2000 to 2010 were enrolled in the splenectomy group and 52 464 randomly selected subjects without splenectomy were enrolled in the non-splenectomy group. Both groups were matched by sex, age, comorbidities and the index year of undergoing splenectomy. The incidence of empyema at the end of 2011 was calculated. A multivariable Cox proportional hazards regression model was used to estimate the HR with 95% CI of empyema associated with splenectomy and other comorbidities. RESULTS: The overall incidence rate of empyema was 2.56-fold higher in the splenectomy group than in the non-splenectomy group (8.85 vs 3.46 per 1000 person-years). The Kaplan-Meier analysis revealed a higher cumulative incidence of empyema in the splenectomy group than in the non-splenectomy group (6.99% vs 3.37% at the end of follow-up). After adjusting for confounding variables, the adjusted HR of empyema was 2.89 for the splenectomy group compared with that for the non-splenectomy group. Further analysis revealed that HR of empyema was 4.52 for subjects with splenectomy alone. CONCLUSION: The incidence rate ratio between the splenectomy and non-splenectomy groups reduced from 2.87 in the first 5 years of follow-up to 1.73 in the period following the 5 years. Future studies are required to confirm whether a longer follow-up period would further reduce this average ratio. For the splenectomy group, the overall HR of developing empyema was 2.89 after adjusting for age, sex and comorbidities, which was identified from previous literature. The risk of empyema following splenectomy remains high despite the absence of these comorbidities.

[ANALYSIS OF MICROFLORA OF PLEURAL CAVITY IN PLEURAL EMPYEMA].

In the pleural empyema (PE) treatment, not depending on introduction of multiple operative procedures and the medicinal preparations application, some issues remain unsolved, including the infection agents verification, the most rapid bronchial fistula elimination and the lung volume restoration. The EP infection agents spectrum, their sensitivity to preparations were revealed, as well as the enhanced rate of the methicillin-resistant stamms (MRSA) and the microorganisms associations verification. A reduction of the infection agents sensitivity towards "simple" antibacterial preparations was established, so the physicians, treating PE, must prescribe "hard" antibiotics, what enhances its cost.

Dose dependency of outcomes of intrapleural fibrinolytic therapy in new rabbit empyema models.

The incidence of empyema (EMP) is increasing worldwide; EMP generally occurs with pleural loculation and impaired drainage is often treated with intrapleural fibrinolytic therapy (IPFT) or surgery. A number of IPFT options are used clinically with empiric dosing and variable outcomes in adults. To evaluate mechanisms governing intrapleural fibrinolysis and disease outcomes, models of Pasteurella multocida and Streptococcus pneumoniae were generated in rabbits and the animals were treated with either human tissue (tPA) plasminogen activator or prourokinase (scuPA). Rabbit EMP was characterized by the development of pleural adhesions detectable by chest ultrasonography and fibrinous coating of the pleura. Similar to human EMP, rabbits with EMP accumulated sizable, 20- to 40-ml fibrinopurulent pleural effusions associated with extensive intrapleural organization, significantly increased pleural thickness, suppression of fibrinolytic and plasminogen-activating activities, and accumulation of high levels of plasminogen activator inhibitor 1, plasminogen, and extracellular DNA. IPFT with tPA (0.145 mg/kg) or scuPA (0.5 mg/kg) was ineffective in rabbit EMP (n = 9 and 3 for P. multocida and S. pneumoniae, respectively); 2 mg/kg tPA or scuPA IPFT (n = 5) effectively cleared S. pneumoniae-induced EMP collections in 24 h with no bleeding observed. Although intrapleural fibrinolytic activity for up to 40 min after IPFT was similar for effective and ineffective doses of fibrinolysin, it was lower for tPA than for scuPA treatments. These results demonstrate similarities between rabbit and human EMP, the importance of pleural fluid PAI-1 activity, and levels of plasminogen in the regulation of intrapleural fibrinolysis and illustrate the dose dependency of IPFT outcomes in EMP.

Ventana torácica y anestesia local en la supuración pleural / Thoracic window and local anesthesia in pleural suppuration

Introducción: la colección purulenta en la cavidad pleural es causa de complicaciones, por procesos infecciosos pulmonares, y de alta mortalidad. Con frecuencia se trata de enfermos con deterioro del estado general, situación que se agrava en enfermos de edades geriátricas. Objetivo: mostrar la experiencia en el uso de la toracostomía con resección costal y anestesia local en el Hospital Universitario Manuel Fajardo para la atención de enfermos con empiema pleural.Métodos: se estudiaron 24 pacientes con empiema pleural atendidos desde enero de 1998 hasta octubre de 2015, con edad avanzada y estado físico precario en el Hospital Universitario Manuel Fajardo a los que se les realizó una ventana pleurocutánea con anestesia local. Resultados: La edad promedio fue de edad 72 años; 75 por ciento presentó enfermedades asociadas. La relación hombre/mujer fue de 3 a 1. La causa más frecuente fue el derrame paraneumónico infestado, 100 por ciento tuvo antecedentes de pleurostomía. Hubo cultivo negativo en 20,8 por ciento pacientes. Los gérmenes más frecuentes fueron el estreptococo, estafilococo y gérmenes gramnegativos. Las costillas resecadas fueron los arcos costales anteriores sexto y séptimo y el tiempo promedio de cierre de las ventanas fue de 8 meses, sin mortalidad quirúrgica.Conclusión: la ventana torácica pleurocutánea es un procedimiento quirúrgico de baja mortalidad, ideal para solucionar una cavidad pleural tabicada con gran utilidad en enfermos de edades geriátricas y con estado físico precario, por la factibilidad de realizarla con anestesia local(AU)

Introduction: pleural cavity purulent collection causes high mortality and complications in lung infections processes. It often comes to patients with deterioration of general condition, a situation muchworsened in patients of geriatric age. Objective: to show the experience in using costal thoracostomy and local anesthesia in care for elderly patients with pleural empyema and poor physical condition. Methods: study carried out in 24 patients with pleural empyema, advanced age and poor physical condition cared for from January 1998 to October 2015 at Comandante Manuel Fajardo University Hospital and who also underwent pleurocutaneous window with local anesthesia.Results: average age was 72 years. The male/female ratio was 3 to 1. 75 percent of the patients presented associated diseases. The most frequent cause was infested parapneumonic effusion. There was pleurostomy history in 100 percent of the cases, negative culture in 20.8 percent, while the most common germs were streptococcus, staphylococcus and gram-negative bacteria. The resected ribs were the sixth and seventh previous costal arches. El average windows closing time was 8 months. There was no surgical mortality. Conclusion: pleurocutaneous thoracic window is a surgical procedure with low mortality, ideal to settle a pleural cavity tabicada with great utility in patients at geriatric age and in precarious physical condition, from the feasibility of being performing under local anesthesia(AU)

Ventana torácica y anestesia local en la supuración pleural / Thoracic window and local anesthesia in pleural suppuration

Introducción: la colección purulenta en la cavidad pleural es causa de complicaciones, por procesos infecciosos pulmonares, y de alta mortalidad. Con frecuencia se trata de enfermos con deterioro del estado general, situación que se agrava en enfermos de edades geriátricas. Objetivo: mostrar la experiencia en el uso de la toracostomía con resección costal y anestesia local en el Hospital Universitario Manuel Fajardo para la atención de enfermos con empiema pleural. Métodos: se estudiaron 24 pacientes con empiema pleural atendidos desde enero de 1998 hasta octubre de 2015, con edad avanzada y estado físico precario en el Hospital Universitario Manuel Fajardo a los que se les realizó una ventana pleurocutánea con anestesia local. Resultados: La edad promedio fue de edad 72 años; 75 por ciento presentó enfermedades asociadas. La relación hombre/mujer fue de 3 a 1. La causa más frecuente fue el derrame paraneumónico infestado, 100 por ciento tuvo antecedentes de pleurostomía. Hubo cultivo negativo en 20,8 por ciento pacientes. Los gérmenes más frecuentes fueron el estreptococo, estafilococo y gérmenes gramnegativos. Las costillas resecadas fueron los arcos costales anteriores sexto y séptimo y el tiempo promedio de cierre de las ventanas fue de 8 meses, sin mortalidad quirúrgica. Conclusión: la ventana torácica pleurocutánea es un procedimiento quirúrgico de baja mortalidad, ideal para solucionar una cavidad pleural tabicada con gran utilidad en enfermos de edades geriátricas y con estado físico precario, por la factibilidad de realizarla con anestesia local(AU)

Introduction: pleural cavity purulent collection causes high mortality and complications in lung infections processes. It often comes to patients with deterioration of general condition, a situation muchworsened in patients of geriatric age. Objective: to show the experience in using costal thoracostomy and local anesthesia in care for elderly patients with pleural empyema and poor physical condition. Methods: study carried out in 24 patients with pleural empyema, advanced age and poor physical condition cared for from January 1998 to October 2015 at Comandante Manuel Fajardo University Hospital and who also underwent pleurocutaneous window with local anesthesia. Results: average age was 72 years. The male/female ratio was 3 to 1. 75 percent of the patients presented associated diseases. The most frequent cause was infested parapneumonic effusion. There was pleurostomy history in 100 percent of the cases, negative culture in 20.8 percent, while the most common germs were streptococcus, staphylococcus and gram-negative bacteria. The resected ribs were the sixth and seventh previous costal arches. El average windows closing time was 8 months. There was no surgical mortality. Conclusion: pleurocutaneous thoracic window is a surgical procedure with low mortality, ideal to settle a pleural cavity tabicada with great utility in patients at geriatric age and in precarious physical condition, from the feasibility of being performing under local anesthesia(AU)

[VIDEO-ASSISTED THORACIC SURGERY USING LOCAL ANESTHESIA IN LUNG ABSCESSES AND PYOPNEUMOTHORAX].

The article presents the results of 42 video-abscessoscopies (VAS) in acute and gangrenous lung abscess and 32 video-thoracoscopies (VTS) in pyopneumothorax, which were performed using local anesthesia and sedation. There were several indication to operation: sanation of cavities, removal of necrotic sequestration and fibrin, decollement, biopsy. Perioperative complications developed after 11 surgeries (13%): emphysema of soft tissues of pectoral cells (5), phlegmon of the thorax (3), bronchial hemorrhage (2), pneumothorax (1). One of the patients died, because of progressing of main disease. VAS and VTS were carried out in 5-8 days after cavity drainage of abscess or pleural cavity in 50 patients.. In other 15 cases operations were performed directly before drainage. The bronchial hemorrhage and phlegmons of the thorax were noted in patients of second group. The patients had good tolerance of VAS and VTS operations fulfilled using local anesthesia and sedation. They are safe in case that operation follows drainage of abscess or pleural cavity after decrease of inflammatory processes.

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.

Single-trocar thoracoscopy under local anesthesia for pleural space infection.

OBJECTIVE: The role of single-trocar thoracoscopy for complicated parapneumonic effusion (CPE) and pleural empyema is not established as yet. The aim of this study was to report our experience and analyze the efficacy and safety of debridement by single-trocar thoracoscopy for the patients with CPE and multiloculated empyema. METHODS: We performed a retrospective study reviewing the medical records of the patients treated parapneumonic effusion and multiloculated empyema by single-trocar thoracoscopy under local anesthesia at our department from January 2000 to December 2012. RESULTS: A total 29 patients with CPE and multiloculated empyema were treated by single-trocar thoracoscopy. As the staging of pleural infection, class 5 and class 7 by Light classification were 21 and 8 patients, respectively. The onset of the symptom was on average 13.9 ± 11.7 days before the procedure. This procedure was successful in 23 of 29 patients (79.3%) without further operation under general anesthesia. Complication occurred in 1 case of 29 patients (3.4%). Six patients required subsequently the operation under general anesthesia, and one of the 6 patients died to multiple organ failure caused by sepsis. A microbiological diagnosis could be made in fifteen patients (51.7%). CONCLUSIONS: Debridement by single-trocar thoracoscopy can be an acceptable approach as the first-line procedure in patients with CPE and empyema. This procedure can provide not only appropriate and expeditious treatment but also information of pleural cavity to decide indication for thoracotomy under general anesthesia.

[Nutritional treatment for bronchopleural fistula-promising effect of arginine as a pharmaconutrient].

Pharmaconutrition, which is a supportive nutritional care of surgical patients, has been proven to shorten hospital stay, decrease the incidence of infection, and reduce hospital costs in selected groups of patients. Arginine, one of the most essential pharmaconutrients, has also been proven to enhance would healing process. In severely malnourished patients like bronchopleural fistula with resultant empyema, aggressive nutritional approach should be mandatory. And management of the fistula is also important in stabilizing the ongoing infection. Our hypothesis was that basic nutritional support enhanced with arginine would be effective in not only improving the general condition including nutritional status but also in healing the fistula. We report a case of major bronchopleural fistula in which arginine-supplemented diet as well as aggressive nutritional support could accelerate the postoperative recovery after open thoracic window, ultimately leading to the healing of the fistula.

Unexpected hypozincaemia in a patient with discharging empyema that proved resistant to replacement therapy.

A 45-year-old man was admitted with a massive discharging empyema. He had severe chronic malnutrition and was noted to be zinc and selenium deficient. A high-calorie oral diet supplemented with iron, zinc and selenium was started, together with antibiotic therapy and continued prescription of the patient's regular medication, including a PPI (proton pump inhibitor). Although selenium increased to normal levels after 4 weeks of supplementation, zinc levels failed to normalise. Antibiotic therapy improved the empyema and a steady increase in weight was achieved. The patient was noted to have erythematous skin lesions, hair loss and reduced wound healing, all of which may be attributable to zinc deficiency. We propose that competition for intestinal absorption of nutrients and the use of a PPI may have covertly contributed to the inability to normalise serum zinc levels in this case.

[Perioperative nutritional support with immune-enhancing diet for surgical closure of open thoracic window].

Immunonutrition, which is a therapeutic approach to modulate acute surgical or medical conditions, has been proven to decrease surgical site complications in patients undergoing major elective surgery for upper gastrointestinal and esophageal malignancy. For immunonutrition to be carried out effectively, specific nutrients called pharmaconutrients are quite important. In our case, to enhance the perioperative nutritional status of the patient, special formulas supplemented with specific pharmaconutrients, which are arginine and omega-3 fatty acids, were orally administered. The open thoracic window for chronic empyema caused by postoperative bronchopleural fistula was successfully closed. Perioperative immunonutrition is likely to have beneficial effect in decreasing postoperative infectious complications in high-risk malnourished thoracic surgical patients.

[A case of cryptococcal empyema successfully treated by debridement by medical thoracoscopy with local anesthesia].

Cryptococcal empyema is a rare disease which usually occurs in immunocompromised patients. We describe a 57-year-old man with diabetes mellitus with a mass-like shadow in the right middle lung field. Transbronchial lung biopsy of the right lung revealed numerous yeast-like fungi in fibrotic and necrotic lesions. These findings, together with positive serum cryptococcal antigen yielded a diagnosis of pulmonary cryptococcosis secondary to diabetes mellitus. Despite treatment with several anti-fungal drugs, and dyspnea and pleural effusion developed. He was referred to our hospital for further examination and therapy. The presence of positive cryptococcal antigen and numerous yeast-like fungi were confirmed cytologically in the pleural effusion. Therefore, we suspected that pulmonary cryptococcosis had perforated into the thoracic space and empyema had developed. Because antifungal drugs were ineffective, debridement of the fibrinopurulent material by medical thoracoscopy and chest drainage were performed. The clinical symptoms of this patient improved with antifungal treatment for 1 year, and we successfully treated the cryptococcal empyema without recurrence. Debridement by medical thoracoscopy and chest drainage were useful for this case of cryptococcal empyema.

[Iatrogenic pleuropneumonia as a complication of nutritional treatment of preterm-delivery newborn]. / Jatrogenna pleuropneumonia jako powiklanie leczenia zywieniowego u noworodka urodzonego przedwczesnie.

Our study presents a case of pleuropneumonia caused by a leak of nutritional formula to pleural cavity, which was caused by perforation of the oesophagus. The child was born in 28 hbd with 1400 g birth weight and was fed with mother's milk by a nasogastric tube. From day 11 of life general state of the neonate worsened and on chest X-ray the contrast showed leaking into the right pleural cavity and the end of gastric tube was seen in the right lung area. With this diagnosis the child was admitted to the University Hospital in Bydgoszcz. The child was conservatively treated and in two contrast X-ray examinations there was no pathology of the oesophagus. CT of chest showed pleural empyema which was repeatedly punctured. On the 19th day of hospitalization thoracotomy with resection of interior pulmomery lobe was performed. From the 14th day after surgery, the child was again enterally fed and in good general state. He was discharged on the 51st day of hospitalization. This case should pay our attention to the fact that respiratory distress syndrome of preterm-delivery newborns may be caused by iatrogenic proceedings not only infections and lack of surfactant. Some complications can be accomplished with the nutrition treatment in every dimension.