[Surgical treatment of tuberculous empyema in children]. / Khirurgicheskoe lechenie tuberkuleznoi émpiemy plevry u detei.

OBJECTIVE: To analyze surgical treatment of tuberculous pleural empyema in children depending on the stage of the process. MATERIAL AND METHODS: There were 82 patients aged 4-17 years with tuberculous pleural empyema. Clinical and X-ray features of different stages of disease are described. Certain types of surgical interventions at each stage of the process are analyzed. RESULTS: In 72 children with empyema stage III 76 surgeries were performed. Postoperative complications occurred in 2 (2.6%) cases (delayed lung inflation) that required thoracocentesis with pleural drainage. There was no postoperative mortality. CONCLUSION: Complex treatment of tuberculous pleural empyema in children and adolescents with the use of modern surgical methods is followed by satisfactory outcomes in all patients. However, surgical technique, postoperative morbidity and hospital-stay depend on the stage of the process. Unfortunately, almost 90% of patients had empyema stage III. Therefore, minimally invasive surgery was not advisable and extensive, traumatic surgeries were required.

Lung Cancer in Patients With Tuberculous Fibrothorax and Empyema: Computed Tomography and 18F-Fluorodeoxyglucose Positron Emission Tomography Findings.

OBJECTIVE: The aim of this study was to describe the characteristics of lung cancers in patients with tuberculous fibrothorax or empyema. METHODS: We retrospectively evaluated 138 consecutive patients with a diagnosis of lung cancer combined with fibrothorax (n = 127) or empyema (n = 11) from January 2005 to May 2015. All patients underwent computed tomography, and 105 underwent F-fluorodeoxyglucose positron emission tomography. Clinical, pathologic, and computed tomography characteristics and maximum standardized uptake values on positron emission tomography of 76 cancers ipsilateral to the fibrothorax or empyema (group 1) were compared with those of 62 contralateral cancers (group 2). RESULTS: The median age at diagnosis of patients was 70 years, with a male-to-female ratio of 8.9:1. The most common type was squamous cell carcinoma (41.3%) followed by adenocarcinoma (39.1%). Most were in the peripheral lung (70.3%), and half abutted the pleura. The median maximum standardized uptake value was 8.9. Tumors in group 1 were larger (median, 48.5 vs 42.8 mm, P = 0.036) and more advanced (T3 or T4) (P = 0.014) than those in group 2. CONCLUSIONS: Lung cancers ipsilateral to tuberculous fibrothorax or empyema presented larger and advanced T stages, and the diagnosis could be delayed. The most common type cancer was squamous cell carcinoma.

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 decortication in patients with chronic tuberculous empyema by three-dimensional computed tomography densitometry.

BACKGROUND: Decortication for chronic pleural empyema (CPE) is to restore lung volume by removing empyema sac and thickened pleura. Extent of lung volume restoration after decortication has been undefined. This study aims to evaluate lung volume restoration using densitometry with three-dimensional reconstruction computed tomography (CT). METHODS: We studied 23 patients with CPE who underwent decortication and follow-up CT. CT and pulmonary function test (PFT) were evaluated at a median of 19.1 months postoperatively. The volumes of operated and nonoperated lung were measured by pre- and postoperative CT-densitometry. Preoperative and postoperative values of lung volumes, PFTs, and thoracic asymmetry rates were compared statistically. RESULTS: The mean preoperative volumes of operated and nonoperated lung were 1,239 and 2,094 mL, respectively and 1,848 and 2,311 mL postoperatively. The postoperative lung expansion rate was 71% on the operated side (p < 0.001) and 15% on the nonoperated side (p = 0.026). The mean improvement rate of total lung volume was 31%. The postoperative value of forced vital capacity, forced expiratory volume during 1 second and lung diffusion capacity of carbon monoxide improved 28.0%, 27.4% (p < 0.001), and 17.9% (p < 0.012), respectively. The thoracic asymmetry decreased from 4.3% before surgery to 2.8% after surgery (p = 0.026). CONCLUSIONS: With the use of CT-densitometry, we quantified the changes of each lung volume. Decortication for CPE can improve re-expansion of diseased and healthy lung. Improvement of nonoperated lung may be due to the overall improvement of chest wall elasticity. Coincidentally, we discovered that the improvement of total lung volume was positively associated with the improvement of PFT after decortication.

Open decortication for patients presenting with stage III tuberculous empyema with low density lines on CT imaging.

To explore the influence of CT findings on the optimal timing of open decorticationin patients with stage III tuberculous empyema. A total of 80 patients with stage III tuberculous empyema who had undergone open decortications were recruited; 44 patients had chest CT findings indicating low-density lines, while 36 patients did not show this imaging finding. Demographic data, perioperative data and preoperative and postoperative chest CT images were collected. In the low-density line group, the duration of disease (P = 0.0030) and the preoperative anti-tuberculosis time (P = 0.0016) were longer than those of the group without low-density lines, and the ESR (P = 0.0218), CRP (P = 0.0027) and leukocyte count (P = 0.0339) were lower in the low-density line group. Additionally, in the median operative time (P = 0.0003), intraoperative blood loss (P < 0.0001), volume of catheter drainage during 48 h after operation (P = 0.0067), chest tube duration (P < 0.0001), and length of hospital stay (P = 0.0154) were significantly lower in the low-density line group than in the group without low-density lines. A total of 88.64% of participants in the low-density line group showed hyperplasia with hyaline degeneration in pathological examination, which was observed only in 41.67% of patients without low-density lines. In addition, gaseous necrosis was considerably higher in patients without a low-density line (P = 0.004), while the low-density line group had a higher rate of treatment success (P < 0.05). Patients with stage III tuberculous empyema presenting with low-density lines around the thickened fibrous pleural rind on preoperative CT imaging may be good candidates for open decortication.

Surgical outcomes and the factors affecting lung expansion following open window thoracostomy in chronic tuberculous empyema with destroyed lung.

BACKGROUND: Patients with chronic tuberculous empyema and destroyed lung on a prolonged intercostal tube with failed lung expansion considered unsuitable for single-lung ventilation have poor outcomes. The study's objective was to analyze the surgical outcomes and lung expansion factors in these patients following the open window thoracostomy (OWT) procedure. METHODS: In a prospective study, patients (males = 63, females = 12) diagnosed with tuberculosis who underwent OWT were analyzed between 2017 and 2018. Factors including age, sex, side, comorbidities, body mass index (BMI), bacteriological culture, and patency of OWT site were evaluated for lung expansion. RESULTS: Mean preoperative weight 40.96 ± 5.70 kg increased significantly postoperatively. Pseudomonas aeruginosa (30.66%) was the most typical organism isolated and smoking (21.3%) was the common risk factor. At 6-month follow-up, complete lung expansion was noted in 60% of patients, while partial and no expansion is seen in 17.3% and 22.3% patients. Similarly 82.4% patients with pre-operative BMI>18.5 kg/m2 had complete lung expansion, while with BMI < 18.5 kg/m2, 41.7% and 45.8% had partial and no-expansion. Complete lung expansion was seen in 97.1%, 18.2%, and 23.1% of patients with obliterated OWT, sputum, and pleural pus positive for acid-fast bacilli (active disease), while in 57.9% of patients with comorbidities, complete lung expansion was absent. CONCLUSION: The analysis of various factors concludes that lung expansion is not affected by age, sex, side of the disease, and co-morbid conditions; however, extensively diseased lungs with low BMI and positive bacteriological culture, especially P. aeruginosa, active disease, smoking, and patent OWT, interfered with the expansion of the lung.

Pyothorax-associated lymphoma: imaging findings.

OBJECTIVE: The purpose of this study was to evaluate the radiologic features of pyothorax-associated lymphoma on CT scans and chest radiographs. MATERIALS AND METHODS: Radiographs and CT scans of 21 patients with biopsy-proven pyothorax-associated lymphoma (17 men, four women; median age, 71 years; range 52-77 years) were retrospectively identified. Two readers in consensus analyzed the morphologic imaging features of pyothorax-associated lymphoma and determined their relation to the preexisting chronic empyema cavity. In 13 cases, gallium scans were available and were reviewed. RESULTS: Sixteen patients had a history of artificial pneumothorax therapy for tuberculosis. Pyothorax-associated lymphoma was visualized mainly (71.4% of cases) as extrapulmonary pleural masses on chest radiographs. The CT features included a lenticular (60%) or crescentic (20%) soft-tissue mass located eccentrically at the margin of a coexistent empyema cavity, which was present in all cases. Masses of pyothorax-associated lymphoma were commonly located in the lateral costal pleura (50%) or at the costophrenic angle (30%). The tumor matrix often appeared heterogeneous and contained areas of necrosis (60%). Direct invasion of the chest wall, ribs, lung parenchyma, and abdomen was found in 75%, 50%, 25%, and 25% of patients. Gallium scans, when available, showed marked uptake in 10 of 13 patients (76.9%). CONCLUSION: In patients who have undergone artificial pneumothorax therapy for tuberculosis more than 20 years in the past, a pleural soft-tissue mass adjacent to the margin of a coexistent empyema cavity suggests the presence of pyothorax-associated lymphoma. Knowledge of the typical radiologic findings and locations of pyothorax-associated lymphoma help in the diagnosis of this rare pathologic entity.

Computed tomography features of extensively drug-resistant pulmonary tuberculosis in non-HIV-infected patients.

OBJECTIVE: To describe the computed tomography (CT) findings of pulmonary extensively drug-resistant tuberculosis (XDR-TB) in non-HIV-infected patients and to compare them with those of non-XDR multidrug-resistant tuberculosis (MDR-TB). METHODS: Retrospective review of microbiological results and drug-susceptibility tests of 260 non-HIV-infected patients who had been diagnosed with pulmonary MDR-TB from 1994 to 2005 revealed that 47 patients had XDR-TB, whereas the other 213 patients had non-XDR MDR-TB. Twenty of the 47 XDR-TB patients and 85 of the 213 non-XDR MDR-TB patients with available CT examinations were included in this study. Two radiologists reviewed the CT studies in consensus for the presence and extent of micronodules, tree-in-bud appearance, lobular consolidation (<2 cm), consolidation, cavity, bronchiectasis, emphysema, pleural effusion, lymphadenopathy, bronchopleural fistula, and empyema. We then compared the CT features of XDR-TB with those of non-XDR MDR-TB. RESULTS: Micronodules and tree-in-bud appearance were the most frequent CT abnormalities and were seen in all XDR-TB patients (100%). Consolidations, cavities, bronchiectasis, and lobular consolidations were found in 85%, 85%, 80%, and 70% of XDR-TB patients, respectively. The extents of micronodules, tree-in-bud appearance, lobular consolidation, consolidation, cavity, bronchiectasis, and emphysema were 3.60, 3.55, 1.35, 1.85, 1.65, 1.45, and 0.25 lobes, respectively. Compared with non-XDR MDR-TB, XDR-TB showed a significantly larger extent of tree-in-bud appearance and consolidation (P < 0.05). With respect to other CT features, there were no significant differences between XDR-TB and non-XDR MDR-TB. CONCLUSION: Computed tomography findings of pulmonary XDR-TB are similar to those of non-XDR MDR-TB; however, XDR-TB tends to have more extensive consolidation and tree-in-bud appearance.

Chronic tuberculous empyema in an 8-year-old boy.

Mycobacterium tuberculosis (MTB) as a causative organism of empyema thoracis is rare, especially in children. An 8-year-old boy with tuberculous empyema and no history of contact with tuberculosis presented with minimal symptoms other than mild deformity of the chest wall. He had been vaccinated with bacillus Calmette-Guérin. A chest CT scan demonstrated intrathoracic lymphadenopathy, thickened and calcified pleural rind and rib thickening adjacent to the empyema. The diagnosis was confirmed by post-operative histopathological examination, positive acid-fast stains and DNA PCR. In countries with a high burden of tuberculosis, MTB should be considered in the differential diagnosis of empyema despite minimal symptoms.

Empyema thoracis due to nocardiosis and Mycobacterium tuberculosis mixed infections in an AIDS patient.

A 26-year-old Thai man presented with progressive dyspnea for four months and right pleuritic chest pain two days before admission. The chest radiograph showed massive right pleural effusion. Thoracentesis was done, and the culture grew Nocardia spp as well as positive strain for acid-fast bacilli. An anti-HIV test was reactive, with a CD4 count of 12 cells/mm3. The patient was treated with inter-costal tube drainage (ICD) inserted for empyema thoracis. The antimicrobials used trimethoprim-sulfamethoxazole and anti-TB drugs CAT-1 orally. One month later, anti-retroviral therapy with HAART was initiated. At follow-up after 6 months, he was healthy appearing, with a nearly normal chest radiograph.

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.

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.

[The surgical treatment of chronic tuberculous empyema of the pleura].

333 patients with chronic tuberculous empyema were treated in the Central Military Clinical Tuberculous Hospital N 4. Among them there were 325 (97,6%) men and 8 (2,4%) women. The patients' age varied from 18 to 87 years. The main causes of empyema development were the following: the exudative pleurisy--in 179 (53,8%) cases, the complications of lung resection--in 69 (20,7%), the ineffective artificial pneumothorax--in 50 (15,0). In 34 (10,2%) patients the empyema was the result of spontaneous pneumothorax and in 1 (0,3%) patient it developed due to generalization of tuberculosis of extra-pulmonary localization. The treatment was based on extensive surgical interventions performed in patients during the stable and subacute phases of pathologic process. It allowed achieving the good results in 89,2% and satisfactory results--in 9,9% patients.

Tuberculous Empyema Post Bilateral Lung Transplant.

Tuberculous empyema in lung transplantation recipients is a rare entity, with only a handful of cases reported in the English-language literature. We are reporting a case of tuberculous empyema 3 months after uncomplicated bilateral lung transplantation. The recipient underwent video-assisted thoracic surgery for diagnosis and decortication. Both the recipient and donor lacked a history of tuberculosis or tuberculosis exposure.

Thoracoscopic Decortication of Stage III Tuberculous Empyema Is Effective and Safe in Selected Cases.

BACKGROUND: Open decortication of advanced tuberculous empyema remains standard of care. As with other aspects of thoracic surgery, minimally invasive approaches are making inroads into procedures traditionally performed open. In this retrospective analysis, we sought to examine feasibility, efficacy, and outcomes of thoracoscopic decortication of stage III tuberculous empyema in our experience. METHODS: The records of all patients in whom thoracoscopic decortication of stage III tuberculous empyema was performed between March 2012 and December 2015 were examined. Demographic and perioperative data were analyzed to assess the surgical outcomes of this study group. To assess long-term efficacy, patients were followed for a minimum of 6 months. RESULTS: One hundred patients fit the study criteria, of these 67 were men. Ninety cases were successfully completed thoracoscopically. Mean operative time was 204 ± 34.2 minutes with mean blood loss of 384 ± 28 mL. Median chest drain duration and hospital stay was 7 days. There was no perioperative deaths. Morbidity rate was 33%, composed mostly of prolonged air leak (29%). Six-month follow-up revealed completely expanded lung in all patients except one with small apical asymptomatic air space. Intraoperative cultures were positive for mycobacteria in 25% patients. Six (6%) of these patients had multidrug-resistant tuberculosis and required a modification in their antituberculous therapy. CONCLUSIONS: Thoracoscopic decortication of advanced tuberculous empyema is feasible, safe, and effective with good short- and long-term results in selected patients. In a substantial portion of patients, operative cultures required modifying drug treatment to treat underlying tuberculosis.

Chest wall defect and chronic pleural infection: surgical treatment with thoracomyoplasty and open window thoracostomy.

We report a rare case of a 75-year-old hemiplegic man with a chronic pleural infection, a bronchopleural fistula, and a full-thickness defect of the chest. In one operation we performed open-window thoracostomy and pleural decortication as well as reconstruction of the chest defect and reclosure of the bronchopleural fistula with a latissimus dorsi muscle flap. The patient made a good recovery and was sent for rehabilitation in good condition. Surgical treatment was essential to control and ultimately halt the septic process. Use of a muscle transplant in a hemiplegic patient did not reduce mobility.