Empyema necessitans caused by Mycobacterium tuberculosis in an immunocompetent patient.

A 22-year-old man, a recent immigrant from Mexico, was admitted to a Wisconsin hospital because of a swelling of the chest wall and right axilla. Originally, it was thought to be a skin infection with Staphylococcus aureus. When the treatment was unsuccessful, the patient returned to the hospital and the abscesses were found to have been caused by Mycobacterium tuberculosis. Furthermore, there were pleural collections and it was thought that he had a manifestation called empyema necessitans, an extension of purulent pleural liquid through adjacent tissues to form an abscess on the thoracic wall.

[Application of early videothoracoscopic pulmonary decortication in the treatment of an acute pleural empyema and suppurated clotted hemothorax].

There was presented the experience of performance of videothoracoscopic pulmonary decortications in 22 patients, suffering suppurated clotted hemothorax, and in 188--an acute pleural empyema. In 97.3% patients the cessation of purulent process and pulmonary volume restoration were achieved. Residual cavities with the pulmonary nonairtightness signs were revealed in 3 (1.4%) patients, the empyema recurrence--in 1 (0.5%), suppuration of the wound, made by thoracic port--in 1 (0.5%), all the patients are alive.

Risk factors for tuberculous empyema in pleural tuberculosis patients.

Tuberculous empyema (TE) is associated with high mortality and morbidity. In the retrospective cohort study, we aimed to find risk factors for TE among pleural tuberculosis (TB) patients. Between July 2011 and September 2015, all culture-confirmed pleural TB patients (474 cases) were enrolled in our study. Empyema was defined as grossly purulent pleural fluid. Demographic and epidemiological data were collected for further analysis. Multivariate logistic regression analysis was used to evaluate risk factors of TE in pleural TB, age-adjusted odds ratio (OR) and 95% confidence interval (CI) were calculated to show the risk. The mean age was 35.7 ± 18.1 years old, males comprised 79.1% of the participants (375 cases). Forty-seven patients (9.9%) were multidrug-resistant TB (MDR-TB), 29 (6.1%) had retreatment TB, 26 (5.5%) had diabetes mellitus. The percentage of empyema patients was 8.9% (42 cases). Multivariate analysis revealed that male (adjusted OR = 4.431, 95% CI: 1.411, 13.919), pleural adenosine deaminase (ADA, >88 U/L) (adjusted OR = 3.367, 95% CI: 1.533, 7.395) and white blood cell (WBC, >9.52 109/L) (adjusted OR = 5.763, 95% CI: 2.473, 13.431) were significant risk factors for empyema in pleural TB, while pulmonary TB (adjusted OR = 0.155, 95% CI: 0.072, 0.336) was the protective factor for the patients. TE remains a serious threat to public health in China. Male sex is a significant risk factor for TE while the presence of pulmonary TB is protective, and high levels of pleural ADA and WBC count could aid in early diagnosis of TE. This finding would help towards reducing the mortality and morbidity associated with TE.

[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.

Loculated empyema due to tuberculosis in a child.

A 9-year-old girl from black ethnic origin presented with a history of fever, cough, loss of weight and right-sided chest wall pain for 2 weeks. Chest X-ray demonstrated an effusion, which was shown to be loculated on chest CT scan. She was not responding to medical treatment and at thoracotomy loculated pus was drained. Mycobacterium tuberculosis (TB) was cultured from the pus. TB is a rare cause of loculated empyema with an overlapping clinical and radiological picture with pyogenic infections.

[Tuberculous pyopneumothorax: about 18 cases]. / Pyo-pneumothorax tuberculeux: à propos de 18 cas.

Tuberculous pyopneumothorax is a rare but serious complication of evolutive pulmonary tuberculosis. We report a series of 18 cases with tuberculous pyopneumothorax admitted to the Pneumo-Phthisiology Department of the Mohammed V Military Teaching Hospital in Rabat between January 2005 and December 2009. Our study included 15 men and 3 women, the average age was 35 ± 7 years. 4 patients were diabetic. Smoking was found in 9 cases. Right-sided pneumothorax was found in 13 cases. Chest radiograph showed cavitary lesions in 15 patients and extensive bilateral lesions in 8 cases. The search for Mycobacterium tuberculosis in the fluid from the gastric tube was positive in 16 cases. Chest drainage associated with antituberculosis treatment according to the 2SRHZ/7RH regimen and respiratory kinesitherapy were performed in all cases. The average duration of pleural drainage was 4 weeks. In 3 cases we noted persistent pleural suppuration requiring pleural toilet using thoracoscopy with pleurectomy and limited pulmonary resection to eliminate tuberculous parenchymal lesions and the persistence of a large pleural pocket with restrictive ventilatory defect that required surgery for pleural decortication in two cases. The outcome was favorable with minimal pachypleuritis as sequelae in the remaining cases. Tuberculous pyopneumothorax is a severe form, which is often associated with active cavitary tuberculosis. Evolution is generally progressive despite antituberculosis treatment and thoracic drainage, hence the need for early diagnosis and treatment of all forms of tuberculosis.

[Evaluation of open window thoracostomy for chronic tuberculous empyema with broncho-pleural fistula; a retrospective analysis of 33 cases].

We report here our 13-year experience treating chronic tuberculous empyema by open window thoracostomy. The subjects were 33 patients (28 males and 5 females) with a median age of 70 (range: 56-83) years who underwent surgery between January 1990 and December 2002. Patients with a history of pulmonary resection or thoracoplasty were excluded. All patients complained of cough and purulent sputum related to the presence of bronchopleural fistula. Previous illnesses included pulmonary tuberculosis (n = 20) and tuberculous pleurisy (n = 14) treated by artificial pneumothorax (n = 1) or chemotherapy (n = 22). Median duration from the initial episode of tuberculosis to surgery was 44 (range: 1-60) years. Mycobacterium tuberculosis (n = 9), Aspergillus fumigatus (n = 6), methicillin-resistant Staphylococcus aureus (MRSA) [n = 5], and Pseudomonas aeruginosa (n = 5) were representative microorganisms isolated from empyema. Preoperative mean %VC was 48 (range: 31-74)%. Mean follow-up was 34 (range: 1-131) months. Seven patients died of empyema-related disease within 6 months postoperatively. Nine patients underwent curative surgery to close the thoracostomy, including extrapleural pneumonectomy (n = 5), muscular transposition with thoracoplasty (n = 3), and lobectomy with muscular transposition and thoracoplasty (n = 1). In 17 patients, the thoracostomy was left open throughout the observation period because of severe impairment of pulmonary function. In elderly patients with severely impairment of pulmonary function, open window thoracostomy does not control empyema well and has a high rate of mortality.

[Chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae treated by open window thoracostomy followed by thoracoplasty and latissimus dorsi muscle transposition].

We describe a case of chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae successfully treated by open window thoracostomy followed by thoracoplasty and transposition of the latissimus dorsi muscle. A 69-year old man with a history of artificial pneumothorax for pulmonary tuberculosis was referred to our hospital with fever and purulent bloody sputum. He was diagnosed as having right chronic tuberculous empyema with bronchopleural fistulae. Immediate tube thoracostomy markedly relieved symptoms except for low-grade fever. Sputum and empyema cavity cultures were repeatedly positive for MRSA. Open window thoracostomy (5th to 7th ribs resection) was performed to control the infection. The empyema cavity was cleaned with no residual calcified pleura. His condition gradually improved and he underwent thoracoplasty and transposition of the latissimus dorsi muscle 22 months after the initial surgery. He was discharged 25 days postoperatively in good condition. Seventeen months after the curative surgery, he remains well with no evidence of recurrence. A two-stage operation, open window thoracostomy to control infection followed by thoracoplasty and transposition of the latissimus dorsi muscle, is useful in cases of chronic tuberculous MRSA empyema with bronchopleural fistulae.

Decortication is a valuable option for late empyema after collapse therapy.

BACKGROUND: Infection of previous collapse therapy spaces may raise challenging problems. This study evaluated a conservative surgical approach based on decortication. METHODS: Since 1979, 28 patients (mean age, 60 +/- 6 years) have presented at an average of 37 +/- 7 years after artificial pneumothorax for tuberculosis. Diagnosis of empyema was made on follow-up in 12 patients and on symptoms in 16 patients. Mean vital capacity was 66% +/- 16% of normal. Microorganisms were isolated in 13 patients (Aspergillus fumigatus in 5, Mycobacterium tuberculosis in 4, anaerobes in 4). Decortication was made in 24 patients, associated with thoracoplasty in 4, and with partial lung resection in 2 patients. Thoracoplasty alone was performed in 2 patients, and 2 patients underwent an extrapleural pneumonectomy. RESULTS: Both extrapleural pneumonectomies were complicated with empyema requiring thoracoplasty, resulting in one postoperative death. Operative mortality after decortication was nil. Mean intraoperative blood loss during decortication was 1,830 +/- 1,310 mL. All patients were extubated within 24 hours, except 1 patient who was ventilator-dependent preoperatively. Prolonged air leaks were common (mean duration of drainage, 16 +/- 11 days), but ultimately sealed. Existence of symptoms was predictive of prolonged air leaks (p < 0.01). CONCLUSIONS: We conclude that decortication may provide a one-stage cure avoiding the hazards of extrapleural pneumonectomy; the nonfunctioning remaining lung may resolve the space problem.

Fine needle aspiration biopsy of mastitis secondary to empyema necessitatis. A report of two cases.

BACKGROUND: Empyema necessitatis is a relatively rare entity. Two instances of mastitis secondary to empyema necessitatis, diagnosed by fine needle aspiration biopsy are reported. CASES: One case was tuberculous in etiology and was initially recognized by cytologic findings of epithelioid and granulomatous cellular reactions and the presence of acid-fast bacilli, which were subsequently cultured and speciated as Mycobacterium tuberculosis. The other case was due to coexisting Actinomyces and Actinobacillus. These organisms were cytologically suggested by "sulfur" granules of filamentous, gram-positive bacilli, admixed gram-negative coccobacilli and Splendore-Hoeppli phenomenon in an exudative cell background and were confirmed by microbiologic culture as Actinomyces israelii and Astinomyces actinomycetemcomitans, respectively. CONCLUSION: The usefulness of fine needle aspiration cytology in the diagnosis of empyema necessitatis, supported by ancillary microbial culture, histochemistry, and radiographic imaging, is well illustrated by these two cases.

Empyema necessitans: very late complication of pulmonary tuberculosis.

Empyema necessitans is a rare clinical finding nowadays. We report the case of a patient admitted in our ward for investigation of an unknown onset anterior chest wall mass, with no accompanying signs or symptoms. It is noteworthy that the patient had had pulmonary tuberculosis submitted to thoracoplasty more than 60 years before. Thoracic MRI showed a large heterogeneous mass, with a thick wall and internal septations located at the right anterior chest wall, as well as a heterogeneous content inside the right pleural cavity, with direct communication between both. An aspirative puncture of both masses was performed, with positive cultures for Mycobacterium tuberculosis, thus leading to the diagnosis of pleural tuberculosis with anterior chest wall empyema necessitans. A drain was inserted and antibiotics started. This case draws our attention to a very rare complication of pulmonary tuberculosis and its surgical treatment, though it aroused many decades after primary infection.

Chronic tension empyema.

A 60-year-old man who had suffered from chronic left tuberculous empyema for 25 years, was diagnosed with chronic tension empyema based on enlargement of the empyema cavity. To prevent compression of the heart and left lung, we removed the empyema capsule. This procedure relieved the compression of the left lung, and the patient's lung function improved.

[Pleural effusions--experience of Pneumo-phtisiology Hospital Tudor Vladimirescu--I: Clinical study]. / Pleureziile--experienta Spitalului de Pneumoftiziologie Tudor Vladimirescu I: studiul clinic.

Pleural effusions still represent major problem of respiratory tract pathology because of the invalidity potential of pleural involvement and because of the increasing incidence of diseases frequently accompanied by pleural effusion such as tuberculosis and malignant pleural proliferations. The retrospective study concerned 221 cases with pleural effusions divided into three groups depending on the etiology (bacillary, neoplastic and others). Two categories of features were assessed: parameters assessed in the first 48 hours (epidemiological data, history data, clinical data, IDR and sedimentation rate) and parameters assessed after thoracentesis and/or pleural biopsy (LDH in pleural fluid and BK presence in pleural fluid and biopsy specimens). Bacillary etiology was dominating the studied group but possibly because the hospital was well known as a mainly antituberculous medical unit. The main profile of the investigated patients was: man, teenaged or adult, smoker and often alcoholic living in town. Clinical appearance was influenced by the triad: etiologic agent, age, amount of pleural fluid. Reduced amount of pleural fluid was related to acute onset, usually in young men and symptomatology dominated by thoracic pain. In contrast, massive pleural effusion was related with chronic onset, dyspnea and adult or old age. LDH and glyco-pleuria values are not pathognomic but useful for diagnostic orientation but if microscopic or culture evidence of BK in pleural fluid or tissue specimens are added, the diagnostic accuracy is increasing. In conclusion, a thorough clinical examination completed with a complex panel of laboratory investigations, including biochemical microbiological and special tests from pleural fluid and also a cytological examination could guide the diagnostic in establishing the type and the cause of pleural effusion.