A potential prospect: The novel treatment of intrapleural saline irrigation with intrapleural tyloxapol in treating thoracic empyema.

The treatment for empyema thoracis has been evolving over the years, including the usage of intrapleural fibrinolytic therapy (IPFT), for example, alteplase with intrapleural deoxyribonuclease (DNase) to enhance the drainage of pleural effusion. Here, we report two cases of thoracic empyema that were successfully treated with intrapleural saline irrigation and intrapleural tyloxapol apart from parenteral antibiotics as the pillar of the treatment. Both patients averted surgical procedure (decortication) and were discharged well. Upon follow-up, both cases showed clinical cure, biochemical recovery, and radiological improvement, indicating a good treatment outcome. This is the first reported cases on combination of saline irrigation with tyloxapol as alternative treatment for pleural infection.

Seasonal variations of empyema in Taiwan: A 10-year analysis.

BACKGROUND: Empyema is a serious infection in pleural space. Finding out seasonal variations of empyema and its pathogens can help in providing preventive measures, and implicating future researches. METHODS: This study is a 10-year observational study in a single center. Patients with empyema thoracis receiving thoracoscopic decortication between January 2012 and December 2021 were included in the study. RESULTS: There were 1082 empyema patients enrolled in this study. No seasonal variation was noted (spring = 25.7 %, summer =25.5 %, autumn = 24.8 %, winter = 24.0 %). However, we observed seasonal variations in pathogens. Streptococcus species had slightly higher prevalence in winter and spring than summer and autumn (54.3 % vs. 45.7 %) without significant difference (p = 0.251). On the contrary, Staphylococcus species occurred more often in summer and autumn than winter and spring (61.5 % vs. 38.5 %) (p = 0.035). Klebsiella species were more likely found in autumn (34.9 %) (p = 0.050), and Pseudomonas species showed no peak prevalence in any season (p = 0.423). The incidence of Streptococcus species increased over the years. CONCLUSIONS: Although no seasonal variation was found in severe empyema patients requiring surgery, there were seasonal variations for the pathogens in Taiwan. The medical community should focus on Streptococcus species in winter and spring and Staphylococcus species in summer and autumn.

Fungal empyema thoracis, a rare but an emerging entity: a retrospective case series from Pakistan.

Background and objective: Fungal empyema is a rare entity which is associated with high mortality. It is mostly seen in immune-compromised hosts. However, there is limited data available on fungal empyema from developing countries regarding risk factors, treatment, and outcome. This study was conducted to determine the risk factors, clinical features, treatment, and outcome of fungal empyema. Methods: A retrospective observational study was performed on proven fungal empyema cases, admitted at Aga Khan University Hospital, Karachi, Pakistan during January 2018 to May 2021. We excluded all those patients with polymicrobial bacterial and fungal empyema or with negative pleural fluid cultures. A preformed questionnaire was filled out for each case. Results: A total of 26 patients were diagnosed with fungal empyema with a mean age of 43.6 ± 20.3 years. Of these, 16 (61.5%) patients were male. Diabetes mellitus was the most frequent comorbidity (n = 11, 42.3%), followed by hypertension (n = 9, 34.6%), malignancy (n = 6, 23.1%), and asthma (n = 1, 3.8%). Ten (38.5%) patients had multiple comorbidities. Candida spp. was isolated in 21 (80.8%) patients and Aspergillus spp. in 7 (26.9%) patients. Fusarium spp. was isolated from one (3.9%) patient. Video-assisted thoracoscopy surgery was done in 14 (53.8%) patients and 12 (46.1%) patients were managed with tube thoracostomy. Twenty-one (80.8%) patients received antifungal agents. Overall, in-hospital mortality was 38.5% (n = 10) and all patients developed respiratory failure. Clinical improvement was seen in 16 (61.5%) patients. Conclusion: Our data suggest that fungal empyema has a poor outcome as almost one-third of our patients died. Early diagnosis and intervention can improve outcome.

Fungal Empyema; A Case series from Pakistan • This study was carried out as there are limited data available globally on fungal empyema. • We conducted a retrospective case study of 26 patients and our findings suggest that the fungal empyema has a poor outcome. • One third of our patients died during hospital stay. • Early diagnosis and treatment are important in fungal empyema. • Diabetes mellitus was found as a possible risk factor for fungal empyema, which should be evaluated further in future studies.

Isoniazid Mono-Resistant Tuberculosis Presenting as Empyema Thoracis With Citrobacter koseri and Morganella morganii Infections: The World's First Reported Case of Its Type.

Drug resistance is very common in developing countries. Isolated cases of concomitant infection with Mycobacterium tuberculosis, Citrobacter koseri, and Morganella morganii are rare. Furthermore, there is no report available in the literature of concurrent infection of Citrobacter koseri and Morganella morganii in an isoniazid mono-resistant tuberculosis patient. In this case, we present a concomitant infection with drug-resistant strains of Mycobacterium tuberculosis, Citrobacter koseri, and Morganella morganii in a 40-year-old Indian male who presented with fever, dry cough, and chest pain. He was initiated on an isoniazid mono regimen and a broad-spectrum antibiotic, following the national guidelines.

Percutaneous management of complicated empyema thoracis using pigtail, report of a case from University Hospital of Nepal: a case report.

Empyema thoracis is a condition characterized by the accumulation of pus in the pleural cavity of the lungs. Empyema thoracis is a cause of high mortality in man and its occurrence is increasing in both children and adults. Traditionally, chest tube drainage has been a preferred method of treatment, but recent studies have shown that pigtail catheter drainage is a more effective and less invasive alternative. Image-guided drainage is also preferred over blind drainage, and alternative drainage sites are being explored. These management changes have improved patient outcomes and reduced the risk of complications. Case presentation and clinical discussion: A 66-year-old female presented with complaints of cough, fever, and chest pain. A clinical examination was done and relevant investigations were sent. She was then treated in the line of left-sided empyema thoracis. A pigtail catheter was inserted into the loculated empyema via the left 9th intercostal space through a posterolateral approach with ultrasonography guidance. Conclusion: The main aim of this article is to provide an overview of a rare management approach for empyema, a condition characterized by the accumulation of pus in the pleural cavity of the lungs. In this case report, the authors have focused on pigtail catheter drainage over traditionally performed chest tube drainage, and image-guided drainage has been performed over blind drainage ensuring accurate placement and reducing the risk of damage to surrounding tissues. Another notable change in empyema management is the shift in drainage sites from the safety triangle to other sites based on the site of loculations under ultrasonography guidance.

The outcomes of thoracoscopic decortication between fungal empyema and bacterial empyema.

BACKGROUND: Fungal empyema is an uncommon disease and is associated with a high mortality rate. Surgical intervention is suggested in stage II and III empyema. However, there were no studies that reported the outcomes of surgery for fungal empyema. METHODS: This study is a retrospective analysis in a single institute. Patients with empyema thoracis who underwent thoracoscopic decortication between January 2012 and December 2021 were included in the study. We separated the patients into a fungal empyema group and a bacterial empyema group according to culture results. We used 1:3 propensity score matching to reduce selection bias. RESULTS: There were 1197 empyema patients who received surgery. Of these, 575 patients showed positive culture results and were enrolled. Twenty-eight patients were allocated to the fungal empyema group, and the other 547 patients were placed in the bacterial empyema group. Fungal empyema showed significantly longer intensive care unit stay (16 days vs. 3 days, p = 0.002), longer median ventilator usage duration (20.5 days vs. 3 days, p = 0.002), longer hospital stay duration (40 days vs. 17.5 days, p < 0.001) and a higher 30-day mortality rate (21.4% vs. 5.9%, p < 0.001). Fungal empyema revealed significantly poorer 1-year survival rate than bacterial empyema before matching (p < 0.001) but without significant difference after matching. CONCLUSIONS: The fungal empyema patients had much worse surgical outcomes than the bacterial empyema patients. Advanced age and high Charlson Comorbidity Index score are independent predictors for poor prognosis. Prompt surgical intervention combined with the use of antifungal agents was the treatment choice for fungal empyema.

Fatal Pyopneumothorax in a COVID-19 Patient.

The COVID-19 pandemic has impacted every aspect of our lives since its start in December 2019. Among various COVID-19 complications, pleural complications are also increasingly reported but rarely from Nepal. Here, we presented a case of pyopneumothorax in a 52-year-old male patient referred from another center and admitted to the ICU of Nepal Armed Police Force Hospital with a diagnosis of severe COVID-19 pneumonia in the background of alcohol withdrawal syndrome with delirium tremens and generalized tonic-clonic seizures. He developed a rapid decline in respiratory status with a right-sided pneumothorax and underwent an immediate needle thoracostomy, followed by chest tube insertion. On the sixth day of admission, he had thick yellowish pus in the chest drain (pyopneumothorax), and despite the rigorous efforts in treatment, he died on the 15th day of admission. Though relatively uncommon, clinicians should consider pleural complications like pneumothorax, pleural effusion, pneumomediastinum, and empyema in patients with impaired immune status. In such patients, we should ensure prompt diagnosis with the earliest intervention and rationale use of antibiotics.

An Advanced Comprehensive Physiotherapy Management for Empyema Thoracis and Scoliosis: A Case Report.

Tuberculous empyema is caused by Mycobacterium tuberculosis infection of the pleural cavity, resulting in purulent pleural fluid formation. Tuberculous empyema most commonly develops in patients with tuberculous pleuritis treated with artificial pneumothorax. However, it can also develop in patients with chronic tuberculous pleuritis, usually in patients with pulmonary tuberculosis treated with antituberculous chemotherapy. Scoliosis is a three-dimensional spine deformity caused by several factors, including genetic susceptibility, anterior and posterior spinal development imbalance, and connective tissue abnormalities (skeletal muscle and nerves). Although surgery is the most talked-about treatment option, there is high-quality evidence suggesting the use of conservative therapy in the management of scoliosis. A systematic rehabilitation plan with a variety of approaches was developed, and it was found to be a highly successful protocol for treating the patient's empyema and scoliosis.

Management of Empyema Thoracis in Low-Resource Settings.

Most cases of empyema thoracis are sequelae of severe pneumonia, but chest trauma and complications of chest tube insertion as cause are not uncommon in low-resource settings. Diagnosis is usually delayed due to delayed presentation to health care facilities, low index of suspicion among health care professionals, and inability to properly stage the disease with the available diagnostic tools. Early use of antibiotics and appropriate-sized and well-placed chest tube drainage is associated with good outcomes at a decreased cost. Surgical management of empyema thoracis is indicated when chest tube drainage and antibiotic treatment fail to achieve complete resolution.

Surgical Treatment for Empyema Thoracis: Prognostic Role of Preoperative Transthoracic Echocardiography and Serum Calcium.

BACKGROUND: Empyema is a major cause of mortality and hospitalization. Symptoms include difficulty breathing and chest pain. Calcium plays an essential role in the physiology of the cardiovascular system. However, there is little evidence on the role of echocardiography and the serum calcium levels of patients undergoing video-assisted thoracoscopic surgery (VATS) for empyema. This study aimed to investigate the risk factors for postoperative mortality in patients with empyema who required surgery. METHODS: This single-institution retrospective study compared the outcomes of VATS for thoracic empyema (in terms of survival and mortality) in 122 patients enrolled between July 2015 and June 2019. RESULTS: This study examined patients with thoracic empyema. The majority of the patients were males (100/122, 81.9%). The in-hospital/30-day mortality rate was 10.6% (13 patients). The calcium levels were 7.82 ± 1.17 mg/dL in the survival group and 6.88 ± 1.88 mg/dL in the mortality group (p = 0.032). In the mortality group, the utilization of echocardiography and serum calcium levels independently contributed to the risk prediction more than clinical variables. Patients in our cohort exhibited elevated pulmonary artery systolic pressure (PASP) and hypocalcemia, which were associated with increased postoperative mortality. CONCLUSION: Elevated PASP and calcium levels at the low end of the normal range demonstrated significant prognostic value in predicting mortality in patients with thoracic empyema who required surgical intervention. Recognizing this potential is critical in order to obtain better outcomes.

Prognostic Factors in the Management of Empyema Thoracis in Northern Nigeria.

Background: Empyema thoracis portrays pleural effusion with demonstrable actively multiplying bacteria. It is a significant cause of morbidity, and commonly complicates parapneumonic effusions. It is important to identify those factors that can be used to prognosticate the outcome of its management in our locality so that those that are modifiable could be applied to improve management outcomes. Materials and Methods: A prospective cohort study of patients managed for empyema thoracis at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria from February 2017 to January 2018 was conducted. Eighty-three patients were enrolled for this study and recruitment into the study included all consecutive patients being managed for empyema thoracis in ABUTH, Zaria during the study period. Data collected included age, gender, aetiology, microbial isolates, BMI, initial and total empyema volumes, and duration before hospital presentation. The patients were subsequently managed and observed, and the outcome of management (duration of drainage and hospital stay, percentage of lung expansion, and need for decortication) was noted. Results: Patients in the paediatric age group correlated positively with an earlier presentation to the hospital. The duration before presentation correlated positively with the stage of the disease. The duration before presentation and the total empyema volume indexed to body surface area could prognosticate all four outcome parameters assessed. The age and stage of the disease prognosticated the lung expansion and the need for decortication. The initial empyema volume indexed to body surface area prognosticated the length of hospital stay. The presence of complications was a determinant of the need for decortication. Adolescents and adults had 2.1 times increased probability of requiring a decortication for successful management. Conclusion: The age, stage of the disease, duration before presentation, initial empyema volume indexed to body surface area, and total empyema volume indexed to body surface area can be used to prognosticate the outcome of empyema thoracis. With the onset of complication comes a higher chance of requiring decortication. Children are less likely to require decortication for satisfactory management of empyema thoracis.

An Unusual Presentation of Ludwig's Angina with Empyema Thoracis and External Carotid Artery Pseudoaneurysm.

Ludwig's angina is a rapidly spreading soft-tissue infection and commonly occurs following odontogenic infection. A 30-year-old male presented to the emergency department, 7 days after the extraction of molar teeth with a sudden onset of mandibular swelling. He was diagnosed with Ludwig's angina with empyema thoracis and external carotid artery (ECA) pseudoaneurysm. He was successfully managed with video-assisted thoracoscopic surgery-guided drainage and endovascular embolization of ECA pseudoaneurysm. We share our experience of challenges faced during the management of unusual presentation of complicated Ludwig's angina.

Clinico-radiological profile of the patients with empyema thoracis: A prospective analytical study.

BACKGROUND: Empyema thoracis is defined as the presence of pus in the pleural cavity and carries significant morbidity and mortality. This study aimed to explore the demographic and clinico-radiological characteristics of patients with empyema thoracis. MATERIAL AND METHODS: The present study was conducted in a tertiary care teaching hospital in North India. The patients diagnosed with empyema thoracis were included in the study. Demographic, etiologic, clinical, radiographic, and outcome data were prospectively collected and analyzed. RESULTS: The study included 48 patients. The median age of empyema thoracis patients was 37(IQR 26-45) years. Common presenting symptoms were breathlessness (n = 37,77%) and chest pain (n = 34,70%). Contrast-enhanced computed tomography (CECT) of the chest showed type III empyema in 52% (21) patients followed by type 1 and type II in 25% and 22%, respectively. CECT thorax showed the collapse of lung and consolidation in (n = 28, 70%) and (n = 24, 60%) patients, respectively. All the patients, except for one, were managed with underwater seal intercostal tube drainage (ICD) procedure for the management of empyema. The median time to remove the ICD tube among 35 patients was 14 (IQR 9-21) days. Forty patients (83.3%) responded to the treatment and were discharged. Eight patients (16.7%) deteriorated and succumbed to the disease. CONCLUSION: Patients of empyema thoracis required a prolonged period of chest tube drainage and carried significant morbidity and mortality.

Large infected pulmonary cyst mimicking empyema thoracis.

Infected pulmonary cyst could be misdiagnosed as empyema thoracis. Here, we report an infected pulmonary cyst in a middle-aged male patient. This report could serve as a reminder for differential diagnosis of infected pulmonary cyst, for which surgical approach would be more safe and effective method.

VATS thoracoscopic decortication for empyema thoracic: A retrospective experience and analysis of 162 cases.

OBJECTIVE: To analyse the experience of empyema thoracis management using video-assisted thoracoscopic surgery. METHODS: The retrospective study was conducted at the Combined Military Hospitals, Rawalpindi and Lahore, Pakistan, and comprised data of empyema thoracis cases who underwent thoracoscopic decortications by the same consultant surgeon between January 2009 and 2018. Uniportal or multiportal video-assisted thoracoscopic decortications was performed. Histopathology and microbiological sampling were done in all cases. RESULTS: Of the 162 cases, 114(70.4%) were males and 48(29.6%) were females. The overall mean age was 44±16.37 years. Three ports were utilised in 58(36%) patients. Hospital stay of 122(75.3%) patients was <5 days post-procedure. Post-thoracotomy neuralgia occurred in 19(11.7%) patients, while 9(5.5%) had surgical site infection. Overall complications were 30(18.5%). There was no mortality. CONCLUSIONS: Video-assisted thoracoscopic decortications was found to be a safe, effective and efficient procedure.

Pleural empyema in children - benefits of primary thoracoscopic treatment.

INTRODUCTION: Pleural empyema is the condition of the pleural cavity when initially sterile pleural effusion has become infected. In the majority of cases, it is of parapneumonic origin. Parapneumonic effusions and pleural empyemata usually continuously progress in severity. The American Thoracic Society divides them into three stages: exudative, fibrinopurulent and organizing. The therapy depends on the stage. AIM: To assess whether thoracoscopy should be considered better than conservative treatment and to assess the feasibility of the thoracoscopic approach to the 3rd phase of pleural empyema. MATERIAL AND METHODS: The clinical course of 115 patients treated from 1996 to 2017 was analyzed. 45 patients operated on thoracoscopically after the failure of conventional treatment were compared with 70 patients treated by primary thoracoscopic drainage and decortication. RESULTS: The results of the study demonstrated that patients treated primarily by thoracoscopy had a shortened length of hospital stay (16.6 vs. 19.3 days), reduced drainage time (7.9 vs. 9.8 days), and shorter time of general therapy (31.8 vs. 38.0 days). They required fibrinolysis less frequently (12.8 vs. 26.7% of patients) and had reduced risk of reoperation (10 vs. 15.6% of cases). Operation time in the 3rd stage was only 15 min longer. The difference in length of hospital stay was only 0.8 days in favor of less severe cases. CONCLUSIONS: The thoracoscopic approach is safely feasible in the 3rd stage of pleural empyema and should be considered as the preferred approach. Furthermore, the post-operative stay and general course of the disease are milder whenever surgery would not be delayed by prolonged conservative treatment attempts.

Surgical outcome of empyema thoracis patients with special correlation to pre-operative contrast-enhanced computerized tomography (CECT) thorax morphometry.

PURPOSE: Empyema thoracis is a very common disease. The surgical outcome of empyema patients depends upon various factors. To the best of our knowledge, there is no study in literature describing the surgical outcome of patients in relation to the contrast-enhanced computerized tomography (CECT) thorax morphometric findings. In this study, we examined the surgical outcome of empyema thoracis patients in relation to both clinical and radiological findings. MATERIALS AND METHODS: It is a prospective hospital-based study conducted between October 2016 and August 2018. A total of 30 patients, who underwent decortication during the study period, were included. They were divided into three performance groups (excellent performance, average performance and poor performance groups) according to the outcome. The surgical outcome was correlated with the pre-operative clinical, radiological, intra-operative and post-operative parameters. RESULTS: Intra-operative ability to complete decortication, intra-operative expansion of the lungs and presence of broncho-pleural fistula were significantly different between the three performance groups. Duration of the disease, pre-operative duration of antitubercular therapy (ATT) intake and duration of pre-operative intercostal drain (ICD) were statistically insignificant between groups. In computed tomography (CT) morphometry, residual lung volume of the involved lung and volume of empyema were found to be significantly different between the performance groups. The residual volume of the involved lung (expressed in terms of the percentage of lung volume of the normal opposite lung) can predict the complete expansion of the lung with sensitivity of 71% and specificity of 70%. CONCLUSION: The pre-operative residual lung volume of the involved lung, empyema volume, completeness of decortication, intra-operative expansion of the lung and presence or absence of broncho-pleural fistula can determine the surgical outcome in empyema thoracis patients.

Epidemiologic Trends in Pleural Infection. A Nationwide Analysis.

Rationale: Recent trends in the care and outcomes of pleural infection are not well characterized.Objectives: To investigate trends in hospital-based healthcare use, outcomes, and management of pleural infection across the United States.Methods: We identified adult hospitalizations for pleural infection from 2005 through 2014 in the Healthcare Cost and Utilization Project-National Inpatient Sample using International Classification of Diseases, Ninth Edition Clinical Modification diagnosis codes. We calculated weighted estimates of national trends in hospitalization, hospital length of stay, hospital mortality, inflation-adjusted cost, and management practices. We tested trend significance using fitted regression models.Results: Over one decade, there was a significant decline in hospitalizations (54.4 per million to 41.2 per million U.S. adult population), length of stay (13.5 ± 0.2 to 11.2 ± 0.2 d), mortality (4.2-2.6%), and costs ($32,829 to $29,458) (all P < 0.001). Both tube thoracostomy and video-assisted thoracoscopic surgery saw an increase as the procedure of first choice, along with declining use of thoracotomy (all P < 0.001). Most patients who underwent video-assisted thoracoscopic surgery (94%) or tube thoracostomy (64.9%) as the initial procedure did not require a second invasive procedure.Conclusions: Over the 21st century's first decade and a half, inpatient costs, use, and mortality have improved among U.S. adults hospitalized with pleural infection. Simultaneously, there has been a shift toward less invasive interventions upfront.

Citrobacter freundii: A Cause of Cardiac Tamponade and Empyema Thoracis in a Nigerian Child.

Citrobacter infection is an uncommon but serious, difficult to treat infection associated with high mortality. Accumulation of pus or fluid in a pericardial space causes restriction of cardiac filling and consequent decrease in cardiac output. We herein report Citrobacter freundii, a rare infectious cause of this uncommon disorder. Our patient is a 10yr old male referred with complaints of cough productive of mucoid sputum and associated chest pain of two weeks duration, difficulty in breathing and orthopnoea for one week. He was acutely ill looking in respiratory distress with tachypnoea and tachycardia. Blood pressure was normal with pulsus alternans, there was increased jugular venous pressure, diffused apex beat and distant heart sounds with pericardial rub. Retroviral screening and gene Xpert for Mycobacterium tuberculosis were negative. Chest radiograph showed enlarged heart of "water bottle" appearance with cardiothoracic ratio of 0.77 and right sided pleural effusion which was drained. Transthoracic Echocardiogram confirm pyopericardium with multiples echoes in cardiac temponade. Echo-guided percutaneous pericardiocentesis yielded 600mls of purulent aspirates. Citrobacter freundii Sensitive to gentamycin, co-amoxiclav but resistant to cefuroxime and cefixime was cultured from pericardial aspirates and sputum. Patient recovered fully after pericardiocentesis and intravenous antibiotics. In this case report, we describe Citrobacter freundii causing cardiac temponade and empyema in a Nigerian immunocompetent child which to our knowledge has thus far not been reported. Pyopericardium may follow rare causes as Citrobacter freundii which require high index of suspicion.