A Case of Thoracic Empyema Caused by Actinomyces naeslundii.

BACKGROUND Actinomycosis is a clinically significant but uncommon infectious disease caused by anaerobic commensals of Actinomyces species, and the incidence of thoracic empyema is rare. We report an extremely rare case of empyema caused by Actinomyces naeslundii (A. naeslundii). CASE REPORT A 39-year-old man presented to our hospital with fever and dyspnea. He had massive pleural effusion and was diagnosed with a left lower-lobe abscess and left thoracic empyema. Thoracic drainage was performed and Ampicillin/Sulbactam was administered for 3 weeks. Four years later, the patient presented with back pain, and chest X-ray showed increased left pleural effusion. After close examination, malignant pleural mesothelioma was suspected, and computed tomography-guided needle biopsy was performed, which yielded a viscous purulent pleural effusion with numerous greenish-yellow sulfur granules. A. naeslundii was identified through anaerobic culture. Thoracoscopic surgery of the empyema cavity was conducted, and Ampicillin/Sulbactam followed by Amoxicillin/Clavulanate was administered for approximately 6 months. No recurrence has been observed for 1 year since the surgical procedure. CONCLUSIONS Actinomyces empyema is a rare condition, and this case is the second reported occurrence of empyema caused by A. naeslundii. The visual identification of sulfur granules contributed to the diagnosis. Long-term antibiotic therapy plays a crucial role in treatment.

Delayed severe hemothorax caused by a staple line of a bullectomy performed 11 years earlier.

BACKGROUND: At present, relatively few lung surgeries are performed without endostaplers. Although there are few staple-related adverse events, severe events must be shared to improve safety. CASE PRESENTATION: A 74-year-old male suddenly collapsed and was transferred to the Emergency Rescue department. He had shock vitals and contrast-enhanced CT revealed extensive right hemothorax with contrast leakage. He lost consciousness and tension massive hemothorax was suspected. We performed emergency thoracotomy at two sites and were able to achieve hemostasis and save the patient. Upon examining the patient's medical history after his condition stabilized, it was revealed that he was a lung cancer patient who was taking ramucirumab and cilostazol. In addition, the CT scan taken one month before onset revealed the bleeding site of the fifth intercostal artery were almost contact with the staple line from a prior right spontaneous pneumothorax surgery that was performed 11 years previously, which was seemed to damage the intercostal artery. CONCLUSION: Despite the difficulty in achieving hemostasis due to drug administration history, we successfully treated a case of remote period massive hemothorax attributed to staples, thereby saving the patient. When using drugs that increase the risk of bleeding events, it may be important to consider the position of the staple line while assessing the risk. In the emergent or ICU setting, if the initial incision is not effective, the placement of a new second incision may be valuable.

Intrapleural findings of pulmonary light-chain deposition disease.

Light-chain deposition disease is accompanied not only by characteristic CT findings but also by characteristic gross findings of the visceral pleura. Medical thoracoscopy could diagnose LCDD by the findings of the thoracic cavity.

Delayed cardiac tamponade caused by a staple line after wedge resection of the lung.

An 80-year-old woman was diagnosed with an adenocarcinoma of the left lower lobe, clinical stage IA3. Taking the patient's age and medical history into consideration, a wedge resection was performed. After the resumption of rivaroxaban on postoperative Day 3, the patient suddenly developed cardiac tamponade on postoperative Day 5. A drainage tube was placed by pericardiocentesis, and the haemodynamics recovered immediately. No recurrence of cardiac tamponade was observed. The confluence of staple lines is a risk factor for tissue damage. Some covering is recommended, especially when the stapling line contacts the pericardium on the left side.

Reconstructed Diaphragm by Fascia Lata: 13 Years In Vivo.

We report a case of resection of a reconstructed diaphragm with fascia lata after 13 years. A 66-year-old man was diagnosed with a solitary fibrous tumor of the pleura. Thirteen years prior, resection for left postoperative pleural dissemination of solitary fibrous tumor with diaphragmatic resection was performed, and left fascia lata was used for diaphragmatic reconstruction. He relapsed, and the diaphragm was re-resected and re-reconstructed with right fascia lata. The resected, reconstructed fascia lata had microvessels in the fibrous stroma, and it was observed that the autologous tissue had become more resistant to infection by obtaining a blood supply.

Urinary fluorescent metabolite O-aminohippuric acid is a useful biomarker for lung cancer detection.

INTRODUCTION: Urine contains diagnostically important metabolites that can act as natural fluorophores. However, whether these fluorescent metabolites can be used in lung cancer diagnosis is unknown. OBJECTIVES: This study was conducted to determine whether fluorescent urinary metabolites could be useful biomarkers for lung cancer detection. METHODS: A total of 46 lung cancer patients and 185 volunteers without cancer were evaluated between November 2013 and November 2014. Samples of the first urine of the day were collected from lung cancer patients and diagnosed at the Hamamatsu University School of Medicine and the Hamamatsu Medical Center prior to cancer treatment, and from volunteers without cancer at the Hamamatsu Medical Imaging Center. Fluorescent urinary metabolites were screened by high-performance liquid chromatography and select effective fluorescent substances for distinguishing cancer from non-cancer status. RESULTS: The fraction of patients at each stage of cancer severity were: 41.3% stage I, 8.7% stage II, 19.6% stage III, and 30.4% stage IV. A robust predictive biomarker for lung cancer was selected by the multivariate logistic analysis of fluorescent metabolites and identified to be O-aminohippuric acid (OAH). The area under the curve (AUC) data for OAH was 0.837 (95% CI 0.769-0.898, P < 0.001). CONCLUSION: We identified a fluorescent urinary metabolite that can predict lung cancer. OAH exceeds the AUC (0.817) of lung cancer detection by AminoIndex® cancer screening, can be analyzed non-invasively without additional sample processing, and may be a valuable addition to existing lung cancer prediction models.

Mediastinal Metastasis of Breast Cancer Mimicking a Primary Mediastinal Tumor.

BACKGROUND Breast cancer is becoming a common disease in women. It progresses slowly and may recur after a long time. Therefore, when a tumor is found in the chest of a patient with a history of breast cancer, an immediate concern is whether it is a primary tumor or a metastatic tumor. However, mediastinal metastasis is extremely unlikely to occur before lung metastasis, and breast cancer is not likely to have a solitary mediastinal metastasis. Additionally, patients should not undergo invasive procedures unnecessarily, so careful consideration is required. CASE REPORT We present 2 cases. In case 1, a 48-year-old woman with a history of breast cancer had a mediastinal tumor. Based on imaging findings, cystic thymoma was suspected. Thoracoscopic intraoperative rapid biopsy showed a lymphocyte-predominant tumor tissue; therefore, the tumor was resected via a median sternotomy. The final pathological diagnosis was breast cancer metastasis. In case 2, a 47-year-old woman who underwent breast cancer resection 15 years earlier was referred for upper limb edema. Based on imaging findings, a left medial vein occlusion due to mediastinal tumor was diagnosed. Our experience in case 1 suggested that a biopsy alone should be performed first. A tumor biopsy was performed through a small transverse neck incision in case 2, and the final diagnosis was metastatic breast cancer of the mediastinum. CONCLUSIONS In patients with a suspected primary mediastinal tumor on imaging, the possibility of a metastatic tumor should be considered if they have a history of breast cancer, regardless of how long in the past it was.

Pulmonary vein stump thrombus: an early complication following upper division segmentectomy of the left lung.

We report a rare case of a pulmonary vein stump thrombus detected by a contrast-enhanced computed tomography for transient syncope 2 days after upper division segmentectomy of the left lung for metastatic pulmonary tumor. The thrombus disappeared without embolic events after anticoagulation with intravenous heparin followed by oral warfarin. Considering this case and previous reports, thoracic surgeons should be aware of pulmonary vein stump thrombus, a latent source of systemic embolization, after pulmonary resection, especially lobectomy or segmentectomy of the left upper lobe. This possible serious complication can occur at any time from the early postoperative period.

Surgery for secondary spontaneous pneumothorax: risk factors for recurrence and morbidity.

OBJECTIVES: Secondary spontaneous pneumothorax (SSP) is more common in elderly patients; it has high rates of recurrence and mortality, even if surgery is performed. There has been little study on the surgical treatment of SSP. Therefore, we analysed the outcomes of surgical treatment of SSP patients, and investigated the risk factors of recurrence and morbidity. METHODS: We studied 97 consecutive surgical treatments on 94 patients with SSP who had emphysematous changes of lung retrospectively. Emphysematous changes on preoperative computed tomography image were evaluated by the Goddard score, which is a visual scoring system. First, video-assisted thoracoscopic surgery was performed, followed by bullectomy for the responsible lesions. RESULTS: The rate of morbidity was 20.6% and that of mortality was 4.1%. Recurrence rate was 9.3%. By multivariate analysis, a Goddard score≥7 (odds ratio: 8.93, P=0.033) and treatment of bulla without the use of staplers (odds ratio: 11.57, P=0.019) were significant risk factors for morbidity, while pulmonary fibrosis tended to increase the risk of recurrence (hazard ratio: 4.21, P=0.051), and a Goddard score≥7 (hazard ratio: 7.79, P=0.023) was a significant risk factor for recurrence. CONCLUSIONS: Surgical treatment in patients with SSP had favourable results. Treatment in which the base of the bulla cannot be definitely shut off with staplers is associated with increased morbidity. Significant emphysematous change on preoperative computed tomography image and pulmonary fibrosis are predictors of recurrence. Patients with these findings should be investigated in terms of the indications of surgery and additional treatment, not only bullectomy.

Acute empyema with intractable pneumothorax associated with ruptured lung abscess caused by Mycobacterium avium.

Nontuberculous mycobacterial lung disease rarely features pleural involvement. Therapeutic strategies for this situation have not been well established. We present a case of acute empyema with intractable pneumothorax associated with ruptured lung abscess caused by Mycobacterium avium in an immunocompromised patient. Combined treatment that included multidrug antibiotic therapy and nonresectional surgery resulted in a good outcome.

Secondary spontaneous pneumothorax associated with emphysema and ruptured bullae at the azygoesophageal recess.

PURPOSE: With secondary spontaneous pneumothorax (SSP) associated with emphysema, lesions responsible for pneumothorax can be located anywhere along the lung surface. Among such lesions, ruptured bullae at the azygoesophageal recess (AER) have received little attention thus far. METHODS: We conducted a retrospective study of 38 right SSP patients with emphysema who underwent surgery. Among them, we reviewed the clinical characteristics and technical problems of patients with surgically proven ruptured bullae at the AER. RESULTS: Ruptured bullae at the AER were found in 10 of 38 patients. They accounted for 26.3% of all 38 patients and for 66.7% of 15 patients whose bullae at the AER were identified by preoperative computed tomography (CT). On CT, all the bullae were relatively large and oriented in a predominantly vertical axis. At surgery, they were confirmed as white, thin-walled structures originating from the mediastinal part of the apical segment of the right lower lobe. Surgery typically consisted of stapling bullectomy with video-assisted thoracic surgery. Technical problems in surgical treatment included poor mobilization of the base of the bulla and a restricted working space. CONCLUSION: Bullae at the AER are common and possibly lead to rupture. The presence of a bulla at the AER seen by CT can be predictive of rupture. Although the AER is a unique location, video-assisted bullectomy is the method of choice for treating these lesions.

Pleural space sterilization using gentian violet irrigation for postbullectomy empyema associated with artificial material infection.

Postoperative empyema associated with artificial material infection involves several treatment problems. We report the successful treatment of a case of post-bullectomy empyema with a small alveolar fistula that was associated with artificial material infection by Streptococcus viridans. In this case, complete empyema space sterilization was obtained by tube drainage and daily pleural irrigation using 0.1% gentian violet solution. This treatment circumvented the need for invasive surgery, including removal of the infected artificial materials and space-filling and/or collapse procedures. Consequently, gentian violet irrigation may be a useful treatment option in selected cases with complicated thoracic empyema.

Spontaneous pneumothorax and a coexistent azygos lobe.

We present a primary spontaneous pneumothorax involving a possible diagnostic and surgical pitfall. A 25-year-old man with a previously identified azygos lobe was admitted to our hospital because of right primary spontaneous pneumothorax. A preoperative chest X-ray at the onset of the pneumothorax as well as after resolution by tube drainage showed an azygos fissure but no azygos vein. Chest computed tomography revealed the dislocated azygos vein external to the azygos fissure on the mediastinal side of the reexpanded upper lobe. Thoracoscopic bullectomies were uneventfully performed. The azygos arch was found dangling in the free inferior border of the mesoazygos. An azygos vein located in this position can be a potential surgical hazard especially in video-assisted thoracic surgery. This case suggests that the presence of an azygos lobe can be missed on chest X-ray when a pneumothorax occurs in a patient with an azygos lobe.

Anomalous systemic arterial supply to the basal segments of the left lung with two aberrant arteries.

A 30-year-old man was admitted to our hospital because of hemoptysis. Digital subtraction aortography revealed an anomalous systemic artery (10 mm diameter) from the descending thoracic aorta to the basal segments of the left lung. The presence of another smaller aberrant artery from the abdominal aorta was strongly suspected on the basis of aortography. We confirmed the presence of a smaller aberrant artery (3 mm diameter) traversing the pulmonary ligament after thoracotomy. We performed left lower lobectomy with resection of the two aberrant arteries via posterolateral thoracotomy with a favorable postoperative outcome. Although it is rare, the possibility of the presence of several aberrant arteries should be considered in anomalous systemic arterial supply to the basal segment of the left lung. Preoperative identification of aberrant arteries was useful for a safe operative procedure.

Right upper lobe venous drainage posterior to the bronchus intermedius: preoperative identification by computed tomography.

BACKGROUND: Anatomical variations of the pulmonary vessels relevant to pulmonary surgery are of concern to thoracic surgeons. Among such variations, the right upper lobe vein posterior to the bronchus intermedius (UVPBI) has received little attention thus far. METHODS: Chest computed tomographic images and medical records of 725 patients were retrospectively reviewed. The frequency, drainage pattern, diameter, and associated anatomical characteristics of the UVPBI were assessed, and our right thoracotomy cases with the UVPBI were examined. RESULTS: The UVPBI was found in 41 (5.7%) of 725 computed tomography cases, and in 9 (3.9%) of 230 right thoracotomy cases. Three UVPBI drainage sites were observed: (1) the superior pulmonary vein group, 55%; (2) the inferior pulmonary vein group, 41%; and (3) the superior segmental vein group, 4%. The diameter of the UVPBI at the level of the bronchus intermedius ranged from 1 to 7 mm (4.1 +/- 1.6 mm). The diameter of the UVPBI in the superior pulmonary vein group was significantly greater than that in the inferior pulmonary vein group (p < 0.01). The prevalence of a central vein was 43.9% for all UVPBI cases and 15.8% for large UVPBI cases (> or = 5 mm in diameter). Of the 9 right thoracotomy patients, 1 suffered UVPBI injury; this patient's UVPBI was not identified either preoperatively or intraoperatively. CONCLUSIONS: The UVPBI is not as rare as was previously believed. It can be a main drainage route of the right upper lobe. Preoperative identification of this venous variation by computed tomography is useful for safe and accurate surgical procedures.

Full-thickness chest wall reconstruction using autologous tissue grafts after resection of recurrent desmoid tumor.

We report the case of a 62-year-old woman with a recurrent desmoid tumor of the chest wall who successfully underwent a full-thickness chest wall resection as well as skeletal and soft tissue reconstruction. In chest wall reconstruction, we used various kinds of autologous tissue grafts, i.e. rib, fascia lata and the transverse rectus abdominis myocutaneous flap. Judging from the reconstructed wall's strength, shape and flexibility, as well as wound healing, it is possible to conclude that this combined procedure is feasible because benefits of the procedure outweigh the disadvantage of additional operations for harvests.

Combined operation for myasthenia gravis and coronary artery disease.

A 57-year-old man with ocular myasthenia gravis was admitted to our hospital because of acute respiratory insufficiency associated with myasthenic crisis. He had a history of unstable angina indicated percutaneous coronary artery angioplasty. He was diagnosed with generalized nonthymomatous myasthenia gravis and a triple vessel coronary artery disease. We conducted a simultaneous surgical intervention, including extended thymectomy and coronary artery bypass grafting, using a standard cardiopulmonary bypass via median sternotomy. The patient had already been immunocompromised at surgery for having diabetes, and postoperative long-term steroid therapy. In this rare and special condition, a meticulous overall therapeutic strategy was needed in order to avoid myasthenic crisis and prepare for the worst case scenario of mediastinitis.

Solitary fibrous tumor of the pleura with hemothorax at the thoracic apex.

A 31-year-old man was referred to our hospital with a diagnosis of a left lung mass and substantial pleural effusion. 1,300 mL of blood was drained. Chest computed tomography (CT) and magnetic resonance imaging (MRI) revealed a hypervascular, round shaped mass, 9 cm in diameter occupying the left thoracic apex. The mass was broad-based, arising from the area of antero-lateral parietal pleura at the level of the thoracic apex and the first rib. The tumor was successfully resected via median sternotomy and left first intercostal thoracotomy without either claviculectomy or claviculotomy. For the complex surgical access and the tumor's hypervascularity, a careful operative procedure was needed to avoid massive bleeding. The tumor was diagnosed microscopically and immunohistochemically as a solitary fibrous tumor of the pleura and did not meet the criteria for malignancy.

Pulmonary resection with chest wall removal and reconstruction for invasive pulmonary mucormycosis during antileukemia chemotherapy.

A 54-year-old woman undergoing chemotherapy for acute myeloid leukemia developed invasive pulmonary mucormycosis in the right upper lobe at the neutropenic nadir. Amphotericin B therapy became ineffective after an abscess formed in the affected lung, and insufficient infection control compelled us to interrupt chemotherapy. The lesion was suspected of invading the anterior chest wall. After right upper lobectomy combined with the anterior chest wall resection, the chest wall defect was reconstructed using autologous free rib grafts. Successful control of the fungal infection by resection enabled us to restart chemotherapy with concomitant use of Amphotericin B. In selected cases of leukemia-associated pulmonary mucormycosis refractory to Amphotericin B therapy, aggressive surgical intervention may facilitate anti-leukemia chemotherapy and prolong survival.