Vascular and Neurological Complications in Sphenoid Sinusitis.

Although the cavernous sinus and internal carotid artery are in close proximity to the sphenoid sinus, vascular complications in sphenoid sinusitis are rare due to the intervening mucosa and bone. Variations like dehiscence or aggressive infection can cause vascular complications, leading to cavernous sinus thrombosis, while perivascular inflammation of the internal carotid artery can result in stenosis or occlusion. Untreated or aggressive sphenoid sinusitis can cause neurological complications such as cerebral infarcts, meningitis, subdural empyema, cerebral abscess, and cranial nerve injuries. Magnetic resonance imaging (MRI) of the brain with angiography can depict these complications at an early stage. Additionally, mastoiditis can cause dural venous sinus thrombosis, which, if left untreated, can result in venous infarcts. We report a case of an 11-year-old male with sphenoid sinusitis who developed a left middle cerebral artery (MCA) territory infarct, cavernous sinus thrombophlebitis, subdural empyema, and meningitis. He also developed left transverse and sigmoid sinus thrombosis due to left mastoiditis.

Subdural Empyema as a Sequela of Severe Erosive Sinusitis: A Case Report.

Intracranial subdural empyema is a rare but critical neurosurgical emergency marked by pus accumulation between the brain and the dura mater. It typically arises from bacterial or fungal infections, often secondary to sinusitis, otitis media, or head trauma. Symptoms can range from mild headaches to significant neurological deficits and altered mental status. Diagnosis is confirmed through advanced imaging techniques such as MRI and CT scans. Timely intervention is essential to prevent neurological damage and systemic complications, usually involving surgical drainage and antimicrobial therapy. We present the case of a 45-year-old male who visited the emergency room several times with progressive lethargy and altered mental status. He was admitted and later transferred to our trauma center for a suspected subdural hematoma. An emergent right-sided craniotomy was performed, and a subdural empyema was found. The patient improved following subdural drainage and antibiotic treatment, including 600 mg linezolid every 12 hours, 2 g cefepime every eight hours, and 500 mg metronidazole every eight hours. This case highlights the effectiveness of prompt medical and surgical intervention in managing this rare condition and offers valuable insights for improving future patient outcomes.

Changes in the epidemiology of pediatric brain abscesses pre- and post-COVID-19 pandemic: a single-center study.

BACKGROUND: An increased incidence of brain abscesses was observed post-COVID-19 pandemic. However, it remains unclear how the COVID-19 pandemic influenced the epidemiology of brain abscesses. This study aimed to investigate changes in the epidemiology of brain abscesses pre- and post-COVID-19 pandemic. METHODS: A retrospective study of demographic, clinical, radiological, and laboratory characteristics of patients with brain abscesses in Children's Hospital of Soochow University from 2015-2023 was performed. RESULTS: A total of 34 patients were admitted to the hospital during the study. The post-COVID-19 cohort had an average of 5.5 cases/year, which is a 129.2% increase compared to the pre-COVID-19 cohort's average of 2.4 cases/year. Additionally, the rates of fever upon admission (86.36% vs 50%, p = 0.04) and experiencing high-grade fever within 6 weeks before admission (40.91% vs 8.33%, p = 0.044) were significantly increased. A potential rise in the rate of intensive care unit admission was observed (36.36% vs 8.33%, p = 0.113). The average value of globulin in the post-COVID cohort was significantly higher compared to the pre-COVID cohort (31.60 ± 5.97 vs 25.50 ± 5.08, p = 0.009). Streptococcal infections were the predominant cause of brain abscesses in both cohorts (40% vs 43.75%, p = 0.57). CONCLUSIONS: There was a significant increase in the number of brain abscess patients after the COVID-19 pandemic. This underscores the importance of children receiving the streptococcal vaccine.

'Iatrogenic septic pit': empyema, a rare complication after endobronchial valve placement.

Objective: Patients with severe emphysema who do not experience relief with non-invasive therapies such as medication and physical activity may need advanced treatments. Bronchoscopic lung volume reduction using endobronchial valves (EBV) is an alternative therapy that may improve exercise capacity and quality of life in carefully selected cases. This treatment is less invasive compared to lung reduction surgery or transplants.Clinical presentation: In this case report, a rarely described complication after EBV insertion is presented: empyema. Conclusion: However EBV has advantages in selected cases, it can be associated with different complications such as pneumothorax, valve migration, and pneumonia.

Unilateral Unusual Post-traumatic Breast Pain and Swelling in a Young Adult: A Case of Tuberculous Empyema Necessitans.

Empyema necessitans is a very rare and morbid complication of pleural empyema. It is defined as the extension of pleural infection to the chest wall and surrounding soft tissues. Our case highlights an unusual presentation of empyema necessitans in a 29-year-old man. The patient had no prior comorbidities and presented to the emergency department with a 15-day history of growing left unilateral chest pain and swelling. This was initially clinically misdiagnosed as a post-traumatic hematoma. Contrast-enhanced chest CT scan allowed a diagnosis and the ruling out of the main differentials, such as skeletal lesions extending to adjacent structures but also benign and malignant soft tissue masses. The treatment involved surgical drainage of the abscess. Microbiological analysis of the abscess content identified Mycobacterium tuberculosis as the causative pathogen. The patient was subsequently treated with antituberculous drugs, leading to a favorable clinical outcome. This case outlines the importance of an enhanced chest CT scan in making an early diagnosis, defining the extent of the disease, and discussing differentials, all of which are paramount to better results with fewer complications. Moreover, it highlights the fact that blunt trauma may facilitate the formation of a fistula when an underlying infection is present.

A retrospective study to evaluate the safety and efficacy of intrapleural alteplase in pediatric empyema.

INTRODUCTION: Medical treatment of pediatric empyema consists of appropriate antibiotics, chest tube insertion, and intrapleural fibrinolytic drugs to facilitate pleural drainage. There is a lack of consensus about the drug of choice for fibrinolytic therapy, so this study was designed to evaluate the safety and efficacy of intrapleural alteplase in pediatric empyema. MATERIAL AND METHODS: The medical records of all children with empyema treated with intrapleural alteplase at a university hospital between January 2016 and December 2020 were retrospectively reviewed. Efficacy outcomes were assessed by chest tube output before and after the first dose of alteplase, pleural fluid volume before and after therapy, a need for surgical intervention, and length of hospital stay. Safety was assessed by the frequency and severity of side effects. RESULTS: 40 children aged 2 months to 9 years hospitalized with empyema received intrapleural alteplase. Thirty patients (75%) experienced full recovery after three doses of intrapleural alteplase. The median length of hospital stay was 16 days. Chest tube output increased significantly after the first dose of alteplase. Pleural fluid volume decreased significantly after treatment. The most common side effect was pain (30%). Two patients experienced severe complications: 1 had a pulmonary hemorrhage and the other experienced a bronchopleural fistula. These patients recovered fully spontaneously. CONCLUSIONS: According to our results, the administration of intrapleural alteplase was safe and effective in facilitating pleural drainage in pediatric patients with empyema. However, further clinical trials will be needed to determine the optimal dose, frequency, and duration of intrapleural alteplase treatment.

Thoracic Angiosarcoma Arising from Chronic Tuberculous Pyothorax: A Case Report.

Angiosarcoma is a rare malignancy that can arise from chronic pyothorax. We herein report a 75-year-old Japanese man with a history of tuberculosis who presented with left-sided chest pain that had persisted for 4 months. Chest computed tomography revealed an encapsulated left-sided pleural effusion with chest wall invasion, and histopathology confirmed angiosarcoma arising from a chronic tuberculous pyothorax. Chemotherapy with paclitaxel (80 mg/m2 weekly) was ineffective and was discontinued after 3 months. Our findings emphasize that physicians should inform patients with chronic tuberculous pyothorax about malignant complications for which chest pain is the initial symptom, in addition to highlighting the need for careful follow-up.

Surgical Management of Complicated Thoracic Fungal Infections: A Case Series from a Tertiary Referral Center.

Although rare in the general population, pulmonary fungal infections usually occur in immunocompromised patients. The mainstay of pulmonary fungal infection treatment is prolonged intravenous antifungal therapy. However, surgical management may be required in cases of complex disease, resistance to medical therapy or percutaneous procedures, or associated complications such as fungal empyema and massive hemoptysis. In this series, we present three patients with complicated thoracic fungal infections who underwent individualized surgical management over a 3-month period in 2022 at our institution. Complicated pulmonary fungal infections require surgical intervention to ensure complete resolution. The choice of operation is dependent on several factors, and surgeons operating on these patients must be privy to the various surgical modalities that may be required to successfully treat these patients.

Factors involved in the conversion from video-assisted thoracoscopic surgery decortication to open thoracotomy in non-complicated, non-MDR/XDR stage III tuberculous empyema patients: A retrospective intention-to-treat study.

Background: This retrospective intention-to-treat study aims to identify risk factors associated with intraoperative conversion from Video-Assisted Thoracoscopic Surgery (VATS) Decortication to open thoracotomy in patients with Stage III Tuberculous Empyema, specifically focusing on non-Multi-Drug Resistant (MDR)/Extensively Drug-Resistant (XDR) cases. Methods: The study included 122 patients with non-MDR/XDR tuberculous empyema who were initially scheduled for VATS decortication. Patients were divided into two groups: the Thoracoscopy group (n = 64), who successfully underwent VATS decortication, and the Conversion group (n = 58), who required intraoperative conversion to open thoracotomy. Complex cases were excluded from the study. The analysis focused solely on factors leading to conversion, rather than overall treatment outcomes. Results: A notable difference was observed in the rate of regular preoperative glucocorticoid utilization between the two cohorts, with the Conversion group exhibiting a lower percentage (46.5 %) in comparison to the Thoracoscopy group (75.0 %). Furthermore, the Thoracoscopy group displayed a significantly reduced frequency of ipsilateral lung abnormalities prior to the surgery (37.5 %), as opposed to that of the Conversion group (65.5 %). Multivariate logistic regression analysis revealed that the regular preoperative glucocorticoid use (odds ratio (OR) = 3.444, 95 % confidence interval (CI): 1.602-7.407) and pre-existing pulmonary lesions (OR = 0.31, 95%CI: 0.150-0.663) were potential influential factors. Conclusion: Inconsistent preoperative glucocorticoid administration and ipsilateral lung lesions were identified as exacerbating factors leading to the complexity of VATS decortication by causing intraoperative pulmonary tissue contusion or hemorrhage, thus hindering the successful completion of VATS decortication and necessitating a conversion to thoracotomy. Awareness of these factors can aid surgeons in making well-informed decisions regarding the preoperative surgical approach.

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.

Empyema necessitans.

Empyema necessitans should be suspected in any patient presenting with constitutional symptoms, pleural effusion, and a subcutaneous chest wall mass. Thoracic sonography is a readily available tool, which can expedite diagnosis and timely management.

Double trouble: an unusual case of Klebsiella pneumoniae invasive syndrome with liver abscess, gallbladder empyema and infective endocarditis.

BACKGROUND: Klebsiella pneumoniae invasive syndrome (KPIS) is characterized by primary pyogenic liver abscess associated with metastatic infections. Although rare, Klebsiella endocarditis carries a high mortality risk. CASE PRESENTATION: A 60-year-old lady with type II diabetes mellitus presented with fever, malaise, right hypochondriac pain and vomiting for two weeks. Ultrasound abdomen revealed a collection within liver, and distended gallbladder with echogenic debris within. 3 days after ultrasound guided pigtail drainage of gallbladder empyema, newly presence murmur detected. Pus, urine, and blood cultures obtained were positive for Klebsiella pneumonia. Echocardiogram exhibited oscillating mass attached to anterior mitral valve leaflet. After 6 weeks of intravenous ceftriaxone, follow-up echocardiogram and ultrasound showed complete resolution of mitral valve vegetation, hepatic and gallbladder collection. CONCLUSION: Concomitant extrahepatic infective endocarditis (IE) should raise concerns in daily practice for patients with Klebsiella pneumoniae liver abscesses, despite the rarity of Klebsiella endocarditis. In the absence of diagnostic suspicion, antibiotic treatment regimens may be shortened, and adverse effects from IE infection may ensue.

Intracranial Subdural Empyema During Long-term Chemotherapy for Metastatic Colorectal Cancer: Case Report.

BACKGROUND/AIM: Although chemotherapy for colorectal cancer has advanced remarkably, long-term chemotherapy can lead to a variety of infections. However, if chemotherapy must be discontinued to control infection, there is a risk of progression of colorectal cancer. Intracranial subdural empyema is a life-threatening intracranial infection. The condition requires 6-8 weeks of antibiotic therapy, and the patient must discontinue chemotherapy during treatment. We herein present a case of intracranial subdural empyema during long-term chemotherapy for metastatic rectal cancer. CASE REPORT: A 69-year-old woman with unresectable metastatic rectal cancer had a convulsive seizure and was admitted to our hospital. The cause of the convulsive seizure was considered a metastatic brain tumor from rectal cancer. However, on the basis of contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging, we diagnosed intracranial subdural empyema. The infection was controlled by antibiotics, but chemotherapy for rectal cancer was discontinued during antibiotic treatment. As a result, the rectal cancer progressed, and the patient died 65 days after admission to our hospital. CONCLUSION: Intracranial subdural empyema may develop rarely during chemotherapy. This condition requires long-term treatment with antibiotics; therefore, early detailed imaging and diagnosis may improve the prognosis.

Surgery versus intrapleural fibrinolysis for management of complicated pleural infections: a systematic review and meta-analysis.

BACKGROUND: Complicated pleural infection comprises of complex effusions and empyema. When tube thoracostomy is ineffective, treatment options include surgical drainage, deloculation and decortication or intrapleural fibrinolysis. We performed a systematic review and meta-analysis to examine which technique is superior in treating complicated pleural infections. METHODS: PubMed, MEDLINE and EMBASE databases were searched for studies published between January 2000 to July 2023 comparing surgery and intrapleural fibrinolysis for treatment of complicated pleural infection. The primary outcome was treatment success. Secondary outcomes included hospital length of stay, chest drain duration and in-hospital mortality. RESULTS: Surgical management of complicated pleural infections was more likely to be successful than intrapleural fibrinolysis (RR 1.18; 95% CI 1.02, 1.38). Surgical intervention group benefited from statistically significant shorter hospital length of stay (MD: 3.85; 95% CI 1.09, 6.62) and chest drain duration (MD: 3.42; 95% CI 1.36, 5.48). There was no observed difference between in-hospital mortality (RR: 1.00; 95% CI 0.99, 1.02). CONCLUSION: Surgical management of complicated pleural infections results in increased likelihood of treatment success, shorter chest drain duration and hospital length of stay in the adult population compared with intrapleural fibrinolysis. In-hospital mortality did not differ. Large cohort and randomized research need to be conducted to confirm these findings.

Diagnosis and Management of Tuberculous Pleural Effusion in a Patient With Chronic Obstructive Pulmonary Disease: A Case Report.

A 63-year-old man had been smoking bidis for 25 years and developed tubercular empyema, further complicated by pneumothorax and other pulmonary issues. Over a period of three weeks, the individual experienced a gradual onset of symptoms, including progressive shortness of breath, cough, fever, and chest pain. Radiographic examinations revealed significant left-sided pleural effusion with consolidation and evidence of pneumothorax. Other findings included anemia, hyponatremia, substantially increased lactate dehydrogenase, and adenosine deaminase (ADA), consistent with tubercular or chronic infection. The comprehensive treatment plan involved the administration of antibiotics, antitubercular drugs, draining of the pleural fluid, nebulized bronchodilators, corticosteroids, and broad-spectrum antibiotics. The patient exhibited a positive response, showing notable clinical improvement, which was closely monitored through sequential chest X-rays and ECGs. This would continue to highlight the vital need for early tuberculosis detection in patients with chronic obstructive pulmonary disease due to clinical overlap with other diseases. To diagnose and follow up on tuberculous pleural effusion cases, it was critical to integrate both clinical and radiographic findings with laboratory data. It emphasizes the necessity for a multidisciplinary approach to improve overall treatment outcomes.

The incidence of pleural infections in Finland.

BACKGROUND: The incidence of pleural infections appears to be increasing in Western countries for unclear reasons. The aim of the study was to describe the incidence and treatment patterns of pleural infections in Finland over three decades. METHODS: Data regarding each treatment episode for pleural infections in the Finnish special medical care between January 1994 and December 2016 was obtained from a national database and compared to the demographics of Finnish residents obtained from the national census bureau. The annual incidence rates, type of treatment given, as well as the lengths of the hospitalization were analyzed. RESULTS: A total of 28,463 episodes were reported, of which 55% were inpatient episodes. Of these, 76% concerned males, and the median age of patients was 60 (interquartile range 49-70) years. The overall incidence of pleural infections was 23.4 per 100.000 patient-years, with a male-to-female -ratio of 3.3:1. The annual incidence rates increased throughout the study period with an average annual percentage change of +11.4% (95% CI ±7.4%). The highest incidence rates (>200 per 100.000 patient-years) were observed in men aged 80 or more. Altogether 88% of patients were treated conservatively. The proportion of patients treated by mini-invasive surgery significantly increased during study period (0-5.9%, p < 0.001) and was associated with shorter hospitalization (median 6 [interquartile range 4-12] days) than open surgery (median 7 [4.5-13] days) (p < 0.001). CONCLUSION: The incidence of pleural infections has increased significantly over the previous decades in Finland and appears to be higher than previously reported, particularly in elderly men.

Ultrasound and Intrapleural Enzymatic Therapy for Complicated Pleural Effusion: A Case Series with a Literature Review.

Pleural effusion is the most common manifestation of pleural disease, and chest ultrasound is crucial for diagnostic workup and post-treatment monitoring. Ultrasound helps distinguish the various types of pleural effusion and enables the detection of typical manifestations of empyema, which presents as a complicated, septated effusion. This may benefit from drainage and the use of intrapleural enzyme therapy or may require more invasive approaches, such as medical or surgical thoracoscopy. The mechanism of action of intrapleural enzymatic therapy (IPET) is the activation of plasminogen to plasmin, which breaks down fibrin clots that form septa or the loculation of effusions and promotes their removal. In addition, IPET has anti-inflammatory properties and can modulate the immune response in the pleural space, resulting in reduced pleural inflammation and improved fluid reabsorption. In this article, we briefly review the literature on the efficacy of IPET and describe a case series in which most practical applications of IPET are demonstrated, i.e., as a curative treatment but also as an alternative, propaedeutic, or subsequent treatment to surgery.

Unexpected spontaneous expectoration of a grass bur: A case report.

Adult foreign body aspiration is rare and represents only 15%-25% of all foreign body aspirations and 1 in 400 bronchoscopy procedures. Typically, adults present non-emergently and exhibit non-specific symptoms, which makes the diagnosis of foreign body aspiration especially difficult when a history of aspiration cannot be elicited. We present a 63-year-old male with a past medical history of chronic obstructive pulmonary disease hospitalized for left thoracic empyema caused by the aspiration of a grass bur. Our patient did not recall the aspiration event and the diagnosis was further obfuscated by a lack of radiographic evidence and other distracting disease processes. Thus, this case exemplifies the rationale for maintaining a suspicion of foreign body aspiration even for patients with little historical or radiographic evidence to support the presence of a foreign body. This is particularly salient for patients with a tumultuous hospital course or those who fail to respond to treatment.

Subdural empyema-a rare complication of chronic otitis media: a case report.

BACKGROUND: Subdural empyema is an extremely rare and fatal intracranial complication of chronic otitis media. Due to its rarity and vague symptoms, it is often diagnosed late if not completely missed; specially in developing countries where the diagnostic modalities are hardly available or accessible. To the best knowledge of the authors, this is a preliminary reported case of subdural empyema as a complication of chronic otitis media in Eritrea. It aims to provide vital information on the clinical presentation, preferred diagnostic modalities, and the proper management of such cases. CASE REPORT: An 8 years old female patient from the Rashaida ethnic group presented with fever, right ear purulent discharge, right post-auricular swelling, and altered mental status. Prior to her admission, she had history of recurrent purulent discharge from her right ear for almost 2 years, and had been diagnosed with chronic otitis media. Upon admission her GCS was 13/15 which later on deteriorated to be 3/15 on day 3. MRI was done and showed a right fronto-tempo-parietal subdural empyema with mass effect, shifting the midline to the left. She was immediately started on empirical broad-spectrum antibiotics. After the diagnosis was made, craniotomy was done, and 30 ml of pus was removed from the subdural space. Culture and sensitivity of the pus obtained intraoperatively was done but produced no yield. Hence, she was continued on the empirically started antibiotics. The patient's condition was well improved by post-operative day 4. CONCLUSION: It is important to have a high index of suspicion of intracranial complications in patients with history of chronic otitis media or other otologic complaints, who present with neurologic manifestations. Subdural empyema still being uncommon even among the intracranial complications of COM, it is often missed. Hence, timely diagnosis with MRI, immediate surgical evacuation of the empyema along with the prolonged administration of broad-spectrum antibiotics is highly recommended.

Navigating the Confluence of Esophageal Disruption and Pyopneumothorax: A Complex Clinical Encounter.

Esophagopleural fistula (EPF) is a rare complication often associated with underlying esophageal malignancies. We present the case of a 64-year-old male who presented with left-sided pyopneumothorax and was diagnosed with EPF secondary to esophageal carcinoma. Imaging studies revealed a hydropneumothorax with an esophageal-pulmonary fistula communicating with the pleural cavity. The diagnosis was confirmed through computed tomography (CT) scan with oral contrast administration, highlighting the utility of this modality in diagnosing EPF. The patient was further referred to the surgical oncology team for esophageal resection and fistula closure.