Massive pleural empyema secondary to amoebic liver abscess in a child.

BACKGROUND: Pleural empyema secondary to a ruptured amoebic liver abscess is a rare complication in the pediatric population. CASE REPORT: We report the case of a 13-year-old male with right flank abdominal pain, productive cough with foul-smelling sputum, fever, and respiratory distress. Physical examination revealed breathlessness, decreased vesicular murmur in the right hemithorax, abdominal distension, hepatomegaly, and lower limb edema. Laboratory tests revealed mild anemia, leukocytosis without eosinophilia, elevated alkaline phosphatase, hypoalbuminemia, and positive immunoglobulin G antibodies against Entamoeba histolytica in pleural fluid. He required a chest tube and treatment with metronidazole. After 2 months of follow-up, the abscesses disappeared, and the empyema decreased. CONCLUSIONS: Massive pleural empyema secondary to a ruptured liver abscess is a rare complication. The epidemiological link associated with the symptoms and serological tests can help in the diagnosis.

INTRODUCCIÓN: El empiema pleural secundario a ruptura de absceso amebiano hepático es una complicación poco frecuente en la población pediátrica. CASO CLÍNICO: Se reporta el caso de un paciente de sexo masculino de 13 años que presentó dolor abdominal en flanco derecho, tos productiva con esputo de mal olor, fiebre y dificultad respiratoria. Al examen físico se encontró amplexación y murmullo vesicular disminuido en hemitórax derecho, distensión abdominal, hepatomegalia y edema de miembros inferiores. Los resultados del laboratorio evidenciaron anemia leve, leucocitosis sin eosinofilia, elevación de fosfatasa alcalina, hipoalbuminemia y anticuerpos IgG contra Entamoeba histolytica positivo en líquido pleural. Requirió tubo de drenaje torácico y tratamiento con metronidazol. A los dos meses de seguimiento los abscesos desaparecieron y el empiema disminuyó. CONCLUSIONES: El empiema pleural masivo secundario a ruptura de absceso hepático es una complicación poco frecuente. El nexo epidemiológico asociado con la sintomatología y pruebas serológicas pueden ser de ayuda en el diagnóstico.

Epidemiología del derrame pleural paraneumónico en la infancia durante la implementación de la vacuna antineumocócica conjugada de 13 serotipos / Epidemiology of pediatric parapneumonic pleural effusion during 13-valent pneumococcal conjugate vaccine implementation

Introducción: La incidencia del derrame pleural paraneumónico, incluyendo el empiema, ha sufrido variaciones en las últimas décadas, que se han relacionado con la implantación de distintos tipos de vacuna antineumocócica conjugada. Métodos: Se han revisado retrospectivamente los datos de los 10 hospitales públicos de la provincia de Alicante (España), que abarcan una población de 279.000 niños menores de 15 años, entre 2010 y 2018. Se desglosaron los derrames menores de 10mm (DP−) y los de 10mm o más (DP+). Resultados: Se han analizado 366 episodios de derrame pleural paraneumónico, 178 DP− (48,6%) y 188 DP+ (51,4%), con una mediana de edad de 4 años (rango intercuartílico: 2-7 años) y una evidente estacionalidad con máximo en invierno y mínimo en verano. Se identificó al agente etiológico por cultivo en 34 pacientes (9,3%), destacando Streptococcus pneumoniae (24 pacientes) seguido por Streptococcus pyogenes (7 pacientes). El serotipo de S. pneumoniae más frecuente fue el 19A (6 pacientes) y se han identificado 3 fallos vacunales. La tasa anual media de incidencia fue de 14,3 casos por 100.000 menores de 15 años (7,0 para DP− y 7,3 para DP+), sin cambios significativos a lo largo del tiempo, aunque sí se apreciaron diferencias marcadas de la incidencia entre los distintos departamentos sanitarios. Conclusiones: No hemos encontrado variaciones temporales en la incidencia del derrame paraneumónico pese a la implementación de la vacuna antineumocócica conjugada de 13 serotipos. Es destacable la variabilidad de la incidencia entre departamentos vecinos sin motivo aparente.(AU)

Introduction: The reported incidence of parapneumonic pleural effusion, including empyema, has shown fluctuations in the last decades. It has been related to the implementation of different types of conjugate pneumococcal vaccines. Methods: We have retrospectively reviewed data from all 10 public hospitals in Alicante Province (Spain) covering a population of 279,000 children under 15 years of age, between 2010 and 2018. Effusions less than 10mm (PE−) and those of 10mm or more (PE+) were separated. Results: A total of 366 episodes of parapneumonic pleural effusion have been analyzed, 178 PE− (48.6%) and 188 PE+ (51.4%), with a median age of 4 years (interquartile range: 2-7 years) and marked seasonality with the maximum in winter and the minimum in summer. A culture proven bacterial agent was identified in 34 patients (9.3%), mainly Streptococcus pneumoniae (24 patients) followed by Streptococcus pyogenes (7 patients). The most frequent S. pneumoniae serotype was 19A (6 patients) and 3 vaccine failures were observed. The mean annual incidence rate was 14.3 cases per 100,000 children under 15 years of age (7.0 for PE− and 7.3 for PE+). No significant changes were observed in incidence over time, but noticeable differences in incidence were observed in different health departments. Conclusions: We have not found temporal variations in incidence of parapneumonic effusion despite the implementation of the 13-valent pneumococcal conjugate vaccine. The unexplained disparity in incidence between close departments is noteworthy.(AU)

Massive pleural empyema secondary to amoebic liver abscess in a child / Empiema pleural masivo secundario a absceso hepático amebiano en un niño

Abstract Background: Pleural empyema secondary to a ruptured amoebic liver abscess is a rare complication in the pediatric population. Case report: We report the case of a 13-year-old male with right flank abdominal pain, productive cough with foul-smelling sputum, fever, and respiratory distress. Physical examination revealed breathlessness, decreased vesicular murmur in the right hemithorax, abdominal distension, hepatomegaly, and lower limb edema. Laboratory tests revealed mild anemia, leukocytosis without eosinophilia, elevated alkaline phosphatase, hypoalbuminemia, and positive immunoglobulin G antibodies against Entamoeba histolytica in pleural fluid. He required a chest tube and treatment with metronidazole. After 2 months of follow-up, the abscesses disappeared, and the empyema decreased. Conclusions: Massive pleural empyema secondary to a ruptured liver abscess is a rare complication. The epidemiological link associated with the symptoms and serological tests can help in the diagnosis.

Resumen Introducción: El empiema pleural secundario a ruptura de absceso amebiano hepático es una complicación poco frecuente en la población pediátrica. Caso clínico: Se reporta el caso de un paciente de sexo masculino de 13 años que presentó dolor abdominal en flanco derecho, tos productiva con esputo de mal olor, fiebre y dificultad respiratoria. Al examen físico se encontró amplexación y murmullo vesicular disminuido en hemitórax derecho, distensión abdominal, hepatomegalia y edema de miembros inferiores. Los resultados del laboratorio evidenciaron anemia leve, leucocitosis sin eosinofilia, elevación de fosfatasa alcalina, hipoalbuminemia y anticuerpos IgG contra Entamoeba histolytica positivo en líquido pleural. Requirió tubo de drenaje torácico y tratamiento con metronidazol. A los dos meses de seguimiento los abscesos desaparecieron y el empiema disminuyó. Conclusiones: El empiema pleural masivo secundario a ruptura de absceso hepático es una complicación poco frecuente. El nexo epidemiológico asociado con la sintomatología y pruebas serológicas pueden ser de ayuda en el diagnóstico.

Uma rara apresentação de plexopatia braquial por empiema de necessidade / A rare presentation of brachial plexopathy due to need empyema

Contexto: O empiema tem aumentado sua incidência ao longo das últimas décadas e ainda é a complicação mais comum de pneumonias. Apesar dos avanços no tratamento clínico, o acometimento do tecido pleural por infecções pode levar a sequelas irreparáveis e ainda apresenta uma alta mortalidade. Descrição do caso: Paciente do sexo masculino, 55 anos de idade, relatou queixa de dor em hemitórax e ombro esquerdos e parestesia difusa em membro ipsilateral há três dias. Tomografia de tórax revelou empiema pleural em lobo superior esquerdo e eletroneuromiografia evidenciou plexopatia braquial. Foi feita a punção guiada do empiema que demonstrou infecção por Staphylococcus aureus sensível à meticilina. Após drenagem do abscesso e antibioticoterapia, o paciente apresentou melhora progressiva dos sintomas. Discussão: O empiema de necessidade raramente se apresenta secundário a uma infecção bacteriana aguda, sendo geralmente causado por longas efusões pneumônicas tuberculosas. Sua manifestação clínica mais comum é a presença de massa dolorosa na região anterior do tórax, com exames de imagem mostrando alterações inflamatórias. A terapêutica preconizada se constitui de drenagem e antibioticoterapia. Conclusão: O diagnóstico de empiema de necessidade foi poucas vezes descrito na literatura e deve ser suspeitado em quadros infecciosos pulmonares com repercussão neurológica em plexo braquial.

Empiema pleural por Parvimonas micra en un paciente inmunocompetente: reporte de un caso / Pleural empyema by Parvimonas micra in an immunocompetent patient: a case report

Se presenta el caso de un paciente joven inmunocompetente, con antecedente de tuberculosis pulmonar, que acude al hospital por un cuadro clínico subagudo de fiebre persistente, baja de peso, disnea y abolición del murmullo vesicular. La tomografía de tórax mostró un extenso empiema en hemitórax izquierdo. Se le toman muestras para detección de gérmenes comunes y se le colocan un tubo de drenaje torácico y se inicia antibioticoterapia. La prueba de MALDI-TOF MS identificó a Parvimonas micra, una bacteria anaerobia, comensal de la flora oral, asociado a periodontitis severa, escasamente reportado en empiema pleural, especialmente, en personas inmunocompetentes. En la evaluación odontológica se realizó el diagnóstico de gingivitis y pericoronaritis de la tercera molar. El paciente evolucionó favorablemente. Se sugiere que, en casos de empiemas pleurales subagudos o crónicos, se debe considerar, además de las micobacterias, como agente etiológico al Parvimonas micra, y optar por exámenes como MALDI-TOF MS o secuenciamiento del 16S rRNA, colocación de tubo de tórax, cobertura antibiótica empírica y evaluación odontológica.

We present the case of a young immunocompetent patient, with a history of pulmonary tuberculosis, who attended the hospital with a subacute clinical picture of persistent fever, weight loss, dyspnea and abolition of vesicular murmur. Chest CT scan showed an extensive empyema in the left hemithorax. Samples were taken for detection of common germs. Then, a chest drainage tube was placed and antibiotic therapy started. The MALDI-TOF MS test identified Parvimonas micra, an anaerobic bacterium, commensal to the oral flora, associated with severe periodontitis, but rarely reported in cases of pleural empyema, especially in immunocompetent patients. Gingivitis and pericoronaritis of the third molar were diagnosed during oral evaluation. The patient progressed favorably. Parvimonas micra should be considered as a possible etiological agent in cases of subacute or chronic pleural empyema, in addition to mycobacteria. Tests such as MALDI-TOF MS or 16S rRNA sequencing, chest tube placement, empirical antibiotic coverage and an adequate oral evaluation should be considered in these cases.

Epidemiology of pediatric parapneumonic pleural effusion during 13-valent pneumococcal conjugate vaccine implementation.

INTRODUCTION: The reported incidence of parapneumonic pleural effusion, including empyema, has shown fluctuations in the last decades. It has been related to the implementation of different types of conjugate pneumococcal vaccines. METHODS: We have retrospectively reviewed data from all 10 public hospitals in Alicante Province (Spain) covering a population of 279,000 children under 15 years of age, between 2010 and 2018. Effusions less than 10 mm (PE-) and those of 10 mm or more (PE+) were separated. RESULTS: A total of 366 episodes of parapneumonic pleural effusion have been analyzed, 178 PE- (48.6%) and 188 PE+ (51.4%), with a median age of 4 years (interquartile range: 2-7 years) and marked seasonality with the maximum in winter and the minimum in summer. A culture proven bacterial agent was identified in 34 patients (9.3%), mainly Streptococcus pneumoniae (24 patients) followed by Streptococcus pyogenes (7 patients). The most frequent S. pneumoniae serotype was 19A (6 patients) and 3 vaccine failures were observed. The mean annual incidence rate was 14.3 cases per 100,000 children under 15 years of age (7.0 for PE- and 7.3 for PE+). No significant changes were observed in incidence over time, but noticeable differences in incidence were observed in different health departments. CONCLUSIONS: We have not found temporal variations in incidence of parapneumonic effusion despite the implementation of the 13-valent pneumococcal conjugate vaccine. The unexplained disparity in incidence between close departments is noteworthy.

Factores de riesgo de neumonía adquirida en la comunidad, complicada con empiema pleural

Introducción: la neumonía es la principal causa de derrame pleural (DP) en los niños. Un elevado número de los pacientes ingresan a las unidades de cuidados intensivos pediátricos con derrame pleural paraneumónico (DPP), terminando en el empiema pleural. Objetivo: identificar los factores de riesgo que influyen de forma independiente en la aparición de neumonía adquirida en la comunidad, complicada con empiema pleural. Métodos: se realizó un estudio observacional analítico de casos y controles, se seleccionaron 30 casos y 90 controles. Con una proporción de 1:3. Se realizó el análisis estadístico univariado y multivariado. Resultados: en el análisis univariado, la edad menor de 5 años y el sexo masculino se mostraron sin influencia estadísticamente significativa, mientras que el multivariado mostró que el factor con independencia más importante fue el uso previo de antimicrobiano (OR 6,329 ajustado IC 95% 2,764-8,678), seguido del diagnóstico tardío (OR ajustado 5,492IC 95% 2,559-8,522) y la presencia de comorbilidad (OR ajustado 4,341 IC 95% 2,321−7,529) de manera similar. Conclusiones: los factores de mayor riesgo que contribuyeron al riesgo de desarrollar la neumonía complicada con empiema pleural fueron el uso previo de antimicrobiano, el diagnóstico tardío de empiema y la presencia de comorbilidad.

Introduction: pneumonia is the main cause of pleural effusion (PE) in children. A high number of patients enter pediatric intensive care units with parapneumonic pleural effusion (PPE), ending in pleural empyema. Objective: to identify the risk factors that independently influences the occurrence of community-acquired pneumonia, complicated by pleural empyema. Methods: an analytical observational study of cases and controls was carried out, 30 cases and 90 controls were selected. With a ratio of 1:3. Univariate and multivariate statistical analysis was performed. Results: in the univariate analysis, age under 5 years and male sex showed no statistically significant influence, while the multivariate analysis showed that the most important independent factor was the previous use of antimicrobial (OR 6.329 adjusted CI 95% 2.764-8.678), followed by late diagnosis (adjusted OR 5.492 CI 95% 2.559-8.522) and the presence of comorbidity (adjusted OR 4.341 CI 95% 2.321−7.529) similarly. Conclusions: the highest risk factors that contributed to the risk of developing pneumonia complicated with pleural empyema were previous use of antimicrobials, late diagnosis of empyema, and the presence of comorbidity.

Introdução: A pneumonia é a principal causa de derrame pleural (DP) em crianças. Um número elevado de pacientes é admitido em unidades de terapia intensiva pediátrica com derrame pleural parapneumônico (DPP), terminando em empiema pleural. Objetivo: Identificar os fatores de risco que influenciam independentemente a ocorrência de pneumonia adquirida na comunidade complicada por empiema pleural. Métodos: Foi realizado um estudo observacional analítico caso-controle, selecionados 30 casos e 90 controles. Com uma proporção de 1:3. Foram realizadas análises estatísticas univariada e multivariada. Resultados: Na análise univariada, idade menor de 5 anos e sexo masculino não foram estatisticamente significativos, enquanto a análise multivariada mostrou que o fator independente mais importante foi o uso prévio de antimicrobianos (OR ajustado 6,329 IC 95% 2,764-8,678), seguido pelo diagnóstico tardio (OR ajustado 5,492 IC 95% 2,559-8,522) e presença de comorbidade (OR ajustado 4,341 IC 95% 2,321−7, 529) da mesma forma. Conclusões: Os maiores fatores de risco que contribuíram para o desenvolvimento de pneumonia complicada com empiema pleural foram o uso prévio de antimicrobianos, o diagnóstico tardio de empiema e a presença de comorbidade.

Tuberculosis pulmonar y extrapulmonar en niños / Pulmonary and extrapulmonary tuberculosis in children

La Organización Mundial de la Salud (OMS) informa que ocurren 1.1 millones de casos de tuberculosis (TBC) en niños <15 años. En Chile se observa un aumento de casos en el tiempo. La pandemia por SARS-Cov2 ha implicado una disminución de la pesquisa y un retardo de la atención y diagnóstico de TBC. Se presenta dos casos clínicos de tuberculosis en adolescentes. El primero corresponde a un adolescente con una tuberculosis pulmonar de difícil y tardío diagnóstico, habiéndose descartado inicialmente TBC por estudio molecular y PPD no reactivo. El segundo caso corresponde a un adolescente con una tuberculosis pulmonar y extrapulmonar de diagnóstico tardío, de 8 meses de evolución, posterior a un cuadro leve de Covid.

The World Health Organization (WHO) reports that 1.1 million cases of tuberculosis (TB) occur in children <15 years of age. In Chile, an increase in cases is observed over time. The SARS-Cov2 pandemic has led to a decrease in screening and a delay in care and diagnosis of TB. Two clinical cases of tuberculosis in adolescents are presented. The first corresponds to an adolescent with TB of difficult and late diagnosis, having initially ruled out TB by molecular study and non-reactive PPD. The second case corresponds to an adolescent with pulmonary and extrapulmonary tuberculosis of late diagnosis, of 8 months of evolution, after a mild respiratory infection of Covid.

Empiema pleural iatrogénico por Salmonella tras biopsia renal / Iatrogenic pleural empyema by Salmonella after renal biopsy

El empiema pleural es una infección localizada en la que se produce acumulación de pus en el espacio pleural. La mayoría de los empiemas se deben a una infección pleural consecutiva a neumonía, pero con frecuencia un derrame no infeccioso puede contaminarse por una ejecución no adecuada de los procedimientos y una técnica no estéril durante una punción o drenaje quirúrgico. El empiema pleural debido a la bacteriemia por Salmonella spp. no tifoidea, es una infección localizada rara que generalmente se asocia con inmunodeficiencia subyacente, anemia de células falciformes, enfermedad pulmonar o pleural previa, y cáncer de pulmón. Se presenta el caso de un varón de 76 años de edad que al poco tiempo de practicarle una biopsia renal, comienza con regular estado general, dificultad respiratoria y fiebre, diagnosticándose empiema pleural por Salmonella spp. La mayoría de los casos descritos de empiema pleural por Salmonella spp, son en pacientes con inmunidad comprometida, factores predisponentes o enfermedad pleuropulmonar previa, siendo raros los casos en pacientes no inmunocomprometidos o en pacientes que carecen de otros factores de riesgo conocidos. (AU)

Pleural empyema is a localized infection with collection of pus in the pleural space. Most empyema is due to a pleural infection secondary to pneumonia, but often a non-infectious effusion can be contaminated by poor performance of the procedures and a non-sterile technique during a surgical puncture or drainage. Pleural empyema due to nontyphoidal Salmonella spp. bacteremia is a rare localized infection that is usually associated with underlying immunodeficiency, sickle cell anemia, previous lung or pleural disease, and lung cancer. We present the case of a 76-year-old man who, shortly after performing a renal biopsy, he started with worsening overall status, respiratory distress and fever, so the patient was diagnosed with pleural empyema due to Salmonella spp. Most of cases described of pleural empyema due to Salmonella spp. are in immunocompromised patients, predisposing factors or previous pleuropulmonary disease, with rare cases in non-immunocompromised patients or patients lacking other known risk factors. (AU)

Toracostomía abierta: en ocasiones la mejor opción / Open thoracostomy: Sometimes the best option

El tratamiento quirúrgico del empiema ha evolucionado, desde la medicina hipocrática, a través de los años, teniendo como premisa el drenaje. Con los avances médicos, el abordaje mínimamente invasivo se ha convertido en el estándar, dejando de lado otras técnicas quirúrgicas. La toracostomía abierta, en pacientes seleccionados, puede llegar a ser la última y mejor opción para el control del foco infeccioso: es una opción quirúrgica para el tratamiento de los empiemas en pacientes mórbidos y en fase de organización, cuando otros tratamientos han fallado, con una aceptable morbilidad y mortalidad. Esta técnica debe estar en el arsenal terapéutico del cirujano. Presentamos una serie de 4 casos de pacientes con empiema en fase de organización, en los cuales el riesgo quirúrgico era muy alto, por lo que se optó por realizar una toracostomía abierta, con éxito

The surgical treatment of empyema has evolved from Hippocratic medicine over the years, with drainage as its premise. With medical advances, the minimally invasive approach has become the standard, leaving aside other surgical techniques. Open thoracostomy, in selected patients, may become the last and best option for the control of the infectious focus: it is a surgical option for the treatment of empyemas in morbid patients and in the organization phase when other treatments have failed, with an acceptable morbidity and mortality. This technique should be in the surgeon's therapeutic arsenal. We present a series of four cases of patients with empyema in the organization phase, in which the surgical risk was very high, so it was decided to perform an open thoracostomy, which turn out successful

Empiema pleural en el Instituto Nacional del Torax (INT): Caso cllínico y revisión actual de la literatura / Pleural empyema at the National Thoracic Institute (INT): Clinical case and current review of the literature

El objetivo de este artículo es relatar un caso de empiema pleural complicado observado en el Insituto Nacional del Torax de La Paz Bolivia, en un paciente masculino de 21 años diagnosticado: Derrame Pleural izquierdo, Trauma Torácico izquierdo, contusión pulmonar izuierdo, Hemoptisis de origen a determinar . El epiema pleural es una colección de pus en la cavidad pleural, es más común en niños, es más frecuente en los hombres y su incidencia es mayor en pacientes con antecedentes de alcoholismo, diabetes mellitus, artritis reumatoide y enfermedad pulmonar crónica. Además se expondrá la fisiopatogenia y el tratameinto basado en el control de la infección por instalación de sistema pleural a sello de agua y opciones quirúrgicas siendo abierta o por mínimamente invasiva por toracoscopia.

Tuberculosis y una Gemella spp: Una combinación indeseable / Tuberculosis and a Gemella spp: An undesirable combination

El género Gemella spp corresponde a cocos gram positivos, anaerobios facultativos, catalasa negativos, no móviles y no formadores de esporas, usualmente comensales de la cavidad oral, que no suelen ser patógenos en pacientes inmunocompetentes. Sin embargo, puede comportarse como germen oportunista en pacientes inmunosuprimidos o con otros factores de riesgo como mala higiene dental, cirugía gastrointestinal, enfermedades metabólicas entre otras, y se asocia con endocarditis, meningitis y en menor medida compromiso pulmonar. La información respecto a la susceptibilidad antimicrobiana es limitada y se asemeja a la de S viridans, por lo que la penicilina y ampicilina son los medicamentos de elección, sin tener claridad en cuanto a duración del tratamiento, usualmente considerando llevar a 4 semanas o hasta el drenaje de la colección. Éste reporte de caso describe una paciente con tuberculosis en tratamiento, que desarrolla una infección invasiva con documentación de empiema y bacteriemia secundaria por Gemella morbillorum, representando la asociación poco común de ésta infección bacteriana con tuberculosis.

Gemella spp. corresponds to gram positive cocci, facultative anaerobes, negative catalase, non mobile and non spore producers, part of colonizing flora of the oral cavity that are not common pathogens in immunocompetent patients. Nevertheless it may behave as an opportunistic germ in immunosuppressed patients or with other risk factors that include bad dental hygiene, bowel surgery, and metabolic diseases among others. It's associated with infections such as endocarditis, meningitis and less frecuently can implicate the lung. The information regarding antimicrobial susceptibility is limited and resembles S viridans, so penicillin and ampicillin are the medications of choice, without being clear about the duration of treatment, usually giving 4 weeks or until collection drain. This case report describes a patient with known tuberculosis diagnosis and under treatment, that develops an invasive infection with empyema and secondary bloodstream infection by Gemella morbillorum, depicting a previously uncommon but described association of this bacterial infection with tuberculosis.

Complicated pneumonia with empyema caused by streptococcus anginosus in a child / Complicated pneumonia with empyema caused by streptococcus anginosus in a child

ABSTRACT Objective: To highlight the pathogenicity of Streptococcus anginosus, which is rare in pediatric patients, but can cause severe infections that are known to have a better outcome when treated early with interventional procedures and prolonged antibiotic therapy. Case description: The patient is a 6-year-old boy with global developmental delay, examined in the emergency room due to fever and respiratory distress. The physical examination and diagnostic workout revealed complicated pneumonia with empyema of the left hemithorax; he started antibiotic therapy and underwent thoracic drainage. Pleural fluid cultures grew Streptococcus anginosus. On day 11, the child had a clinical deterioration with recurrence of fever, hypoxia, and respiratory distress. At this point, considering the causative agent, he was submitted to video-assisted thoracoscopic decortication, with good progress thereafter. Comments: Streptococcus anginosus is a commensal bacterium of the human oral cavity capable of causing severe systemic infections. Although reports of complicated thoracic infections with this agent are rare in the pediatric population, they have been increasing in adults. Streptococcus anginosus has a high capacity to form abscess and empyema, requiring different therapeutic approaches when compared to complicated pneumonia caused by other agents.

RESUMO Objetivo: Alertar para a patogenicidade do Streptococcus anginosus que, apesar de raro em pediatria, pode causar infeções graves que necessitam de tratamento invasivo e antibioterapia de longo curso para obter um melhor prognóstico. Descrição do caso: Criança de seis anos, com atraso do desenvolvimento psicomotor, avaliado no serviço de urgência por febre e dificuldade respiratória. O exame físico, juntamente com os exames complementares, revelou uma pneumonia complicada com empiema no hemitórax esquerdo, tendo iniciado antibioterapia e sido submetido à drenagem do líquido pleural. Foi identificado Streptococcus anginosus nesse líquido. No 11º dia de doença, a criança agravou o seu estado clínico, com recidiva da febre, hipoxemia e dificuldade respiratória. Considerando-se o microrganismo identificado, o paciente foi submetido à decorticação pulmonar por videotoracoscopia, com boa evolução clínica posterior. Comentários: Streptococcus anginosus é uma bactéria comensal da cavidade oral humana, que pode causar infecções sistêmicas graves. Apesar de serem raros os casos descritos em pediatria, têm sido cada vez mais descritas infecções torácicas complicadas em adultos. Esse microrganismo também tem a capacidade de formar abcessos e empiemas, que precisam de intervenções terapêuticas diferentes, quando comparados a pneumonias complicadas causadas por outros agentes.

Streptococcus constellatus: causa infrecuente de empiema pleural

RESUMEN Streptococcus Constellatus es un microorganismo comensal en el humano, pero puede causar infecciones en diferentes lugares. Reportamos el caso de un escolar con empiema pleural causado por este microorganismo en asociación a anaerobios. El paciente fue tratado con un drenaje pleural y recibió antibioticoterapia durante seis semanas. Fue dado de alta en buenas condiciones. Se discute el caso y se hace revisión de la literatura. Conclusión: En los últimos 5 años, la enfermedad del dengue produce una carga económica y de enfermedad sustancial en Paraguay. Se requiere la sostenibilidad y el fortalecimiento de acciones multisectoriales para reducir el impacto económico del dengue en la población paraguaya.

ABSTRACT Streptococcus constellatus is a commensal microorganism in humans, but it can cause sometimes different types of infections. We report the case of school-age children with pleural empyema caused by this microorganism in association with anaerobic bacteria. The patient was treated with a pleural drainage and received antibiotic therapy for six weeks. It was discharged in good condition. The case is discussed and literature review is done.

Empyema necessitatis due to Citrobacter freundii: Case report / Empiema necessitatis por Citrobacter freundii. Reporte de caso

Abstract Introduction: This paper presents the first case of empyema necessitatis secondary to infection with Citrobacter freundii (according to the databases consulted), and one of the few reports of this pathology in Colombia. Case presentation: This is the case of a 26-year-old patient from a rural area, with a history of severe cognitive deficit, who was taken to the emergency department due to a clinical picture of 15 days of evolution consisting of neurological deterioration associated with asthenia, adynamia, fever and cough with purulent expectoration. On admission, a chest x-ray was taken, finding pneumonia of the middle lobe with associated pleural effusion, for which empirical antibiotic management was initiated. The patient presented clinical deterioration and appearance of right pectoral mass, so a computed tomography of the thorax was performed, revealing empyema necessitatis. Close drainage and culture of the collection were made, with negative mycobacteria culture and positive report for C. freundii. The patient received specific antibiotic treatment for 8 weeks, with complete improvement of his clinical condition. Conclusion: Besides being the first case of empyema necessitatis by C. freundii that has been reported, this case is important because of the low amount of reports on this pathology in Colombia, considering that its main cause is tuberculosis, which is endemic in the country.

Resumen Introducción. Según lo encontrado en las bases de datos consultadas, el presente es el primer caso de empiema necessitatis secundario a Citrobacter freundii. Además, constituye uno de los pocos reportes de esta patología en Colombia. Presentación del caso. Se trata de un paciente de 26 años procedente de área rural, con antecedente de déficit cognitivo severo, quien fue llevado al servicio de urgencias por cuadro clínico de 15 días de evolución consistente en deterioro neurológico asociado a astenia, adinamia, fiebre y tos con expectoración purulenta. Al ingreso se tomó radiografía de tórax, encontrando neumonía del lóbulo medio con derrame pleural asociado, por lo que se inició cubrimiento antibiótico empírico. El paciente presentó deterioro clínico y aparición de masa pectoral derecha, por lo que se realizó tomografía computarizada de tórax, evidenciando empiema necessitatis. Luego, se hizo drenaje de la colección, con cultivo negativo para micobacterias y aislamiento de C. freundii. Se dio tratamiento guiado por antibiograma durante ocho semanas, con posterior recuperación completa del cuadro clínico. Conclusión. Además de ser el primer caso de empiema necessitatis por C. freundii, este es importante por la escasa cantidad de reportes en Colombia, considerando que su principal causa es la tuberculosis, la cual es endémica en el país.

Uso de estreptoquinasa recombinante intrapleural en una mujer embarazada con empiema pleural / Use of intrapleural recombinant streptokinase in a pregnant woman with pleural empyema

RESUMEN Fundamento: la neumonía complica el 0,78-2,7 por 1 000 embarazos al estar en riesgo la madre y el feto. El empiema como complicación de una neumonía en una paciente embarazada agrega un alto índice de morbimortalidad para la madre y el feto si no se actúa de forma rápida. Objetivo: describir el caso de una mujer de 33 semanas de embarazo, la cual desarrolló un empiema pleural producto de una complicación de una neumonía adquirida en la comunidad tratada con fibrinólisis intrapleural. Caso clínico: paciente gestada de 33 semanas, asmática ingresada en el servicio de terapia intensiva del Hospital Universitario Manuel Ascunce Domenech con el diagnóstico de neumonía grave adquirida en la comunidad complicada con derrame paraneumónico el cual evolucionó hacia el empiema. El mismo fue tratado con tubo de toracostomía y terapia fibrinolítica, con buena evolución clínica y radiológica. Conclusiones: la estreptoquinasa recombinante se puede utilizar de manera segura y efectiva para el manejo del empiema pleural, como agente fibrinolítico intrapleural, durante el embarazo.

ABSTRACT Background: pneumonia complicates 0,78-2,7 per 1 000 pregnancies placing the mother and the fetus at risk. Empyema as a complication of pneumonia in a pregnant patient adds a high rate of morbidity and mortality to the mother and the fetus if one does not act quickly. Objective: to present the case of a pregnant woman of 33 weeks who developed a pleural empyema resulting from acquired pneumonia. Clinical case: 33-week gestated patient, asthmatic admitted to the intensive care unit of the University Hospital Manuel Ascunce Domenech with the diagnosis of severe pneumonia acquired in the community complicated with para-pneumonic effusion, which evolved into empyema. It was treated with a thoracotomy tube and fibrinolytic therapy, with good clinical and radiological evolution. Conclusions: Recombinant streptokinase can be used safely and effectively for the management of PE, as an intrapleural fibrinolytic agent, during pregnancy.

Mini-thoracostomy with vacuum-assisted closure: a minimally invasive alternative to open-window thoracostomy / Minipleurostomia com curativo a vácuo: uma opção minimamente invasiva a pleurostomia

ABSTRACT Thoracostomy is a common treatment option for patients with stage III pleural empyema who do not tolerate pulmonary decortication. However, thoracostomy is considered mutilating because it involves a thoracic stoma, the closure of which can take years or require further surgery. A new, minimally invasive technique that uses the vacuum-assisted closure has been proposed as an alternative to thoracostomy. This study aims to analyze the safety and effectiveness of mini-thoracostomy with vacuum-assisted closure in an initial sample of patients.

RESUMO A pleurostomia é uma opção frequente de tratamento para pacientes com empiema pleural fase III que não toleram decorticação pulmonar. Todavia, esse tratamento é considerado mutilante por envolver a confecção de um stoma torácico, que pode demorar anos para se fechar ou requerer nova cirurgia. Descreveu-se recentemente uma técnica minimamente invasiva que associa uso intrapleural de curativo a vácuo como opção a pleurostomia. A presente comunicação objetiva demonstrar o resultado de uma série inicial de pacientes tratados com a minipleurostomia associada ao uso de curativo a vácuo no que tange a sua efetividade e segurança.

Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion / Cirurgia torácica vídeoassistida antes e depois de drenagem torácica em crianças com derrame parapneumônico complicado

Abstract Objectives To evaluate the effectiveness of videothoracoscopic surgery in the treatment of complicated parapneumonic pleural effusion and to determine whether there is a difference in the videothoracoscopic surgery outcome before or after the chest tube drainage. Methods The medical records of 79 children (mean age 35 months) undergoing videothoracoscopic surgery from January 2000 to December 2011 were retrospectively reviewed. The same treatment algorithm was used in the management of all patients. Patients were divided into two groups: in group 1, videothoracoscopic surgery was performed as the initial procedure; in group 2, videothoracoscopic surgery was performed after previous chest tube drainage. Results Videothoracoscopic surgery was effective in 73 children (92.4%); the other six (7.6%) needed another procedure. Sixty patients (75.9%) were submitted directly to videothoracoscopic surgery (group 1) and 19 (24%) primarily underwent chest tube drainage (group 2). Primary videothoracoscopic surgery was associated with a decrease of hospital stay (p = 0.05), time to resolution (p = 0.024), and time with a chest tube (p < 0.001). However, there was no difference between the groups regarding the time until fever resolution, time with a chest tube, and the hospital stay after videothoracoscopic surgery. No differences were observed between groups regarding the need for further surgery and the presence of complications. Conclusions Videothoracoscopic surgery is a highly effective procedure for treating children with complicated parapneumonic pleural effusion. When videothoracoscopic surgery is indicated in the presence of loculations (stage II or fibrinopurulent), no difference were observed in time of clinical improvement and hospital stay among the patients with or without chest tube drainage before videothoracoscopic surgery.

Resumo Objetivos Avaliar a eficácia da cirurgia torácica videoassistida no tratamento de derrame pleural parapneumônico complicado e determinar se há diferença no resultado da cirurgia torácica videoassistida realizada antes ou depois da drenagem torácica. Métodos Analisamos retrospectivamente prontuários médicos de 79 crianças (idade média de 35 meses) submetidas a cirurgia torácica videoassistida de janeiro de 2000 a dezembro de 2011. O mesmo algoritmo de tratamento foi utilizado no manejo de todos os pacientes. Os pacientes foram divididos em dois grupos: o Grupo 1 foi submetido a cirurgia torácica videoassistida como procedimento inicial; o Grupo 2 foi submetido a cirurgia torácica videoassistida após drenagem torácica prévia. Resultados A cirurgia torácica videoassistida foi eficaz em 73 crianças (92,4%); as outras seis (7,6%) necessitaram outro procedimento. Sessenta pacientes (75,9%) foram diretamente submetidos a cirurgia torácica videoassistida (Grupo 1) e 19 (24%) foram primeiramente submetidos a drenagem torácica (Grupo 2). A cirurgia torácica videoassistida primária foi associada à redução do tempo de internação (p = 0,05), do tempo para resolução (p = 0,024) e do tempo com o tubo torácico (p < 0,001). Contudo, não houve diferença entre os grupos a respeito do tempo até que não tivessem mais febre, do tempo com o tubo torácico e do tempo de internação após a cirurgia torácica videoassistida. Não foram observadas diferenças entre os grupos com relação à necessidade de cirurgia adicional e à presença de complicações. Conclusões A cirurgia torácica videoassistida é um procedimento altamente eficaz para tratar crianças com derrame pleural parapneumônico complicado. Quando a cirurgia torácica vídeoassistida é indicada na presença de loculações (fase II ou fibrinopurulenta) não há diferença no tempo de melhora clínica e no tempo de internação entre os pacientes com ou sem drenagem torácica antes da cirurgia torácica videoassistida.

Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion.

OBJECTIVES: To evaluate the effectiveness of videothoracoscopic surgery in the treatment of complicated parapneumonic pleural effusion and to determine whether there is a difference in the videothoracoscopic surgery outcome before or after the chest tube drainage. METHODS: The medical records of 79 children (mean age 35 months) undergoing videothoracoscopic surgery from January 2000 to December 2011 were retrospectively reviewed. The same treatment algorithm was used in the management of all patients. Patients were divided into two groups: in group 1, videothoracoscopic surgery was performed as the initial procedure; in group 2, videothoracoscopic surgery was performed after previous chest tube drainage. RESULTS: Videothoracoscopic surgery was effective in 73 children (92.4%); the other six (7.6%) needed another procedure. Sixty patients (75.9%) were submitted directly to videothoracoscopic surgery (group 1) and 19 (24%) primarily underwent chest tube drainage (group 2). Primary videothoracoscopic surgery was associated with a decrease of hospital stay (p=0.05), time to resolution (p=0.024), and time with a chest tube (p<0.001). However, there was no difference between the groups regarding the time until fever resolution, time with a chest tube, and the hospital stay after videothoracoscopic surgery. No differences were observed between groups regarding the need for further surgery and the presence of complications. CONCLUSIONS: Videothoracoscopic surgery is a highly effective procedure for treating children with complicated parapneumonic pleural effusion. When videothoracoscopic surgery is indicated in the presence of loculations (stage II or fibrinopurulent), no difference were observed in time of clinical improvement and hospital stay among the patients with or without chest tube drainage before videothoracoscopic surgery.