A 71-Year-Old Man With Diffuse Waxing and Waning Multifocal Lung Lesions, Empyema, and Episodic Fevers Reveals a Rare Diagnosis.

CASE PRESENTATION: A 71-year-old man with history of gastroesophageal reflux disease, chronic sinusitis, arthritis, hypothyroidism, and anemia of chronic disease initially sought treatment with a recurrent left pleural effusion along with other abnormal lung findings on chest CT scan. Before his referral, he was being managed for 3 years at his local hospital for waxing and waning fevers, fatigue, productive cough, chills, and night sweats. He did not report any hemoptysis or chest pain, but reported weight loss of 13 kgs in 15 months. During those 3 years, he was treated with multiple courses of antibiotics and steroids with temporary relief of symptoms. At that time, his chronic sinusitis was suspected to be the cause of his symptoms and he underwent balloon sinuplasty. He was receiving daily sublingual immunotherapy for inhaled respiratory allergens for the previous year after showing positive test results for 17 inhaled allergens. The patient had no other known immunologic workup before our evaluation.

Management of patients with empyema.

Empyema is the term used to describe an accumulation of pus in a body cavity such as the pleural space as a result of bacterial infection. The condition is serious because it is difficult for the immune system to resolve infection in this area. Empyema can be avoided by the use of appropriate antibiotic therapy and good aseptic technique when dealing with any situation that breaches the chest wall. Treatment of this condition may be medical but if the condition does not resolve, surgical intervention is required. The nursing role involves providing support, education and long-term management for patients with empyema.

Parental decisions on children participating in research.

AIM: To observe and report rates of, and reasons for, parents' refusal to consent to the participation of their children in appropriate clinical research. METHODS: The parents of children admitted to hospital with a diagnosis of pneumonia or of empyema were asked for informed consent to research involving blood, urine and nasopharyngeal secretion samples from their child. Circumstances and numbers of agreements and refusals were compared and underlying reasons suggested. RESULTS: Of 144 consent requests, ten were refused, which appeared to be linked to: not wanting the child to undergo further tests, lack of interest in participating in studies, research possibly delaying discharge, and anxiety regarding written consent and the length of information sheets. CONCLUSIONS: Severity of the child's illness appeared to determine the parent's decision. Involvement and assistance of non-research nursing and medical staff and previous introductions to the researchers are helpful. The timing and setting for the consent process should be selected carefully. Adequate, accessible study information for parents and children contributes to successful recruitment of participants.

Artritis séptica esternoclavicular y empiema / Sternoclavicular septic arthritis and empyema

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Characterization of a new mouse model of empyema and the mechanisms of pleural invasion by Streptococcus pneumoniae.

Although empyema affects more than 65,000 people each year in the United States and in the United Kingdom, there are limited data on the pathogenesis of pleural infection. We investigated the pathogenesis of empyema using animal and cell culture models of Streptococcus pneumoniae infection. The pathological processes during the development of empyema associated with murine pneumonia due to S. pneumoniae (strain D39) were investigated. Lungs were examined using histology, and pleural fluid and blood bacterial colony-forming units, cytokine levels, and cellular infiltrate were determined over time. Bacterial migration across mesothelial monolayers was investigated using cell culture techniques, flow cytometry, and confocal microscopy. After intranasal inoculation with 10(7) S. pneumoniae D39 strain, mice developed pneumonia associated with rapid bacterial invasion of the pleural space; raised intrapleural IL-8, VEGF, MCP-1, and TNF-α levels; and caused significant intrapleural neutrophilia followed by the development of fibrinous pleural adhesions. Bacterial clearance from the pleural space was poor, and in vitro assays demonstrated that S. pneumoniae crossed mesothelial layers by translocation through cells rather than by a paracellular route. This study describes key events during the development of S. pneumoniae empyema using a novel murine model of pneumonia-associated empyema that closely mimics human disease. The model allows for future assessment of molecular mechanisms involved in the development of empyema and evaluation of potential new therapies. The data suggest that transmigration of bacteria through mesothelial cells could be important in empyema development. Furthermore, upon entry the pleural cavity offers a protected compartment for the bacteria.

Transmigration of fibrino-purulent inflammation and malignant cells into an artificial dura substitute (Neuro-Patch): report of two cases.

PURPOSE: The objective of this work was to present possible, though rare, complications of Neuro-Patch implantation after brain surgery. METHODS: Two patients, aged 62 and 63 years, who had a partial dural substitution with an artificial polyurethane graft after neurosurgical resection of a gross tumour, are presented. RESULTS: In the two patients, the a-vital tissue was infiltrated by either inflammatory or neoplastic tissue respectively. CONCLUSIONS: This report demonstrates a new pathological point of view in using synthetic materials for the reconstruction of dural defects.

Diagnostic role of closed pleural biopsy in the investigation of exudative pleural effusions.

Closed pleural biopsy is known to be diagnostic in approximately 75% of pleural effusion undiagnosed by thoracocentesis or pleural fluid evaluation. The purpose of this study was to determine the efficacy of closed pleural biopsy in a teaching hospital, Eastern India. The study was undertaken in all patients with exudative pleural effusion who were admitted in the department of chest medicine, Burdwan Medical College and Hospital, Burdwan, during the period from January 2001 to December 2005. Abram's needle was used for closed pleural biopsy in every case. One hundred and thirty-three pleural biopsies were performed with the needle. Twenty-three cases were excluded due to obtaining no pleural tissue. Specific diagnoses were obtained in 64 cases giving a diagnostic yield of 48.12%. Of these 17 revealed malignancy, 37 tuberculosis, and 10 empyema. A non-specific diagnosis was obtained in 46 cases (34.58%). By closed pleural biopsy 48.12% of undiagnosed exudative pleural effusions could be diagnosed which shows that closed pleural biopsy is still of value as a diagnostic procedure, and should be carried out prior to invasive procedures such as thoracoscopy or open pleural biopsy.

Streptococcus acidominimus isolated from a multiloculated empyema in a critically ill adult man with pneumonia: case report and review of literature.

We describe a 55-year-old man with a medical history of hypertension and schizophrenia who presented to the medical intensive care with delirium and respiratory failure requiring intubation. Chest radiography showed a complete opacification of the right hemithorax. Subsequent chest computed tomography with contrast confirmed a multiloculated right pleural effusion, compressive atelectasis, and mediastinal shift to the left. This patient required multiple tube thoracostomies and a video-assisted thoracoscopic decortication to adequately drain the multiloculated empyemas. Streptococcus acidominimus, a common bacterial pathogen in veterinary medicine, was isolated. The organism is an uncommon cause of invasive disease in humans. This is the first case report in which S. acidominimus was isolated from a multiloculated empyema in a critically ill patient causing significant morbidity and must be considered as a potential but rare pathogen.

Ventilation induced pneumothorax following resolved empyema.

We report a case of pneumothorax as a result of positive pressure ventilation in a child previously treated for empyema. Three months following discharge for successful treatment of empyema our patient received a general anesthetic for an elective MRI of the brain for investigation of nystagmus. During recovery from the anesthetic he developed respiratory distress and was found to have a loculated pneumothorax. We propose that pleural fragility in childhood empyema possibly persists even after clinical resolution and in this case for up to 3 months. The complication of pneumothorax should be considered in all patients receiving positive pressure ventilation following resolved empyema.

Missed foreign body and nessitans empyema.

A recurrent empyema over a three-month period ultimately presented as an empyema necessitans (an empyema pointing through the skin) due to Fusobacterium varium. The recurrence of the empyema was due to an animal vertebra aspirated, during a bar-room altercation, into the right main bronchus, mimicking an endobronchial tumour.

Management of empyema in children.

The incidence of empyema complicating community-acquired pneumonia is increasing and causes significant childhood morbidity. Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world. Newer molecular techniques utilizing the polymerase chain reaction have led to an increase in identification of causative bacteria, previously not isolated by conventional culture techniques. This remains an important epidemiological tool, and may help in guiding correct antibiotic use in the future. There are many treatment options, however, and the care a child currently receives is dependent on local practice, which is largely determined by availability of medical personnel and their preferences. Although there are many reported case series comparing treatment options, only two randomized controlled studies exist to guide treatment in children. There is an urgent need for this to be addressed, particularly with the introduction of relatively new surgical techniques such as video-assisted thorascopic surgery.

[Development of new therapeutic method for empyema].

OBJECTIVES: We have investigated whether polylactic acid (PLA) sponge and fibroblast-growth-factor (FGF) released slowly from gelatin beads can induce fibrotic tissue in postpneumonectomy dead space. METHODS: Left pneumonectomy was performed in white Japanese rabbits. In the control group (N = 5), left chest was closed without any treatment. In the PLA sponge group (N = 5), PLA sponge and FGF (100 micrograms) released from gelatin beads were introduced into the left chest cavity. RESULTS: In the control group, herniation of the heart and right lung were observed without fibrotic material in the left chest cavity. In the PLA sponge group, dense fibrotic material was observed by chest CT scan 1 month after the operation. Pathological examinations revealed that PLA sponge and FGF did promote the organization of the fibrotic materials. CONCLUSIONS: Fibrotic materials can be induced in the postpneumonectomy dead space by PLA sponge and FGF released slowly from a gelatin sponge. New therapeutic method may be introduced near future by this concept, reduction of dead space with newly developed own fibrotic materials.

Evarts Ambrose Graham, empyema, and the dawn of clinical understanding of negative intrapleural pressure.

The concept of negative intrapleural pressure is fairly new. Although the phenomenon had already been described, Wirz provided the first definitive analysis of its significance to the mechanics of breathing in 1923. By contrast, empyema has been known since antiquity; from the time of Hippocrates, treatment has consisted of open drainage. Open drainage was often successful and did not result in pneumothorax, because most cases of empyema were associated with adhesions and thickened visceral pleura that prevented the lung from collapsing. The epidemic of group A streptococcal pneumonia in military camps in 1917-1918 was associated with the rapid and early accumulation of empyema fluid and was the catalyst for renewed study of empyema. Use of open drainage to manage this illness resulted in a high immediate mortality rate, probably because patients developed pneumothorax. The work of Evarts Graham and the Empyema Commission married physiological understanding of pleural mechanics with rational clinical treatment and paved the way for further advances in thoracic surgery.