Pleural empyema after COVID-19: A delayed presentation

Globally, the number of coronavirus disease-2019 (COVID-19) cases and deaths shows a declining trend since a peak in January 2022. For now, the pandemic phase looks to be ended, until a severe new variant may trigger another wave. At present, in India, small pockets of COVID-19 cases and post-COVID complications are still being reported. Therefore, physicians should remain vigilant about the atypical presentations and potential delayed or long-term complications of SARS-CoV-2 infection, even in individuals who had a mild COVID-19 infection. Here, we present the case of a 52-year-old male patient with a history of hypertension, who is a non-smoker and developed culture-negative pleural empyema 7 months after a mild COVID-19 infection. The patient was successfully treated with antibiotics and early video-assisted thoracoscopic surgery

Diagnostic utility of cancer ratio in differentiating malignant from non-malignant pleural effusions in a tertiary care centre in central Kerala

Background:Malignant pleural effusion (MPE) is a common clinical condition observed in patients suffering from malignant diseases. None of the tumour markers have both high sensitivity and specificity. A retrospective study on patients with pleural effusion was done to evaluate the diagnostic accuracy of Cancer ratio (CR) in diagnosing MPE.Methods:A retrospective analysis of patients with undiagnosed exudative pleural effusion was done. Results of serum Lactate dehydrogenase (LDH), pleural fluid Adenosine deaminase (ADA), pleural fluid analysis such as cytology and histopathology reports of pleural biopsy were analyzed. Serum LDH: pleural fluid ADA ratio (CR) was calculated and compared with histopathology report. Data were analyzed statistically.Results:A total of 102 patients were enrolled in the study (56 males and 46 females). The sensitivity and specificity of CR at the cut off level of >20 were 57.14% and 75.47% respectively. The positive predictive value was 68.29% and the negative predictive value was 65.57%. CR>20 (p<0.001) is statistically significant in predicting malignancy in undiagnosed exudative pleural effusions. Conclusions:CR has a high sensitivity and specificity and is a novel tool in differentiating malignant from nonmalignant pleural effusions. Patients with unconfirmed diagnosis but higher CR will identify the need for early biopsy, follow-up and frequent or repeat chest imaging to assess the progression.

To lyse or not to lyse? Use of intrapleural tissue plasminogen activator and DNase in the management of parapneumonic effusions and empyema

Despite a range of management options, pleural effusions and empyema continue to present therapeutic challenges in the clinical setting. With treatment options ranging from simple use of antibiotics to more complex surgical procedures, several important considerations need be made as to what type of treatment is best for each patient on a case by case basis. One treatment modality of increasing interest is the use of intrapleural fibrinolytics to facilitate drainage of effusions. This presents a viable option especially in patients in whom surgery is not preferred. But, as with many therapeutic approaches, the use of intrapleural fibrinolytics is laden with significant controversies and has been a subject of considerable debate over the last couple of years. With accruing evidence for and against this modality of treatment, the ensuing discussion has been whether or not it should be a routine treatment choice and which group of patients should this consideration be made for. This paper gives a background on the epidemiology and etiology of parapneumonic effusions and empyema and briefly outlines the available options of management. Furthermore, we extensively discuss available evidence on the use of intrapleural fibrinolytics as a management option for parapneumonic effusions and empyema, with particular emphasis on use of tissue plasminogen activator (tPA) and DNase.

Analysis of risk factors for complicated parapneumonic effusion in children / 临床儿科杂志

Objective To investigate the related risk factors of complicated parapneumonic effusion (CPPE) in children. Method The clinical data of 88 children with parapneumonic effusion (PPE) were retrospectively analyzed from January 2013 to April 2015. According to the treatment effect of antibiotics, CPPE group and uncomplicated parapneumonic effusion (UPPE) group were divided. The univariate analysis of clinical and laboratory parameters was performed between two groups. Then the multifactor logistic regression was performed further. The receiver operator characteristic (ROC) curve was draw. Results The univariate analysis indicated that the risk factors were the formation of loculation and serum CD3+ and CD19+ levels (Z=2.030~7.457, P30%and the formation of loculation.

Diagnosis and Treatment of Complicated Pleural Effusion / 대한내과학회지

Parapneumonic effusion is pleural effusion that arises in the pleural space, complicated with bacterial pneumonia. This occurs in at least forty percent of bacterial pneumonia. The usual parapneumonic effusion resolves well with antibiotic therapy. However, if bacteria invade the pleural space, a complicated parapneumonic effusion or empyema may result. In addition to appropriate antibiotic therapy, some parapneumonic effusions and empyemas need additional treatment, such as drainage procedures. The necessity of drainage for treatment of parapneumonic effusions depends on the several types or stages of parapneumonic effusion. Empyemas may need additional intervention beyond simple chest tube drainage, including placement of additional drainage tubes under fluoroscopy, video-assisted thoracoscopy with lysis of adhesions, and decortication. Patients with persistent air leaks often require surgical or endoscopic repair procedures.

Efficacy of Pigtail Catheter Drainage in Patients with Thoracic Empyema or Complicated Parapneumonic Effusion / 결핵

BACKGROUND: The management of thoracic empyema and complicated parapneumonic effusion requires adequate antibiotics use and prompt drainage of infected pleural space. Tube thoracostomy for loculated empyema has low success rate and is also an invasive procedure with potential morbidity. Complications include hemothorax, perforation of intra-abdominal or intra-thoracic organs, diaphragmatic laceration, empyema, pulmonary edema, and Horner's syndrome. Given the potential morbidity of traditional chest tube insertion, use of the image-guided pigtail catheter drainage(PCD) of empyema has been employed. We retrospectively analyzed the medical records of patients with empyema or complicated parapneumonic effusion to determine the efficacy of percutaneous pigtail catheter drainage. MATERIALS AND METHODS: 45 patients with complicated parapneumonic effusions or empyema were treated at Gil medical center from January 1998 to June, 1999. All were initially given PCD procedure and the following data were collected: clinical symptoms at the time of diagnosis, alcohol and smoking history, the characteristics of pleural effusion, radiologic findings (at the time of catheter insertion, removal and 1 month after catheter removal), the amount of effusion drained for initial 24 hours, the time from catheter insertion to removal and the use of surgical approach. RESULTS: Male gender was more frequent (42 men vs. 3 women), the mean age of the study population was 52(range: 21~74) years. Empyema was found in 23 patients, complicated parapneumonic effusion in 22 patients. Four patients(three, parapneumonic effusion and one, with empyema) with PCD only treated were cast off. Among the available patients, 36(80%) patients were treated with PCD only or PCD with urokinase. Among the 23 patients with empyema, surgical approach was required in five patients(27.1%, one required decortication, four open thoracostomy), one patient, treated with surgical procedure, died of sepsis. There was no significant difference of the duration of catheter insertion, the duration of hospital admission after catheter insertion and the mean amount of effusion drained for initial 24 hours between the patients with only PCD treated and the patients treated with PCD and urokinase. The duration of catheter insertion(9.4+/-5.25 days vs. 19.2+/-9.42 days, p<0.05) and the duration of hospital admission after catheter insertion(15.9+/-10.45 days vs. 38.6+/-11.46 days, p<0.01) of the patients with only PCD treated were more longer than those of the patients treated with surgical procedure after PCD. They were same between the patients treated with urokinase after PCD and the patients treated with surgical procedure after PCD(11.1+/-7.35 days vs. 19.2+/-9.42 days, p<0.05, 17.5+/-9.17 days vs. 38.6+/-11.46 days, p<0.01). In 16 patients(44.4%) with only PCD treated or PCD and urokinase treated, the amount of effusion at the time of catheter removal was decreased more than 75% and in 17 patients(47.2%) effusion decreased 50~75%. .In one patient effusion decreased 25~50%, in two patients effusion decreased less than 25%. One month after catheter removal, in 35 patients(97.2%, four patients were cast off), the amount of pleural effusion was successfully decreased more than 50%. There were no complications related to pigtail catheter insertion. CONCLUSION: In this study, PCD seemed to be an early efficacious procedure in treating the patients with complicated parapneumonic effusion or empyema without any serious procedure related complication.

The Levels of Interferon-gamma, Interleukin-2 Receptor, Interleukin-6 and Interleukin-10 in the patients with Malignant Pleural Effusion, Tuberculosis Effusion, Parapneumonic Effusion, and Lung Emphysema? / 결핵

BACKGROUND: Cytokines are chemical mediators that control and modulate many infalmmatory processes. They work in different fashions in a variety of diseases. Discriminating between malignant effusion, tuberculous effusion, and parapneumonic effusion are crucial from the clinical view-point in Korea. In the current study, interferon-gamma(INF-γ), soluble interleukin-2 receptor(IL-2R), interleukin-6(IL-6) and interleukin-10(IL-10) were measured for this purpose. METHODS: Pleural fluids from patients with malignant disease, tuberculosis, parapneumonic effusion and lung empysema were collected and gauged using commercial ELISA kits. RESULTS: 34 patients were enrolled in this study. among these 15 cases were malignant effusions, 12 were tuberculosis pleurisy and 7 were paraneumonic effusion and lung empyema. The levels of cytokines measured in this study were as follows, in order of frequency, malignant effusion, tuberculous effusion, parapneumonic effusion and lung empyema. The levels of INF-γ were higher in tuberculous effusion than in malignant or parapneumonic effusion(295.5±585.5 vs. 16.7±50 vs. 10.0±0 pg/ml, p>0.05). The levels of IL-2R were higher in tuberculous effusion than in malignant or parapneumonic effusion(7423.5±3752.8 vs. 3247.4±1713.3 vs. 3790.2±3201.1 pg/ml, p<0.05). No significant differences were found in the levels of IL-6 between the groups(600±12.8 pg/ml in malignant effusion, 556.4±161.7 pg/ml in tuberculous effusion, 514.4±224.8 pg/ml in parapneumonic effusion). IL-10 levels were higher in parapneumonic effusion than in malignant or tuberculous effusions(98.4±141.7 vs. 28.2±55.5 vs. 11.3±11.7 pg/ml, p<0.05). CONCLUSION: These results suggest that the measurement of IL-2R levels in pleural fluids may be a useful means of differentiating between tuberculous effusion and pleural effusions of other origins, and that the measurement of IL-10 levels in pleural fluids may be useful to differentiate between parapneumonic effusion and pleural effusions of other origins.