Advances and challenges in clinical research on hepatic hydrothorax / 临床肝胆病杂志

Hepatic hydrothorax (HH) is a challenging complication of liver cirrhosis associated with portal hypertension, and its pathogenesis and therapeutic measures remain unknown. This article summarizes and reviews the advances and challenges in the research on the pathogenesis, clinical manifestations, diagnosis, and treatment of HH and proposes a multidisciplinary treatment strategy, including reducing the production of ascites, preventing effusion from entering the thoracic cavity, removing pleural effusion, occluding the pleural cavity, and performing liver transplantation, so as to provide a reference for more clinicians.

Role of medical thoracoscopy in the management of parapneumonic effusion and empyema thoracic

Background: The treatment modality use in early pleural empyema mainly depends on the antimicrobial therapy along with thoracocentesis. In case of complicated empyema this modality does not work and lung not fully expand, until removal of adhesions. The main purpose of the current study is to analyze the experience of management of complicated parapneumonic effusion and empyema thoracic through rigid medical thoracoscopy under local anaesthesia. Aim and objective is to study the role of medical thoracoscopy in the management of empyema thoracic and parapneumonic effusion at tertiary health centre.Methods: This is a descriptive case series study in which 49 patients were recruited, who have clinically and radiologically show empyema thoracic, from department of Respiratory medicine, GMC, Kota, Rajasthan. All patients underwent medical thoracoscopy under local anesthesia. Written Informed consent was taken from the study participants. Ethical approval was obtained from Ethical Review Committee of the hospital. Patients who have HIV and Hbsag positive, those with multiple organ failure and bleeding disorders were excluded.Results: Total 49 patients, out of them 41(84%) were male and 8(16%) were female with mean age 45 years (range 18 to 70 years). Final evolution through chest x-ray revealed complete resolution or successful thoracoscopy done in 37 case of fibrinopurulent (92.50%) and 5 cases of organizing empyema (55.56%). overall success rate 85.71%. Total 7 cases (3 case of fibrinopurulent and 4 cases of organizing empyema) refer to higher center for decortications.Conclusions: Medical Thoracoscopy under local anaesthesia is a safe procedure, efficient and cost-effective intervention for early management of complicated empyema, particularly in early stage of empyema (fibro purulent).

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.

Transforming growth factor beta1 (TGF-ß1) levels in a rat model of induced pleural empyema

Abstract Purpose: To evaluate the concentration of transforming growth factor beta 1 (TGFB1) levels in a rat pleural effusion obtained by inoculation of intrapleural bacteria or turpentine through thoracentesis. Methods: Thirty-Nine Wistar rats were divided into three groups: Staphylococcus aureus (SA, n = 17); Streptococcus pneumoniae (SP, n = 12); and turpentine (control, n = 10). Pleural fluid was collected through ultrasound-guided thoracentesis 12 h, 24 h, and 36 h after instillation of bacteria or turpentine. Levels of TGFB1 were measured in pleural fluid. Results: At 12 h, mean TGFB1concentrations were 5.3450 pg/mL in the SA group, 5.3449 pg/mL in the SP group, and 5.3450 pg/mL in controls. At 24 h, they were 4.6700 pg/mL in the SA group, 4.6700 pg/mL in the SP group, and 4.6700 pg/mL in controls. At 36 h, they were 4.6699 pg/mL in the SA group and in control. No difference was observed among the groups in mean TGFB1concentration (p = 0.12); however, a significant intragroup reduction in mean TGFB1 was observed between 12 and 24 h (p < 0.01). Conclusion: The transforming growth factor beta 1 concentrations were not useful as a diagnostic tool or an early marker of infected pleural effusion.

Evaluation of the lung volume by CT three dimensional imaging in the treatment of chronic empyema / 中华放射学杂志

Objective To compare the lung volume before and after the operation for the treatment of chronic empyema with CT 3-dimensional imaging,and to evaluate its role in the assessment of pulmonary function. Methods A total of 78 patients with chronic empyema from 2000 to 2016 in our hospital were enrolled in this study.The patients were divided into two groups according to the operational styles,with 47 cases in the decortication group and 31 cases in the catheter drainage group respectively.Reformation of the chest CT data was used to determine the lung volumes and the routine pulmonary function tests(PFT)were performed before and after the operation. The lung volumes and the PFT results before and after the operation were compared between the two groups with t test. Then multiple linear regression analysis was applied to test the relationship between the lung volumes and the values of PFT after the operation. Results The mean lung volume of catheter drainage group was(1 548±467)cm3,while it was(1 418±802) cm3for the decortication group preoperatively(t=1.665,P=0.07).After the operation,the mean lung volume of decortication group was(2 677±815)cm3,while it was(2 169±185)cm3for the catheter drainage group. There was statistically significant difference for the increase of lung volume between the two groups after operation(t=2.371,P<0.05).There was no significant difference between the two groups before the operation for the values of the PFT(t=1.467 to 1.874,P>0.05). After the operation, the values of the PFT in the decortication group were higher than those in the catheter drainage group(t=1.990 to 2.799, P<0.05). The changes of postoperative lung volume were positively correlated with the values of the PFT(β=0.312 to 0.701,P<0.05). Conclusions Decortication has a better effect on the lung volume and the pulmonary function for patients suffered from chronic empyema. CT modeling (3-dimensional-imaging) is an effective method for evaluating the pulmonary function of postoperative lung according to the lung volume measurement.

Parapneumonic pleural effusion: early versus late thoracoscopy / Derrame pleural parapneumônico: comparação entre toracoscopia precoce e tardia

ABSTRACT Objective: To evaluate the best time to perform thoracoscopy for the treatment of complicated parapneumonic pleural effusion in the fibrinopurulent phase in patients ≤ 14 years of age, regarding the postoperative evolution and occurrence of complications. Methods: This was a retrospective comparative study involving patients with parapneumonic pleural effusion presenting with septations or loculations on chest ultrasound who underwent thoracoscopy between January of 2000 and January of 2013. The patients were divided into two groups: early thoracoscopy (ET), performed by day 5 of hospitalization; and late thoracoscopy (LT), performed after day 5 of hospitalization. Results: We included 60 patients, 30 in each group. The mean age was 3.4 years; 28 patients (46.7%) were male; and 47 (78.3%) underwent primary thoracoscopy (no previous simple drainage). The two groups were similar regarding gender, age, weight, and type of thoracoscopy (p > 0.05 for all). There was a significant difference between the ET and the LT groups regarding the length of the hospital stay (14.5 days vs. 21.7 days; p < 0.001). There were also significant differences between the groups regarding the duration of fever in days; the total number of days from admission to the initiation of drainage; and the total number of days with the drain in place. Eight patients (13.6%) had at least one post-thoracoscopy complication, there being no difference between the groups. There were no deaths. Conclusions: Performing ET by day 5 of hospitalization was associated with shorter hospital stays, shorter duration of drainage, and shorter duration of fever, although not with a higher frequency of complications, requiring ICU admission, or requiring blood transfusion.

RESUMO Objetivo: Avaliar o melhor momento para a realização de toracoscopia no tratamento de derrame pleural parapneumônico complicado na fase fibrinopurulenta em pacientes ≤ 14 anos de idade quanto a evolução e ocorrência de complicações pós-operatórias. Métodos: Estudo retrospectivo e comparativo com pacientes com derrame pleural parapneumônico que apresentavam septações ou loculações à ultrassonografia de tórax e que foram submetidos a toracoscopia no período entre janeiro de 2000 e janeiro de 2013. Os pacientes foram divididos em dois grupos: toracoscopia precoce (TP), realizada até o 5º dia da hospitalização; e toracoscopia tardia (TT), realizada após o 5º dia de internação. Resultados: Foram incluídas 60 pacientes, 30 em cada grupo. A média de idade foi de 3,4 anos, 28 pacientes (46,7%) eram do sexo masculino, e 47 (78,3%) foram submetidos à toracoscopia primária, sem realização de drenagem simples prévia. Os grupos TP e TT foram semelhantes quanto ao sexo, idade, peso e tipo de toracoscopia (p > 0,05 para todos). Observou-se uma diferença significativa quanto à média de duração da internação nos grupos TP e TT (14,5 dias vs. 21,7 dias; p < 0,001). Houve também diferenças significativas entre os grupos quanto ao total de dias com febre, total de dias entre internação e início da drenagem e total de dias com dreno. Oito pacientes (13,6%) apresentaram alguma complicação após a toracoscopia, sem diferença entre os grupos. Não houve óbitos. Conclusões: A TP, realizada até o 5º dia da admissão hospitalar, associou-se a menor duração da internação, menor tempo de drenagem e menor duração da febre, sem estar associada a maior frequência de complicações, necessidade de CTI ou hemotransfusão.

Abordagem vídeo-toracoscópica, sem sutura, das perfurações do esôfago torácico diagnosticadas tardiamente / Video-thoracoscopic approach, without suture, of late thoracic esophageal perforations

RESUMO Objetivos: avaliar a utilização da vídeo-toracoscopia, no tratamento das perfurações tardias do esôfago torácico, sem sutura ou ressecção do órgão. Métodos: análise retrospectiva de pacientes com diagnóstico tardio (>12 horas) de perfuração do esôfago torácico tratados por vídeo-toracoscopia, sem sutura ou ressecção do órgão, num período de 15 anos. Resultados: foram operados 16 pacientes, sendo dez homens e seis mulheres, com idades entre 48 e 66 anos e com tempo entre o diagnóstico da perfuração e a cirurgia variando entre 16 e 26 horas. Todos os pacientes foram submetidos a vídeo-toracoscopia, com decorticação pulmonar, abordagem das loculações pleurais, abertura da pleura mediastinal junto ao local da perfuração e desbridamento dos tecidos desvitalizados, seguido por dupla drenagem da cavidade pleural. Não foi realizada sutura ou ressecção esofagiana, e os pacientes evoluíram com fechamento completo das lesões, sem óbitos. Conclusão: a abordagem cirúrgica vídeo-toracoscópica mostrou-se capaz de controlar a infecção pleural, a expansão pulmonar e possibilitar a completa regeneração do esôfago com perfuração diagnosticada tardiamente.

ABSTRACT Objectives: to evaluate the use of video-thoracoscopy, in the treatment of late perforations of the thoracic esophagus, without suture or organ resection. Methods: retrospective analysis of patients with late diagnosis (> 12 hours) of thoracic esophageal perforation treated by video-thoracoscopy, without suture or organ resection, over a 15-year period. Results: sixteen patients were operated on, ten men and six women, aged between 48 and 66 years, with time between the diagnosis of the perforation and the surgery ranging from 16 to 26 hours. All patients underwent video-thoracoscopy, with pulmonary decortication, pleural loculations approach, opening of the mediastinal pleura near the perforation site and debridement of the devitalized tissues, followed by double drainage of the pleural cavity. No esophageal suture or resection was performed, and the patients evolved with complete closure of the lesions, without deaths. Conclusion: the video-thoracoscopic surgical approach was able to control pleural infection, pulmonary expansion and enable complete regeneration of the esophagus with late-diagnosed perforation.

The impact of a chest tube management protocol on the outcome of trauma patients with tube thoracostomy / Impacto de um protocolo de cuidados a pacientes com trauma torácico drenado

ABSTRACTObjective:to investigate the effect of standardized interventions in the management of tube thoracostomy patients and to assess the independent effect of each intervention.Methods:A chest tube management protocol was assessed in a retrospective cohort study. The tube thoracostomy protocol (TTP) was implemented in August 2012, and consisted of: antimicrobial prophylaxis, chest tube insertion in the operating room (OR), admission post chest tube thoracostomy (CTT) in a hospital floor separate from the emergency department (ED), and daily respiratory therapy (RT) sessions post-CTT. The inclusion criteria were, hemodynamic stability, patients between the ages of 15 and 59 years, and injury severity score (ISS) < 17. All patients had isolated injuries to the chest wall, lung, and pleura. During the study period 92 patients were managed according to the standardized protocol. The outcomes of those patients were compared to 99 patients treated before the TTP. Multivariate logistic regression analysis was performed to assess the independent effect of each variable of the protocol on selected outcomes.Results:Demographics, injury severity, and trauma mechanisms were similar among the groups. As expected, protocol compliance increased after the implementation of the TTP. There was a significant reduction (p<0.05) in the incidence of retained hemothoraces, empyemas, pneumonias, surgical site infections, post-procedural complications, hospital length of stay, and number of chest tube days. Respiratory therapy was independently linked to significant reduction (p<0.05) in the incidence of seven out of eight undesired outcomes after CTT. Antimicrobial prophylaxis was linked to a significant decrease (p<0.05) in retained hemothoraces, despite no significant (p<0.10) reductions in empyema and surgical site infections. Conversely, OR chest tube insertion was associated with significant (p<0.05) reduction of both complications, and also significantly decreased the incidence of pneumonias.Conclusion:Implementation of a TTP effectively reduced complications after CTT in trauma patients.

RESUMOObjetivo:avaliar a implantação do Cuidado Padronizado com o Dreno de Tórax (CPDT) em um hospital público, referência para o trauma, e o impacto independente de cada um dos itens do protocolo no período do estudo sobre desfechos selecionados.Métodos: coorte retrospectiva avaliando implementação do Cuidado Padronizado para o Dreno de Tórax (CPDT). Foram incluídos pacientes entre 15 e 59 anos de idade, hemodinamicamente estáveis, com Injury Severity Score inferior a 17, com lesão isolada na parede do tórax, pulmão e pleura. Foram comparados 99 pacientes antes do CPDT com 92 depois do CPDT. Foi realizada comparação de desfechos selecionados por meio de diferença de proporções. A regressão logística multivariada foi feita para análise do efeito independente de cada variável do protocolo.Resultados:não houve diferença entre os grupos quanto às variáveis sociodemográficas, índice de gravidade e mecanismo de trauma. A implementação do CPDT resultou no aumento no percentual de todos os itens do protocolo. Houve redução significativa (p<0,05) de hemotórax retido, empiema, pneumonia, infecções de ferida operatória e nova operação, queda do percentual de pacientes retornados com complicações, tempo de internação e de permanência do dreno. A fisioterapia revelou-se independentemente associada à redução de sete dos oito desfechos (p<0,05). O antibiótico presuntivo revelou tendência de associação com a redução de empiema e de infecções de ferida operatória (p<0,10) e esteve associado à redução do hemotórax retido (p<0,05). A drenagem no centro cirúrgico esteve associada à redução de empiema, pneumonia e infecção de ferida operatória (p<0,05).Conclusão:a implementação do CPDT foi efetiva na redução de complicações de pacientes com dreno de tórax.

Características del empiema paraneumónico luego del inicio de la vacunación antineumocócica: Centro Hospitalario Pereira Rossell, año 2010 / Features of parapneumonic empyema after the beginning of pneumococcal vaccination: CHPR, 2010

Resumen El empiema paraneumónico (EP) es complicación grave y frecuente de neumonía adquirida en la comunidad (NAC), causado principalmente por Streptococcus pneumoniae. En Uruguay desde 2008 se incorporaron vacunas conjugadas neumocócicas (PCV), que determinaron disminución en la prevalencia de la enfermedad neumocócica y cambios en los serotipos involucrados. Se realizó un estudio descriptivo para evaluar las características de niños menores de 14 años hospitalizados por EP en el año 2010. Fueron identificados 69 pacientes, que representaron una tasa de 63.4/10.000 egresos. El promedio de edad fue 4 años; 37% de los menores de 5 años tenía 3 dosis de PCV. La presentación inicial fue grave, con 30% de casos que requirieron ingreso a terapia intensiva. El tratamiento recibido fue drenaje toráxico en 96%, instilación de estreptoquinasa intrapleural en 64% y cirugía en 6%. La duración de la hospitalización tuvo un promedio de 18 días. Un porcentaje importante de niños presentó complicaciones; uno falleció. Se identificó germen en 62% de los pacientes, la gran mayoría S. pneumoniae. Los serotipos fueron similares a los identificados antes de la implementación de PCV. No se identificaron fallas vacunales. El EP persiste como enfermedad grave, aunque tras la implementación de PCV disminuyó su prevalencia. No hubo cambios significativos en los serotipos. Es importante continuar la vigilancia del efecto de la implementación de PCV sobre esta patología.

Summary Parapneumonic empyema (PE) is a frequent and serious complication of community-acquired pneumonia (CAP), mainly caused by Streptococcus pneumoniae. In Uruguay from 2008 were incorporated neumococcal conjugate vaccines (PCV), which resulted in a decrease in the prevalence of pneumococcal disease and changes in the involved serotypes. A descriptive study was conducted to evaluate the characteristics of children less than 14 years hospitalized for PE in 2010. There were identified 69 patients, representing a rate of 63.4/10.000 of the discharges. The average age was 4 years, 37% of children fewer than 5 years had 3 doses of PCV. Initial presentation was severe, with 30% of cases requiring intensive care admission. Chest drain treatment was received by 96%, intrapleural instillation of streptokinase in 64% and surgery in 6%. The hospitalization had an average of 18 days. A significant percentage of children had complications, one died. In 62% of patients, it was identified an etiology, most S. pneumoniae. The serotypes were similar to those identified before implementation of PCV. No vaccine failures were identified. The EP persists as a serious illness; even the PCV implementation determined it decreased prevalence. No significant changes in the serotypes were detected. It is important the continuing monitoring of the PCV implementation effect in this pathology.

Clinical study of decortication in treatment of senile chronic empyema / 中国医师进修杂志

Objective To compare the safety and feasibility of thoracoscope decortication and conventional thoracotomy decortication in treatment of senile chronic empyema.Methods Thirty-two patients with senile chronic empyema were selected,among total there were 10 patients received thoracoscope decortication (thoracoscope group) and 22 patients received conventional thoracotomy decortication (conventional thoracotomy group).The operative time,intraoperative bleeding volume,postoperative total hydrothorax drainage volume,postoperative drainage time,postoperative thoracic rinse time,postoperative length of stay in hospital and postoperative antibiotic application time were compared between 2 groups.Results There was no statistical difference in operative time between 2 groups (P＞ 0.05).The intraoperative bleeding volume,postoperative drainage time,postoperative total hydrothorax drainage volume,postoperative thoracic rinse time,postoperative antibiotic application time,postoperative length of stay in hospital in thoracoscope group were significantly better than those in conventional thoracotomy group [(331.00 ± 84.65)ml vs.(453.18 ±93.47) ml,(8.80 ±2.53) d vs.(11.59 ±3.57) d,(2 357.00 ±649.03) ml vs.(3 166.82 ±613.42) ml,(5.50 ±2.22) d vs.(7.68 ±2.95) d,(7.40 ± 1.65) d vs.(9.45 ±2.58) d,(12.20 ± 3.65) d vs.(15.32 ± 4.04) d],there were statistical differences (P ＜ 0.05).Conclusion Thoracoscope decortication is safe and feasible in treatment of senile chronic empyema.

Factors predictive of the failure of medical treatment in patients with pleural infection

BACKGROUND/AIMS: The clinical outcomes of some patients with pleural infection may be favorable with medical treatment alone, but in others, the disease progresses and requires additional surgical treatment. However, little is known about the factors affecting this difference. The aim of this study was to investigate the factors predictive of failure of medical treatment in patients with pleural infection. METHODS: A cohort of 127 consecutive patients who were admitted to the hospital with pleural infection was studied. Clinical manifestations and laboratory findings in patients in whom medical treatment succeeded or failed were reviewed. RESULTS: In univariate analysis, the significant factors associated with medical treatment outcome were age, smoking history, duration of chief complaint, serum albumin level, and pleural fluid glucose and lactate dehydrogenase levels (p < 0.05). Multivariate logistic regression analysis identified age and duration of chief complaint as independent predictive factors for failure of medical treatment, with odds ratios of 0.871 (p = 0.013) and 0.797 (p = 0.026), respectively. Receiver operating characteristic curve analysis determined cutoff values of 50.5 years for age and 4.5 days for duration of chief complaint. CONCLUSIONS: We demonstrated that a younger age < 50.5 years and shorter duration of chief complaint < 4.5 days were independent predictive factors for the failure of medical treatment in patients with pleural infection. This suggests their role as evaluative criteria in setting indications for the optimal treatment in patients with pleural infection. A larger, prospective study is required to confirm these findings.

Empiemas pleurales por Gemella spp: una etiología no tan infrecuente / Pleural empyema due to Gemella spp: Report of 12 cases

Background: Gemella genus bacteria can produce localized or generalized severe infections, but very rarely they have been described as causingpulmonary infections or pleural empyemas. Aim: To characterize patients with empyema caused by Gemella genus bacteria. Material and Methods: The database of a Microbiology laboratory of a Spanish hospital was reviewed, searchingfor Gemella positive cultures ofpleural effusions in a period offive years. Results: We identified 12 patients (11 males) with Gemella spp pleural empyema. Eight were infected with G. haemolysans and four with G. morbillorum. All patients had predisposingfactors such as poor oral hygiene, smoking, chronic cardiovascular or respiratory disease, alcoholism or malignancies. In ten cases, a thoracic drainage tube was placed with fibrinolysis in seven. One patient needed surgery because of a relapse of the empyema. Two patients died because of an advanced neoplasm, and the empyema was resolved in the rest. Conclusions: Gemella pleural empyema can occur and its isolation must not be seen as a contamination.

Pneumonia adquirida na comunidade e derrame pleural parapneumônico relacionados a Mycoplasma pneumoniae em crianças e adolescentes / Mycoplasma pneumoniae-related community-acquired pneumonia and parapneumonic pleural effusion in children and adolescents

OBJETIVO: Determinar a prevalência e as características da pneumonia adquirida na comunidade (PAC) e derrames pleurais parapneumônicos (DPP) relacionados a Mycoplasma pneumoniae em um grupo de crianças e adolescentes. MÉTODOS: Estudo observacional retrospectivo com 121 pacientes hospitalizados com PAC e DPP em um hospital de referência terciária, entre 2000 e 2008, divididos em seis grupos (G1 a G6) segundo o agente etiológico: M. pneumoniae com ou sem coinfecção, em 44 pacientes; outros agentes que não M. pneumoniae, em 77; M. pneumoniae sem coinfecção, em 34; Streptococcus pneumoniae, em 36; Staphylococcus aureus, em 31; e coinfecção M. pneumoniae/S. pneumoniae, em 9, respectivamente. RESULTADOS: Na comparação entre os grupos, G1 apresentou frequências maiores em gênero feminino, tosse seca, uso prévio de beta-lactâmicos e na duração dos sintomas até a admissão, assim como menor uso de assistência ventilatória e de drenagem torácica que G2, enquanto G3 teve maiores frequências em uso prévio de beta-lactâmicos e tosse seca, maior duração dos sintomas antes da admissão e menor frequência de uso de drenos torácicos que G4 e G5, ao passo que G3 teve média de idade maior e menor frequência de náuseas/vômitos que G4, assim como menor uso de assistência ventilatória que G5. A coinfecção M. pneumoniae/S. pneumoniae aumentou a duração dos sintomas até a admissão. CONCLUSÕES: Nesta amostra, a prevalência de PAC e DPP por M. pneumoniae foi de 12,75%. Embora a doença apresentasse quadros mais leves que aquela por outros organismos, a evolução foi mais prolongada. Nossos dados sugerem a necessidade de uma maior diligência na investigação de M. pneumoniae em crianças e adolescentes com PAC e DPP em nosso meio.

OBJECTIVE: To determine the prevalence and the characteristics of Mycoplasma pneumoniae-related community-acquired pneumonia (CAP) and parapneumonic pleural effusion (PPE) in children and adolescents. METHODS: This was a retrospective observational study involving 121 patients with CAP/PPE hospitalized in a tertiary referral hospital between 2000 and 2008, divided into six groups according to the etiologic agent (G1 to G6, respectively): M. pneumoniae with or without co-infection, in 44 patients (group 1); etiologic agents other than M. pneumoniae, in 77 (group 2); M. pneumoniae without co-infection, in 34 (group 3); Streptococcus pneumoniae, in 36 (group 4); Staphylococcus aureus, in 31 (group 5); and M. pneumoniae/S. pneumoniae co-infection, in 9 (group 6). RESULTS: In comparison with group 2, group 1 showed higher frequencies of females, dry cough, and previous use of beta-lactam antibiotics; longer duration of symptoms prior to admission; and lower frequencies of use of mechanical ventilation and chest tube drainage. In comparison with groups 4 and 5, group 3 showed higher frequencies of previous use of beta-lactam antibiotics and dry cough; longer duration of symptoms prior to admission; a lower frequency of use of chest tube drainage; a higher mean age and a lower frequency of nausea/vomiting (versus group 4 only); and a lower frequency of use of mechanical ventilation (versus group 5 only). M. pneumoniae/S. pneumoniae co-infection increased the duration of symptoms prior to admission. CONCLUSIONS: In this sample, the prevalence of M. pneumoniae-related CAP/PPE was 12.75%. Although the disease was milder than that caused by other microorganisms, its course was longer. Our data suggest that M. pneumoniae-related CAP and PPE in children and adolescents should be more thoroughly investigated in Brazil.

Bola fúngica por Aspergillus fumigatus em cavidade pleural / Aspergillus fumigatus fungus ball in the pleural cavity

OBJETIVO: Relatar os casos de 6 pacientes com bola fúngica (BF) na cavidade pleural por Aspergillus fumigatus. MÉTODOS: Entre 1980 e 2009, foram diagnosticados 391 pacientes com BF aspergilar no Complexo Hospitalar Santa Casa de Porto Alegre (RS). O diagnóstico de BF na cavidade pleural foi definido com exames de imagem demonstrando derrame e espessamento pleural com nível líquido; exame micológico direto demonstrando hifas septadas, consistentes com Aspergillus sp.; e cultura positiva para A. fumigatus no espécime cirúrgico da cavidade pleural. RESULTADOS: Dos 391 pacientes estudados, 6 (2 por cento) preencheram os critérios diagnósticos estabelecidos. A média de idade desses 6 pacientes foi de 48 anos (variação, 29-66 anos), e 5 (83 por cento) eram do sexo masculino. As queixas mais frequentes dos pacientes foram tosse, expectoração e hemoptise. Quatro (67 por cento) dos pacientes tinham tuberculose curada. Todos os pacientes realizaram remoção cirúrgica da colonização fúngica, e houve infusão intrapleural com anfotericina B em 4; e 2 pacientes receberam tratamento antifúngico sistêmico v.o. Cinco pacientes melhoraram clinicamente, e um foi a óbito após a cirurgia. CONCLUSÕES: Em pacientes adultos com história de doença pulmonar cavitária ou fístula pleural, deve-se realizar uma investigação criteriosa levando em consideração a infecção fúngica, principalmente BF pulmonar. Portanto, a exploração laboratorial torna-se mais eficiente em relação aos recursos disponíveis para elucidação diagnóstica.

OBJECTIVE: To report the cases of 6 patients with fungus ball caused by Aspergillus fumigatus (aspergilloma) in the pleural cavity. METHODS: Between 1980 and 2009, 391 patients were diagnosed with aspergilloma at the Santa Casa Hospital Complex in Porto Alegre, Brazil. The diagnosis of aspergilloma in the pleural cavity was made through imaging tests revealing effusion and pleural thickening with air-fluid level; direct mycological examination revealing septate hyphae, consistent with Aspergillus sp.; and positive culture for A. fumigatus in the surgical specimen from the pleural cavity. RESULTS: Of the 391 patients studied, 6 (2 percent) met the established diagnostic criteria. The mean age of those 6 patients was 48 years (range, 29-66 years), and 5 (83 percent) were male. The most common complaints were cough, expectoration, and hemoptysis. Four patients (67 percent) had a history of tuberculosis that had been clinically cured. All of the patients were submitted to surgical removal of the aspergilloma, followed by intrapleural instillation of amphotericin B, in 4; and 2 received systemic antifungal treatment p.o. There was clinical improvement in 5 patients, and 1 died after the surgery. CONCLUSIONS: In adult patients with a history of cavitary lung disease or pleural fistula, a careful investigation should be carried out and fungal infection, especially aspergilloma, should be taken into consideration. In such cases, laboratory testing represents the most efficient use of the resources available to elucidate the diagnosis.

Staged operations strategy for delayed spontaneous rupture of esophagus with empyema / 国际外科学杂志

ObjectiveTo summarize the effect of staged operations strategy for delayed spontaneous rupture of esophagus with empyema.MethodsThree patients in the department of thoracic surgery of the second affiliated hospital of Guangzhou medical university underwent staged operative treatment for delayed spontaneous rupture of esophagus with empyema.The primary operative procedure consisted of removal of empyema sac,T-tube drainage and jejunostomies.The second operative procedure included alimentary reconstruction with thoracic esophageal resection and exclusion,or with esophageal resection and exclusion later.ResultsAll cases were cured with mean hospitalization of 78.7 days.None of them had any dysphagia at followup of 5-14 months.ConclusionDelayed spontaneous rupture of esophagus with empyema can be managed safely and effectively through staged operations strategy.

Late-Onset Postpneumonectomy Empyema Presenting as Right-Sided Heart Failure: Extrinsic Right Atrial Compression

Although it is rare, the right atrium can be encroached on by abnormal mediastinal structures, including aortic aneurysms, carcinomas, hepatic cysts and diaphragmatic paralysis. Extrinsic compression of the right atrium causes significant hemodynamic compromise and can lead to fatal outcomes. We describe the case of a 66-year old man with a past history of pulmonary tuberculosis that had undergone right pneumonectomy 40 years previously. He then presented with signs and symptoms of right-sided heart failure. These new signs and symptoms were recognized to be secondary to extrinsic compression of the right atrium, which was due to late-onset postpneumonectomy empyema, and the signs and symptoms were successfully relieved by performing open drainage of the empyema.

Tratamento cirúrgico de crianças com pneumonia necrosante / Surgical treatment of children with necrotizing pneumonia

OBJETIVO: Descrever os resultados do tratamento cirúrgico de crianças com pneumonia necrosante. MÉTODOS: Análise retrospectiva dos prontuários de 20 crianças diagnosticadas com pneumonia necrosante e submetidas ao tratamento cirúrgico nos serviços de cirurgia torácica de dois hospitais na cidade de Manaus (AM) entre março de 1997 e setembro de 2008. Dados referentes a idade, sexo, agente etiológico, motivos da indicação cirúrgica, tipo de ressecção cirúrgica realizada e complicações pós-operatórias foram compilados. RESULTADOS: Dos 20 pacientes analisados, 12 (60 por cento) eram do sexo feminino. A média de idade dos pacientes foi de 30 meses. Os agentes etiológicos mais encontrados foram Staphylococcus aureus, em 5 pacientes (25 por cento), e Klebsiella sp., em 2 (10 por cento). Os motivos de indicação cirúrgica foram sepse, em 16 pacientes (80 por cento), e fístula broncopleural, em 4 (20 por cento). Os tipos de procedimentos cirúrgicos realizados foram lobectomia, em 12 pacientes (60 por cento), segmentectomia, em 7 (35 por cento), e bilobectomia, em 1 (5 por cento). Além desses procedimentos, 8 pacientes (40 por cento) foram submetidos à descorticação pulmonar. As complicações pós-operatórias foram as seguintes: fístula broncopleural, em 4 pacientes (20 por cento); empiema, em 1 (5 por cento); pneumatocele, em 1 (5 por cento); e flebite em membro superior esquerdo, em 1 (5 por cento). Quatro pacientes (20 por cento) morreram. CONCLUSÕES: Pacientes com evidências de necrose pulmonar devem ser considerados para a ressecção cirúrgica, que está indicada em casos graves de sepse, fístula broncopleural de alto débito ou insuficiência respiratória aguda que não respondem ao tratamento clínico.

OBJECTIVE: To describe the results of the surgical treatment of children with necrotizing pneumonia. METHODS: A retrospective analysis of the medical charts of 20 children diagnosed with necrotizing pneumonia and submitted to surgical treatment between March of 1997 and September of 2008 in the thoracic surgery departments of two hospitals in the city of Manaus, Brazil. We compiled data regarding age, gender, etiologic agent, indications for surgery, type of surgical resection performed, and postoperative complications. RESULTS: The mean age of the patients was 30 months. Of the 20 patients studied, 12 (60 percent) were female. The most common etiologic agents were Staphylococcus aureus, in 5 patients (25 percent), and Klebsiella sp., in 2 (10 percent). The indications for surgery were sepsis, in 16 patients (80 percent), and bronchopleural fistula, in 4 (20 percent). The types of surgical procedures performed were lobectomy, in 12 patients (60 percent), segmentectomy, in 7 (35 percent), and bilobectomy, in 1 (5 percent). There were 8 patients (40 percent) who also underwent decortication. The postoperative complications were as follows: bronchopleural fistula, in 4 patients (20 percent); empyema, in 1 (5 percent); pneumatocele, in 1 (5 percent); and phlebitis of the left arm, in 1 (5 percent). Four (20 percent) of the patients died. CONCLUSIONS: Surgical resection should be considered in patients with evidence of pulmonary necrosis. Resection is indicated in cases of severe sepsis, high output bronchopleural fistula, or acute respiratory failure that are refractory to clinical treatment.