Lemierre syndrome with pulmonary empyema caused by Prevotella intermedia.

Lemierre syndrome is a rare disease that is most often caused by Fusobacterium necrophorum We present a case caused by Prevotella intermedia in a young, healthy man, complicated by multiple cavitary lung lesions, loculated pleural effusions requiring chest tube placement and trapezius abscess. Our case highlights (a) P. intermedia as a rare cause of Lemierre syndrome and (b) clinical response to appropriate antimicrobial therapy may be protracted.

Empyema caused by Streptococcus constellatus in a patient infected with HIV: a case report and literature review.

BACKGROUND: Empyema caused by Streptococcus constellatus (S. constellatus) is rare in patients with HIV. To analyze the clinical data of a patient living with HIV (PLHIV), who got empyema caused by S. constellatus, investigating the diagnosis and treatment of this disease through literature review to improve the clinical understanding of this disease. CASE PRESENTATION: We have reported here a 58-year-old male PLHIV with cough, wheezing, and fever for 20 days. He has a history type 2 diabetes, alcohol abuse, and a teeth extracted. Chest computed tomography revealed multiple encapsulated pleural effusions, pneumatosis, and partial compressive atelectasis in the right lung. Submission of pleural efusions timely, and then cultures revealed S. constellatus. After comprehensive treatment, including antibiotics, closed pleural drainage, and intrapleural injection of urokinase, the pleural efusion was absorbed, and chest computed tomography also confirmed the improvement. CONCLUSIONS: S. constellatus should not be neglected as a pus pathogen in patients with HIV. comprehensive treatment is important for empyema of S. constellatus.

Lemierre syndrome complicated by bronchopleural fistula.

We present a 19-year-old woman, a case of Lemierre syndrome, who presented with fever, sore throat, and left shoulder pain. Imaging revealed a thrombus in the right internal jugular vein, multiple nodular shadows below both pleura with some cavitations, right lung necrotizing pneumonia, pyothorax, abscess in the infraspinatus muscle, and multiloculated fluid collections in the left hip joint. After inserting a chest tube and administering urokinase for the pyothorax, a bronchopleural fistula was suspected. The fistula was identified based on clinical symptoms and computed tomography scan findings. If a bronchopleural fistula is present, thoracic lavage should not be performed as it may cause complications such as contralateral pneumonia due to reflux.

Prognostic Value of Computed Tomography in Empyema: A Multicenter Retrospective Cohort Study.

Rationale: Chest computed tomography is performed in patients with empyema for various reasons. However, its predictive ability for patient outcomes in empyema has not been evaluated. Objectives: To evaluate the predictive ability of computed tomography findings (pleural thickness, loculation, interlobar pleural effusion, lung abscess, and bronchopleural fistula) for 90-day mortality in empyema. Methods: This multicenter retrospective cohort study was conducted across six acute care hospitals in Japan. We included patients with confirmed empyema diagnoses who underwent chest computed tomography within 7 days of diagnosis. Imaging findings were defined as pleural thickness, loculation, interlobar pleural effusion, lung abscess, or bronchopleural fistula. One radiologist interpreted the computed tomography scans without patient information. The primary outcome was 90-day mortality. We calculated the differences in 90-day mortality between the presence and absence of each computed tomography finding using logistic regression with or without adjustment for early thoracic surgery. Results: A total of 711 patients were included in our study. Thoracic surgery was performed in 27% of patients, and the 90-day mortality rate was 10%. The differences (95% confidence intervals) in 90-day mortality without and with adjustment for early thoracic surgery were as follows: pleural thickness, 3.09% (-1.35% to 7.54%) and 2.70% (-1.80% to 7.20%); loculation, -4.01% (-8.61% to 0.60%) and -3.80% (-8.41% to 0.81%); interlobar pleural effusion, -9.15% (-14.58% to -3.72%) and -8.96% (-14.39% to -3.53%); lung abscess, 7.04% (-1.16% to 15.2%) and 6.86% (-1.34% to 15.05%); and bronchopleural fistula, 13.80% (7.66% to 19.94%) and 13.63% (7.50% to 19.77%), respectively. Conclusions: Although interlobar pleural effusion predicted lower 90-day mortality regardless of early thoracic surgery, the presence of bronchopleural fistula predicted higher 90-day mortality with empyema. Our results warrant further validation.

Is there any role for medical thoracoscopy in the treatment of empyema in children?

It is still controversial whether surgical or nonsurgical treatment approaches are most appropriate for empyema in children, and there are no data regarding the role of medical thoracoscopy in this population. The aim of this study was to describe our experience with medical thoracosocpy in children with multiloculated and organizing pneumonia. We retrospectively reviewed children admitted to our hospital with a diagnosis of empyema from 2011 to 2021 and treated with medical thoracoscopy. A total of six patients with empyema were treated by medical thoracoscopy; empyema was multiloculated in five cases and organized in one case; all children in the study recovered completely with full lung expansion after chest X-rays, and no disease sequelae were reported after clinical follow-up. Our small case series suggests that in selected cases, medical thoracoscopy could safely and effectively treat pleural empyema in children, with less invasiveness and reduced psychological consequences.

Impact of photon counting detector CT derived virtual monoenergetic images and iodine maps on the diagnosis of pleural empyema.

PURPOSE: The purpose of this study was to evaluate the impact of virtual monoenergetic image (VMI) energies and iodine maps on the diagnosis of pleural empyema with photon counting detector computed tomography (PCD-CT). MATERIALS AND METHODS: In this IRB-approved retrospective study, consecutive patients with non-infectious pleural effusion or histopathology-proven empyema were included. PCD-CT examinations were performed on a dual-source PCD-CT in the multi-energy (QuantumPlus) mode at 120 kV with weight-adjusted intravenous contrast-agent. VMIs from 40-70 keV obtained in 10 keV intervals and an iodine map was reconstructed for each scan. CT attenuation was measured in the aorta, the pleura and the peripleural fat (between autochthonous dorsal muscles and dorsal ribs). Contrast-to-noise (CNR) and signal-to-noise (SNR) ratios were calculated. Two blinded radiologists evaluated if empyema was present (yes/no), and rated diagnostic confidence (1 to 4; not confident to fully confident, respectively) with and without using the iodine map. Sensitivity, specificity and diagnostic confidence were estimated. Interobserver agreement was estimated using an unweighted Cohen kappa test. A one-way ANOVA was used to compare variables. Differences in sensitivity and specificity between the different levels of energy were searched using McNemar test. RESULTS: Sixty patients (median age, 60 years; 26 women) were included. A strong negative correlation was found between image noise and VMI energies (r = -0.98; P = 0.001) and CNR increased with lower VMI energies (r = -0.98; P = 0.002). Diagnostic accuracy (96%; 95% CI: 82-100) as well as diagnostic confidence (3.4 ± 0.75 [SD]) were highest at 40 keV. Diagnostic accuracy and confidence at higher VMI energies improved with the addition of iodine maps (P ≤0.001). Overall, no difference in CT attenuation of peripleural fat between patients with empyema and those with pleural effusion was found (P = 0.07). CONCLUSION: Low VMI energies lead to a higher diagnostic accuracy and diagnostic confidence in the diagnosis of pleural empyema. Iodine maps help in diagnosing empyema only at high VMI energies.

Development of organized pleural empyema as a result of occult foreign body aspiration.

Foreign body (FB) aspiration is a rare incident in adults. Many patients cannot recall the episode of aspiration and are hospitalized with complications of an endobronchial FB.

[A Case of Pleural Empyema with Fistula Caused by Endobronchial Metastasis of Renal Cell Carcinoma].

A 52-year-old man complained of asymptomatic gross hematuria and cough. Chest and abdominal computed tomography (CT) revealed a right renal tumor, mediastinal lymph node metastasis, and right endobronchial metastasis. The right endobronchial metastasis was causing obstructive atelectasis in the lower lobe of the right lung. After tumor biopsy, the pathological diagnosis was clear cell renal cell carcinoma. Combination immunotherapy with ipilimumab and nivolumab was initiated, but CT showed enlargement of the metastatic lesion and lung abscess after two courses of treatment. The therapy was then switched to axitinib. Six days after initiation of axitinib, the lung abscess perforated into the pleural cavity, which resulted in the formation of pleural empyema with fistula. Ten days after initiation of axitinib, obstruction of the bronchus was relieved due to shrinkage of the right endobronchial metastasis, which resulted in development of a pneumothorax. Placement of a thoracic drainage tube and administration of an antimicrobial agent improved the pneumothorax and inflammatory response, but the drainage tube could not be removed. Long-term insertion of the thoracic drainage tube considerably diminished the patient's quality of life, and after 4 months, he was transferred to another hospital to receive the best supportive care.

Surgical outcomes and the factors affecting lung expansion following open window thoracostomy in chronic tuberculous empyema with destroyed lung.

BACKGROUND: Patients with chronic tuberculous empyema and destroyed lung on a prolonged intercostal tube with failed lung expansion considered unsuitable for single-lung ventilation have poor outcomes. The study's objective was to analyze the surgical outcomes and lung expansion factors in these patients following the open window thoracostomy (OWT) procedure. METHODS: In a prospective study, patients (males = 63, females = 12) diagnosed with tuberculosis who underwent OWT were analyzed between 2017 and 2018. Factors including age, sex, side, comorbidities, body mass index (BMI), bacteriological culture, and patency of OWT site were evaluated for lung expansion. RESULTS: Mean preoperative weight 40.96 ± 5.70 kg increased significantly postoperatively. Pseudomonas aeruginosa (30.66%) was the most typical organism isolated and smoking (21.3%) was the common risk factor. At 6-month follow-up, complete lung expansion was noted in 60% of patients, while partial and no expansion is seen in 17.3% and 22.3% patients. Similarly 82.4% patients with pre-operative BMI>18.5 kg/m2 had complete lung expansion, while with BMI < 18.5 kg/m2, 41.7% and 45.8% had partial and no-expansion. Complete lung expansion was seen in 97.1%, 18.2%, and 23.1% of patients with obliterated OWT, sputum, and pleural pus positive for acid-fast bacilli (active disease), while in 57.9% of patients with comorbidities, complete lung expansion was absent. CONCLUSION: The analysis of various factors concludes that lung expansion is not affected by age, sex, side of the disease, and co-morbid conditions; however, extensively diseased lungs with low BMI and positive bacteriological culture, especially P. aeruginosa, active disease, smoking, and patent OWT, interfered with the expansion of the lung.

Pediatric empyema: Are ultrasound characteristics at the time of intervention predictive of reintervention?

BACKGROUND: Parapneumonic effusions and empyema are the most frequent complication of pediatric pneumonia. Interventions include chest drain and fibrinolytics (CDF) or thoracoscopic surgery. CDF is considered less invasive, and more cost-effective though with higher rates of reintervention. We hypothesized that sonographic pleural fluid characteristics could identify cases at increased risk of reintervention following primary CDF. METHODS: A retrospective cohort of complicated pneumonia managed with primary CDF (2011-2018). Cases were reviewed using ultrasound criteria to describe pleural fluid. We analyzed the correlation between ultrasound findings and reintervention. RESULTS: We report 129 cases with a median age of 3.8 years and 44% female. A repeat intervention occurred for 24/129 (19%) cases. The interobserver reliability was moderate for the number of septations (κ 0.72, 95% CI [confidence interval]: 0.62-0.81), weak for the size of the largest locule (κ 0.55, 95% CI: 0.44-0.67), and minimal for the level of echogenicity (κ 0.24, 95% CI: 0.11-0.37), pleural thickening (κ 0.29, 95% CI: 0.17-0.42), maximum effusion depth (κ 0.37, 95% CI: 0.22-0.51), and radiologist's risk for reintervention (κ 0.34, 95% CI: 0.18-0.5). A repeat intervention was not associated with any objective sonographic variable. CONCLUSION: We report no association between ultrasound characteristics and repeat intervention for complicated pneumonia following primary CDF treatment. There was minimal interobserver agreement in reporting ultrasound characteristics despite more objective criteria. Clinicians rely on ultrasound findings to support decisions around intervention in pediatric empyema. This study does not support relying on ultrasound to estimate the likelihood of reintervention.

Evaluation of the efficiency of the systemic immune-inflammation index in differentiating parapneumonic effusion from empyema.

AIM: To evaluate the effectiveness of the systemic immune-inflammation index (SII) and other biomarkers in distinguishing parapneumonic effusion (PPE) and empyema. METHODS: Patients who were thought to have pleural effusion secondary to pneumonia in the pediatric emergency department (PED) between 2004 and 2021 were retrospectively evaluated. The patients were divided into two groups as empyema and PPE. The efficacy of infection markers in predicting empyema was compared. RESULTS: Fifty-nine patients (59.3% male) were included in the study. Forty-three (72.9%) patients were in the PPE and 16 (27.1%) were in the empyema group. Length of hospital stay and pleural fluid thickness measured with thoracic ultrasonography were significantly higher in the empyema group (p = 0.018 and p = 0.002, respectively). The mean SII was 1902.73 ± 1588.87 in PPE patients, while it was 6899.98 ± 6678 in empyema patients (p = 0.009). C-reactive protein (CRP), white blood cell (WBC) count, absolute neutrophil count (ANC), and neutrophil-lymphocyte ratio (NLR) ​​were significantly higher in the empyema group; absolute lymphocyte count (ALC) and lymphocyte-monocytes ratio (LMR) were significantly lower than the PPE group. When the best cut-off values of inflammation markers are determined according to the area under the curve, the highest odds ratios suggesting empyema were found in SII, LMR, CRP, and ANC, respectively. CONCLUSION: Inflammation markers can be useful in predicting empyema. The best markers were found to be SII, LMR, CRP, and ANC. High SII is one of the practical diagnostic markers that can be used differentiate empyema from PPE in PED.

[Effective Treatment for Empyema with Fistula by Negative Pressure Wound Therapy:Report of a Case].

A 54-year-old male with alcoholic cirrhosis and diabetes mellitus was referred to our hospital for the treatment of right pleural empyema with fistula. Despite performing a simple suture closure of the pulmonary fistula, air leakage occurred one week after surgery. Hence, we covered the fistula with a pediculed muscle flap associated with an open window thoracostomy. After 32 days of gauze drainage, negative pressure wound therapy( NPWT) was introduced for reducing the residual pleural space. A chest computed tomography( CT) scan showed almost the full expansion of the lung after undergoing 98 days of NPWT. The patient was discharged from the hospital four months after thoracostomy.

Successful treatment of refractory empyema using dual sheet covering.

Managing thoracic empyema with massive air leakage can be challenging. We present a case with thoracic empyema with multiple bronchopleural fistulae and extensive lung parenchymal necrosis due to drain injury. Emergency surgery was performed for respiratory distress due to massive air leakage. As direct sutures could not be achieved due to extensive parenchymal necrosis, polyglycolic acid and oxidized regenerated cellulose sheets were packed into the lesion. Although open-window thoracostomy was required for bronchopleural fistulae, the stoma closure was achieved via vacuum-assisted closure therapy. The dual sheet coverings contributed to the successful recovery by resolving multiple bronchopleural fistulae.

Role of Chest Computed Tomography in Patients Hospitalized with Community-Acquired Complicated Parapneumonic Effusion or Empyema.

BACKGROUND: Data regarding predictors of the outcome in patients with community-acquired complicated parapneumonic effusion (CPPE) or empyema are insufficient. The aim of the present study was to investigate the prognostic factors in these patients. METHODS: Patients with community-acquired pneumonia (CAP) were classified into a CPPE or empyema group and a control group. The patients with CPPE or empyema were further divided into longer and shorter length of stay (LOS) groups, and clinical variables and computed tomographic (CT) findings were compared between the 2 groups. RESULTS: Of outcome variables, LOS was significantly longer in the CPPE or empyema group than in the control group (13 days [interquartile range, 10‒17 days] versus 8 days [6‒12 days], p < 0.001), whereas 30-day mortality and in-hospital mortality were not significantly different between the 2 groups. Patients with CPPE or empyema were divided into shorter LOS (<14 days) and longer LOS (≥14 days) groups. Pneumonia severity index (PSI) class IV‒V (odds ratio [OR], 2.79; 95% confidence interval [CI]: 1.35, 5.76; p = 0.006), increased attenuation of extrapleural fat (OR, 2.26; 95% CI: 1.06, 4.80; p = 0.034), and pleural microbubbles (OR 3.93; 95% CI: 1.03, 14.98; p = 0.045) were independent predictors for prolonged LOS in CAP patients with CPPE or empyema. CONCLUSIONS: Increased attenuation of extrapleural fat and pleural microbubbles assessed with CT and PSI class IV‒V independently predicted prolonged LOS in CAP patients with CPPE or empyema. These findings may be helpful to identify patients who need more intensive evaluation and intervention.