Magnetic resonance imaging findings of empyema necessitatis in a child with a group A streptococcus infection

Empyema necessitatis is a process defined and characterized by the transpleural spread of an infected pleural collection into the adjacent chest wall. Symptoms may be referable to the associated pleural and consolidative infection, but sometimes are associated with chest wall involvement. To our knowledge, the magnetic resonance imaging findings of this process have not yet been previously described in children. We present the magnetic resonance imaging findings of a rare case of a child with empyema necessitatis due to a group A streptococcal agent. The aggressive findings make differentiating infection from a tumor difficult.     

Empyema necessitans in the setting of pneumonia and parapneumonic effusion

Empyema necessitans is a rare complication of pleural space infections and occurs when the infected fluid dissects spontaneously into the chest wall from the pleural space. This process may result from bronchopleural extension of a peripheral lung infection. These cases result from inadequate treatment of an empyema and usually occur after a necrotizing pneumonia or pulmonary abscess. We present two cases of empyema thoracic necessitans.     

Spontaneous bacterial pleuritis in a patient with cirrhosis

Empyema of the left pleural cavity developed suddenly in a nonalcoholic cirrhotic patient. Cultures of the pleural fluid under anaerobic conditions grew Clostridium perfringens, an organism normally found in the enteric flora. The infection developed in an old pleural effusion. Since there was no evidence of trauma, necrotizing pneumonitis or subphrenic infection, spontaneous bacterial pleuritis is proposed.     

Empyema caused by Kingella denitrificans and Peptostreptococcus spp. in a patient with bronchogenic carcinoma

Empyema caused by Kingella denitrificans and Peptostreptococcus spp. was diagnosed in a patient with bronchogenic carcinoma. This appears to be the third report providing evidence of a pathogenic role for K. denitrificans, and the first concerning infection in the pleural space and in a patient with underlying immunosuppressive disease. K. denitrificans should be added to the list of fastidious gram-negative bacteria associated with opportunistic infections in the compromised host.     

Empyema complicating successful lung transplantation.

OBJECTIVE: To assess the prevalence and etiology of empyema complicating successful lung transplantation. DESIGN: Retrospective review. SETTING: University medical center transplant service. PATIENTS: All recipients (n = 392) of single-lung, double-lung, and heart-lung transplantation between May 1984 and April 1997. RESULTS: Of the 392 transplant recipients, empyema was documented in 14 patients (3.6%) at a mean time (+/- SD) of 46 days after transplantation (range, 14 to 167 days). Of these 14 recipients with empyema, 4 recipients (28.6%) died of infectious complications related to empyema. Empyema was seen secondary to Gram-positive, Gram-negative, and saprophytic organisms; however, there was no predominance of a particular organism recovered from the empyemic fluid (chi2 = 0.53; p = 0.75). The development of empyema was not related to whether the transplant was performed secondary to a septic or nonseptic lung disorder (chi2 = 1.06; p = 0.67), nor was it related to the type of transplant procedure performed (ie, single-lung, double-lung, or heart-lung allografts; chi2 = 4.39; p = 0.30). CONCLUSION: Empyema, a relatively uncommon complication of lung transplantation, is not related to the type of allograft received or to whether the recipient had a septic or a nonseptic lung disorder. If empyema does occur, the mortality associated with this infection is substantial.     

Placement of Gastrostomy Tubes in Patients with Ventriculoperitoneal Shunts Does Not Result in Increased Incidence of Shunt Infection or Decreased Survival

The objective of this study was to examine if G-tube (G-tube) placement in patients with ventriculoperitoneal (VP) shunts results in shunt infection or impacts patient survival. We performed a retrospective cohort study. Patients underwent VP shunt and G-tube placement. Incidence of shunt infection and patient survival were calculated. Fifty-five patients qualified for the study. Shunt infection occurred in seven patients (12.5%). The incidence of shunt infection did not differ between surgically placed G-tubes (2/7=29%) and PEG tubes (5/7=71%; P=0.69). There was no difference in the risk of VP infection based on the order of placement (OR=0.61 [0.12–3.02]; P=0.69). No predictors for shunt infection were identified. Kaplan-Meier mortality estimates demonstrated a 21% 1-year mortality rate. There were no predictors of patient survival. We conclude that placement of G-tubes in patients with shunts is safe. The order of placement of G-tube and VP shunt does not affect the incidence of shunt infection or survival.     

脑积水脑室-腹腔分流术后常见并发症及防治对策

目的：探讨脑积水脑室-腹腔分流术后常见并发症的原因及防治措施。方法回顾性分析2008-04～2013-01收治的脑积水脑室-腹腔分流术后并发症患者19例临床资料。结果19例中分流管阻塞7例,感染4例,硬膜下血肿或积液4例,分流管异位2例,分流管自肛门脱出1例,经治疗后患者临床症状不同程度缓解,13例患者再次行脑室-腹腔分流术,16例进行性脑积水患者复查头颅CT或MRI提示脑积水明显好转。19例患者中治愈18例,1例死于严重颅内感染,近期有效率为94.7％。结论临床应严格脑积水脑室-腹腔分流术适应证选择及无菌操作,提高手术技巧,个体化选择分流系统,对年幼患者应用可调压分流管,可减少术后并发症的发生。     

Do antibiotic-impregnated shunts in hydrocephalus therapy reduce the risk of infection? An observational study in 258 patients

Background  

Shunt infection in hydrocephalus patients is a severe, even life-threatening complication. Antibiotic-impregnated shunts (AIS) have been developed in an attempt to reduce rate of shunt infection. The study was performed to analyze if AIS can diminish the rate of shunt infection. The pathogenic nature of shunt infection in patients with AIS systems and those without antibiotic impregnated shunts (non-AIS) was compared.     

Infectious Complications of the Peritoneovenous Shunt

The peritoneovenous shunt has been recently advocated to relieve massive ascites refractory to medical therapy. Several complications of the shunt have been described but the incidence of infection has not been elucidated. We reviewed the records of all patients undergoing peritoneovenous shunt at the Emory University Affiliated Hospitals from 1975 to 1980. Eighty-five peritoneovenous shunts were done in 56 patients. Eighteen of the shunt insertions (21%) were followed by a major infection--eight bacteremias, eight peritonitis, and nine wound infections. Most infections were caused by aerobic gram-negative bacilli or Staphylococcus aureus. Fever was common (62%) in the immediate postoperative period but was not clearly related to infection, or the administration of antibiotics or antipyretics. Shunt removal appeared to be necessary in treating bacteremic patients but not in patients with only peritonitis or wound infections. Infection is a common complication of the peritoneovenous shunt and may limit its usefulness.     

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY AND VENTRICULOPERITONEAL SHUNTS: A DANGEROUS COMBINATION?

Background: We report the largest European series of patients in whom both ventriculoperitoneal shunts (VPS) and percutaneous endoscopic gastrostomies (PEG) have been inserted with the aim of determining if this combination is safe or if there is an increased risk of VPS infection. Patients and Methods: The paper and electronic records of 302 patients who had a ventriculoperitoneal (VP) shunt inserted in the regional Neurosciences unit at Salford Royal NHS Foundation Trust between 2002 and 2007 were reviewed. Results: A total of 24 patients with VP shunts had 26 PEG inserted. Thirteen PEG were inserted in 11 patients with a pre‐existing VP shunt. The median age was 58 years (21–77 Yrs) with seven male and 17 female patients. In total, five patients developed a shunt infection (20.8%) compared to the overall rate of VP shunt infection for Salford Royal NHS Foundation Trust of 7% (P = 0.017). The increase in number of VP shunt infections when the procedures were done more than 10 days apart (2/14) was not significant (P = 0.25). Conclusion: In patients who need long‐term enteral feeding following a VP shunt insertion it may be prudent to delay insertion of a PEG for at least 10 days to reduce VPS infection. In stable patients who have had a VP shunt inserted on previous hospital admissions PEG insertion need not be avoided because of concern regarding cerebrospinal fluid or shunt infection.     

Infection of modified Blalock shunts

A left-sided interposition graft (modified Blalock-Taussig anastomosis) was constructed with polytetrafluoroethylene in a three month old child with tetralogy of Fallot. This shunt thrombosed and a replacement shunt became the site of chronic Pseudomonas infection. The second anastomosis was excised and a third interposition graft was inserted on the right side because the anatomy was unsuitable for a classical Blalock-Taussig shunt. The patient died when he was 12 months old, after signs of infection and shunt occlusion had developed. At necropsy the acutely thrombosed right sided shunt was found to be the site of Candida albicans infection. Gallium and labelled white cell scans, computed tomography, and ultrasound scans had all failed to identify the sites of infection, which were only confirmed at operation or necropsy.     

Infection of modified Blalock shunts.

A left-sided interposition graft (modified Blalock-Taussig anastomosis) was constructed with polytetrafluoroethylene in a three month old child with tetralogy of Fallot. This shunt thrombosed and a replacement shunt became the site of chronic Pseudomonas infection. The second anastomosis was excised and a third interposition graft was inserted on the right side because the anatomy was unsuitable for a classical Blalock-Taussig shunt. The patient died when he was 12 months old, after signs of infection and shunt occlusion had developed. At necropsy the acutely thrombosed right sided shunt was found to be the site of Candida albicans infection. Gallium and labelled white cell scans, computed tomography, and ultrasound scans had all failed to identify the sites of infection, which were only confirmed at operation or necropsy.     

Intracavitary urokinase therapy for multiloculated empyema caused by major leakage from intrathoracic esophagojejunostomy

Empyema following intrathoracic leakage from anastomosis is a severe complication of surgery for esophageal cancer. We present a case report of successful intracavitary urokinase therapy for pleural empyema resulting from leakage from an intrathoracic esophagojejunostomy.     

Contemporary empyema necessitatis

Empyema necessitatis is defined by the extension of an empyema through the parietal pleura, into surrounding tissue. Clinical manifestations are generally subacute, representing the indolent nature of the most commonly implicated pathogens (Mycobacterium tuberculosis and Actinomyces israelii). Treatment with antimicrobials and surgical debridement has drastically reduced mortality; however, with proper initial assessment and treatment of pulmonary infection, this rare complication can often be avoided. We describe a patient with empyema necessitatis to illustrate the importance of timely diagnosis and treatment of parapneumonic pleural effusion, and the need to consider this diagnosis in patients presenting with constitutional symptoms and a chest wall mass.     

Ventriculoatrial shunt infection caused by Staphylococcus warneri: case report and review.

Staphylococcus warneri, a coagulase-negative species, is a rare cause of infection of cerebrospinal fluid (CSF) shunts. In one recently studied case of ventriculoatrial shunt infection, the repeated isolation of S. warneri (i.e., from all of six blood cultures and from a CSF sample obtained directly from the valve of the shunt) suggested that this organism can be clinically significant. Review of the literature clearly indicates that S. warneri is a rare but potentially dangerous pathogen in both immunocompetent and immunocompromised hosts with prosthetic devices. The removal of the infected shunt in association with systemic and local antibiotic administration probably constitutes the treatment of choice in such infections. Further experience is needed to determine the prevalence and the pathogenic significance of S. warneri and of the related organisms Staphylococcus epidermidis and Staphylococcus saprophyticus in patients with prosthetic devices.     

脑室腹腔分流术后感染的研究进展

脑积水是神经外科的常见疾病之一,脑室腹腔分流术的应用改变了脑积水患者的预后。而脑室腹腔分流术后感染是分流失败的主要原因,导致患者智能障碍加重,甚至死亡。该文对脑室腹腔分流术后感染的研究现状进行综述。     

Rifampin-Impregnated Silicone Catheters: A Potential Tool for Prevention and Treatment of CSF Shunt Infections

Background: Infection continues to be one of the major complications of cerebro-spinal fluid shunting procedures. Recent insights in the pathophysiological mechanism of these foreign body infections have elucidated the difficulty of achieving successful treatment without device removal. The development of a rifampin-impregnated silicone catheter yielded excellent results in infection prevention and treatment in vitro as well as in an animal model. Patients and Methods: Here, we describe the application of this device in two patients with a complicated course of shunt infection. Results: In one patient the rifampin-impregnated shunt system was implanted after external drainage to prevent further infection. The shunt infection of the second patient was treated by replacement of the infected shunt system with a rifampin-impregnated device. Both patients recovered immediately without any signs of adverse effects and the two shunt systems have now been working properly for more than 36 and 21 months, respectively. Conclusion: These results suggest that rifampinimpregnated silicone catheters could become a valuable tool in the treatment and prevention of shunt infections. Received: July 30, 2001 · Revision accepted: December 1, 2002 J. A. Hampl (corresponding author)     

Nephritis associated with a diphtheroid-infected cerebrospinal fluid shunt

Hypocomplementemic proliferative glomerulonephritis occurred during diphtheroid infection of a ventricular decompression shunt for cerebrospinal fluid diversion (cerebrospinal fluid shunt) in a young man. Granular deposits of immunoglobulin M (IgM) and the third component of complement (C₃) were found along the glomerular basement membrane. This report provides supportive evidence for immune complex-mediated glomerular injury due to diphtheroid infection in a cerebrospinal fluid shunt.     

Postpneumonectomy empyema

Empyema is a serious complication after pneumonectomy. It is often associated with a bronchopleural fistula. Several risk factors have been associated with an increased incidence of these two challenging complications. Therapy aims at simultaneously treating the infected pleural space and the fistula. The authors describe their favorite methods which include repeated open debridements of the pleural space, primary closure of the fistula, and covering of the bronchial stump using intrathoracic transposition of extrathoracic skeletal muscle followed by delayed closure of the chest wall after instillation of an antibiotic solution (Clagett and modified Clagett procedures). The goals of treatment remain a healthy patient with a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients. Failure is often associated with a persistent or recurrent bronchopleural fistula.     

Treatment of infections of cerebrospinal fluid shunts

There is no unanimity at present concerning the best method of treatment of cerebrospinal fluid shunt-related infections. The most frequently used method includes removal of the shunt followed by antibiotic therapy and later replacement of the shunt. The experience at the University of Cincinnati during the past 15 years indicates that many shunt infections can be effectively treated without shunt removal. This report summarizes experiences with 11 consecutive ventriculoperitoneal shunt infections. These were treated by externalization of the peritoneal catheter followed by intraventricular and systemic antimicrobial therapy and by later replacement of the peritoneal catheter. The advantages of this method include the avoidance of two major operative procedures and the elimination of a period in which the intracranial pressure is not controlled. The need for externalization of the peritoneal catheter relates to the occurrence of localized peritoneal infection and pseudocyst formation, which prevents cure of the infection in many instances if the catheter is left in place. After follow-up periods of four months to five years, 10 of the 11 patients have apparently been cured of their infection.