Thoracic empyema: a study of 56 patients.

Fifty seven children with thoracic empyema (37 boys and 20 girls) aged less than 12 years were seen at the University of Port Harcourt Teaching Hospital between January 1989 and December 1991. Staphylococcus aureus was the most common organism isolated from the pus of these patients (36 (63%) patients). Pseudomonas aeruginosa, the next most common organism, was isolated in 10 (18%) patients. The most common symptoms at presentation were acute illness with fever and cough (51 (89%) patients). All the patients were treated with closed intercostal tube drainage and appropriate antibiotics. Decortication was resorted to in only one patient. There were two deaths and the overall survival rate was 97%.     

Thoracic empyema, application of video-assisted thoracic surgery and its current management

PURPOSE OF REVIEW: Pneumonia in children is frequently complicated by pleural effusions, which rarely progress to empyema. Appropriate clinical management depends on correctly diagnosing the stage of the disease process. Recently, increasing use of video-assisted thoracic debridement has altered the traditional management of pleural effusions and empyema in children, resulting in decreasing reliance on thoracentesis and earlier surgical intervention. RECENT FINDINGS: We review the current literature supporting the clinical indications for video-assisted thoracic debridement compared with traditional management, including the use of thoracentesis, chest tube placement, fibrinolytic therapy and open thoracotomy in children with empyema. Recent studies support the early application of video-assisted thoracic debridement in children with empyema compared with traditional therapy, as it decreases the number of procedures and studies performed and the duration of chest tube drainage and is associated with less pain and shorter recovery period than open thoracotomy. SUMMARY: We propose a clinical algorithm supporting the early use of video-assisted thoracic debridement in the management of empyema in children.     

Surgical treatment outcome of subdural empyema: A clinical study

A retrospective study of 28 patients identified with subdural empyema (SE) at the Department of Neurosurgery between the years 1995 and 2005 was carried out. SE occurred in all patients following bacterial meningitis. The six most frequently encountered clinical features included: (1) fever in 22 (79%) patients; (2) disturbed consciousness in 16 (57%) patients; (3) papilledema in 11 (39%) patients; (4) hemiparesis in 4 (14%) patients; (5) meningismus or meningeal signs in 4 (14%) patients, and (6) seizures in 3 (11%) patients. In the majority of cases, the most frequent causative pathogen of SE was Staphylococcus aureus. Surgery was performed on all patients, which included craniotomy in a group of 20 patients and burr hole drainage in a group of 8 patients. In conclusion, we believe that infants and young children should be carefully monitored following meningitis, in case of SE development, and that surgical intervention in patients presenting with meningitis may facilitate the development of SE. Furthermore, from a surgical point of view, our experience has led us to believe that craniotomy in comparison with burr hole surgery is the best surgical modality for management of SE as the recurrence rate of SE associated with burr hole surgery is high.     

Subdural empyema in a case of Gaucher disease: a rare presentation

Subdural empyema is a surgical emergency; if not recognized and managed early, it may prove fatal. In most of the cases, condition is preceded by paranasal sinusitis, otitis media or trauma. The authors report a previously undescribed case of spontaneous subdural empyema associated with Gaucher disease that had a good outcome following burr hole evacuation of subdural empyema and parenteral antibiotics. Patients with Gaucher disease may be vulnerable to severe bacterial infections, due to defective function of phagocytic cells and hypersplenism.     

Clinical practice: treatment of childhood empyema

Introduction  The incidence of empyema in children is increasing. Adequate knowledge of treatment modalities is therefore essential for every pediatrician. At the university hospital of Leuven, the incidence per 100,000 admissions increased from 40 in 1993 to 120 in 2005. The treatment of choice, however, is still a matter of debate. This is mainly due to the scarcity of prospective randomized trials in children but is further complicated by the absence of uniform terminology. This review starts with clarifying definitions of empyema and complicated versus noncomplicated parapneumonic effusion. The place of different imaging techniques—ultrasound, chest X-ray, computerized tomography and magnetic resonance imaging—is illustrated. All treatment steps are evaluated starting with antibiotic choices, duration of i.v. and oral antibiotics, pleural fluid analysis, indications for chest drain placement, and fibrinolysis. As to the surgical interventions, there is at present insufficient evidence that early surgery is superior to noninvasive medical treatment. Therefore, video-assisted thoracoscopy cannot be advised as general first-line therapy. Conclusion  Since the pathogenicity of empyema is a dynamic process, therapeutic strategy must be decided based on empyema stage and clinical experience. Each referral center should agree on a diagnostic and therapeutic flowchart based on current evidence and local expertise. The flow chart outlined for our center is presented.     

Post-pneumonic thoracic empyema in children: a continued surgical challenge.

The optimal treatment of post-pneumonic thoracic empyema in children is controversial. In this retrospective study, we review our seven-year experience with open surgical drainage in this condition. Between July 1, 1989, and June 30, 1996, 20 children (median age 2.7 years, range 1-8 years) underwent thoracotomy for post-pneumonic empyema in our department. The diagnosis of thoracic empyema was established by the combination of exudate in a pleural tap and the demonstration of multi-loculated pleural effusion by either chest ultrasound or computerized tomography of the chest. The surgical approach was through a posterolateral mini-thoracotomy under general anesthesia. Intrapleural debris, gelatinous, and fibrinous material were evacuated and drains were placed, under vision, at the most dependent pleural locations. The mean length of pre-hospital illness was 5 days (S.D. 3.1 days) and the mean hospital length of stay in a pediatric ward prior to surgery, during which all children received intravenous antibiotics, was 9.4 days (S.D. 7.7 days). A causative pathogen was identified in 8 cases: Streptococcus pneumoniae in 6 cases, Streptococcus group A, and H. influenzae each in one case. Cultures from the pus removed during surgery were sterile for all 19 children who received antibiotics for more than 24 hours prior to surgery. Within 48 hours after surgery, fever dropped to < 37.5 degrees C in 85% of the cases. The postoperative course was uneventful in all cases and the children were discharged home 9 days (S.D. 2.8 days) after surgery. We conclude that open mini-thoracotomy and removal of the entire empyema sac is a safe and curative procedure for children with thoracic empyema.     

Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections

The medical records of 61 children 0 to 18 years of age treated for empyema complicating pneumonia from 1977 to 1989 were reviewed with attention to clinical presentation, bacteriology, treatment and outcome. Streptococcus pneumoniae was the most common infecting organism, followed by Staphylococcus aureus, other streptococcal species, anaerobes, Haemophilus influenzae type b, Pseudomonas aeruginosa, and Eikenella corrodens. No organisms were recovered in 39% of patients. Twelve patients were treated successfully with antibiotics and thoracentesis alone, 23 patients underwent close tube thoracostomy and 26 required decortication. A thickened pleural "peel," scoliosis and opacification of a hemithorax on chest radiograph, as well as low pleural pH and glucose concentration, were associated with a poor response to medical management. A scoring system was developed to define the severity of pleural disease. In patients with severe pleural infections, decortication allowed more rapid defervescence (2.2 vs. 6.5 days) and earlier hospital discharge (4.4 vs. 12.4 days) than did closed tube thoracostomy (P less than 0.001).     

Gastropleural fistula as a complication of empyema thoracis

Gastropleural fistula is an uncommon entity, especially in children. Here we report a 7-year-old child who developed gastropleural fistula as a complication of empyema thoracis. The child was also diagnosed to have chronic granulomatous disease.