Complication of warfarin therapy presenting as empyema

A number of risk indices have been formulated in an attempt to predict risk of a major hemorrhage in an individual on warfarin therapy. No single index to date is able to reliably predict this risk in an individual patient. Although most warfarin related hemorrhages are gastrointestinal or intracranial in origin this case represents a particularly rare entity of a major hemorrhage presenting as an encysted empyema. To the best of our knowledge this has never before been described.     

Spontaneous tension pneumocephalus in a patient with subdural empyema

We report a 45-year old male who developed subdural empyema (SE) with tension pneumocephalus. The patient was admitted unconscious with tonic extensor response to pain. A “gas-forming” organism, Escherichia coli, was detected. Surgical evacuation of the pus and treatment with the appropriate antibiotic did not result in amelioration of his symptoms and the patient died. We identified a rare clinical situation when the SE cavity had a relatively large air loculus that was clearly related to gas-forming bacteria. It appeared that the patient had developed tension pneumocephalus related to the air produced by the pathogen. To our knowledge, this is the first report of a gas-forming organism in an abscess cavity that resulted in tension pneumocephalus and related symptoms.     

Successful management of postpneumonectomy Aspergillus pleural empyema by combined surgical and anti‐fungal treatment with voriconazole and caspofungin

Aspergillus pleural empyema is a rare but often fatal infection complicating thoracic surgery. Three men and one woman aged 23–47 years were diagnosed with Aspergillus pleural empyema after lung resection. Underlying diseases were lung cancer (n = 2), Hodgkin’s disease (n = 1) and thoracic trauma (n = 1). The treatment protocol consisted of systemic anti‐fungal treatment with caspofungin and voriconazole, intrapleural application of amphotericin B and surgical debridement with secondary closure of the leaking bronchial stump. Two patients with chronic Aspergillus pleural empyema had been pretreated with itraconazole and/or amphotericin B. Two patients were treated with a thoracostoma. Two patients had undergone pneumonectomy for previously diagnosed pulmonary aspergillosis. Caspofungin was given for 13–60 days, Voriconazole for up to 100 days. Surgical debridement was performed in all cases and in two cases the created thoracostoma was closed during a second surgical procedure. Aspergillus PCR using blood samples, bronchoalveolar lavage or aspiration fluid was used for monitoring. All four patients had complete clinical and microbiological remission. Our case series shows promising results and underscores the importance of a combined therapeutic approach for Aspergillus pleural empyema consisting of anti‐fungal treatment and surgery. Voriconazole and caspofungin seem to be a suitable combination for this infection.     

Pediatric parapneumonic empyema, Spain

Pediatric parapneumonic empyema (PPE) has been increasing in several countries including Spain. Streptococcus pneumoniae is a major PPE pathogen; however, antimicrobial pretreatment before pleural fluid (PF) sampling frequently results in negative diagnostic cultures, thus greatly underestimating the contribution of pneumococci, especially pneumococci susceptible to antimicrobial agents, to PPE. The study aim was to identify the serotypes and genotypes that cause PPE by using molecular diagnostics and relate these data to disease incidence and severity. A total of 208 children with PPE were prospectively enrolled; blood and PF samples were collected. Pneumococci were detected in 79% of culture-positive and 84% of culture-negative samples. All pneumococci were genotyped by multilocus sequence typing. Serotypes were determined for 111 PPE cases; 48% were serotype 1, of 3 major genotypes previously circulating in Spain. Variance in patient complication rates was statistically significant by serotype. The recent PPE increase is principally due to nonvaccine serotypes, especially the highly invasive serotype 1.     

Interventional radiology treatment of empyema and lung abscesses

Pneumonias in children can be complicated by pleural effusions, empyema and abscesses. The incidence of these complications is increasing, correlated to an increased virulence of the pneumococcal bacterium. These complications may prolong morbidity and lead to decreased pulmonary function. Traditionally, patients were treated medically with antibiotics, and refractory complications were treated surgically with large bore chest tube placement and thoracotomy. Improvements included instilling fibrinolytics into the chest tubes and video-assisted thoracoscopic surgery, which expedited recovery and improved outcomes. Image guided techniques from interventional radiology have been developed as an alternative to treat these patients with minimal invasiveness. These therapies have achieved high success and low complication rates, and are the preferred first-line procedures when available.     

伏立康唑联合两性霉素B治疗曲霉菌性脓胸1例报道

目的 分析1例曲霉菌性脓胸合并支气管胸膜瘘患者的诊治情况,为临床诊治提供参考.方法 使用伏立康唑联合两性霉素B治疗1例曲霉菌性脓胸合并支气管胸膜瘘患者.结果 伏立康唑静脉使用69 d、口服10d,与两性霉素B联合使用53 d,脓胸好转.结论 全身使用伏立康唑联合两性霉素B胸腔灌注是安全、可靠的,也取得了良好的治疗效果.     

Pleural fluids associated with chest infection

Pleural effusions are commonly associated with pneumonias and a small number of these progress to empyema. An understanding of the physiology and pathophysiology of pleural fluid aids the clinician in the management of empyema. There remains much debate about the optimal treatment of empyema in children. Early recognition of the condition is important since delayed therapy may result in unnecessary morbidity. Conventional management with high dose parenteral antibiotics and chest tube drainage remains the mainstay of therapy. However, this treatment modality may fail if the pleural fluid becomes viscous and loculated and, therefore, a more aggressive approach is required. Intrapleural fibrinolytic therapy has been shown to decrease the length of hospital stay and may reduce the need for surgical intervention. The prognosis in children with parapneumonic empyema is excellent with the vast majority retaining normal lung function at long term follow-up.     

What causes post‐traumatic empyema?

Background: Empyema post chest trauma is a morbid condition requiring operative intervention (thoracotomy and decortication). It is hypothesized that patients who have a complicated initial pleural drainage procedure are at increased risk of developing an empyema. Methods: All patients who underwent operative decortication for post‐traumatic empyema over a 24 month period (July 2003 to June 2005) were included in the study. Data were collected on demographics, intercostal catheter (ICC) insertion, prehospital chest decompression and associated injuries. A matched group of patients who had ICC inserted for chest trauma and did not develop an empyema were used as controls. Results: Fourteen patients had decortications for post‐traumatic empyema. Two of three pneumocaths and one ICC were placed within the lung. Five other patients had multiple ‘attempts’ at ICC insertion. Only two patients had a single uncomplicated ICC inserted. The empyema and control group were well matched in terms of age (mean age 40 years in each group, P = 0.83), injury severity score (36.4 vs 35.3, P = 0.85) and presence of chest, abdominal and multi‐system injury. The empyema group had significantly longer median hospital stay (12.8 vs 28.7 days, P = 0.05). The control group had less initial ICC inserted (median of 1.0 vs 2.0, P = 0.02). Only one patient had a complicated ICC insertion, and two uncomplicated pneumocaths were placed. Conclusion: Patients with complex chest injuries in whom difficulties in initial pleural drainage are encountered are at increased risk of developing a post‐traumatic empyema and have a prolonged hospital stay.     

胸腔镜手术治疗急性脓胸的临床应用

目的探讨电视胸腔镜手术在脓胸治疗中的临床应用。方法 2009年4月至2013年7月对36例确诊急性脓胸在电视胸腔镜下进行手术治疗,清理和刮除脓苔,剥离纤维膜,术中彻底冲洗脓腔,术后持续胸腔冲洗。结果 34例完成胸腔镜手术,2例辅助小切口,无中转开胸手术。手术时间45-155 min,平均（104±52）min,术中平均出血量为（260±12.5）ml,抽出的平均脓液量为（740±20.3）ml,放置引流脓液的引流管时间为5-15天,平均术后住院时间为（14±1.5）d。术后随访3-8个月,无复发病例。结论电视胸腔镜手术治疗急性脓胸安全、有效、微创,能达到清除病因、闭合脓腔、加快康复的目的。