Pleural empyema with endobronchial mass due to Rhodococcus equi infection after renal transplantation: A case report and review of literature

BACKGROUND Kidney transplantation is the best option for patients with end-stage renal disease.However,the need for lifelong immunosuppression results in renal transplant recipients being susceptible to various infections.Rhodococcus equi(R.equi)is a rare opportunistic pathogen in humans,and there are limited reports of infection with R.equi in post-renal transplant recipients and no uniform standard of treat-ment.This article reports on the diagnosis and treatment of a renal transplant recipient infected with R.equi 21 mo postoperatively and summarizes the charac-teristics of infection with R.equi after renal transplantation,along with a detailed review of the literature.Here,we present the case of a 25-year-old man who was infected with R.equi 21 mo after renal transplantation.Although the clinical features at the time of presentation were not specific,chest computed tomography(CT)showed a large volume of pus in the right thoracic cavity and right middle lung atelectasis,and fiberoptic bronchoscopy showed an endobronchial mass in the right middle and lower lobe orifices.Bacterial culture and metagenomic next-generation sequen-cing sequencing of the pus were suggestive of R.equi infection.The immunosup-pressive drugs were immediately suspended and intravenous vancomycin and azithromycin were administered,along with adequate drainage of the abscess.The endobronchial mass was then resected.After the patient’s clinical symptoms and chest CT presentation resolved,he was switched to intravenous ciprofloxacin and azithromycin,followed by oral ciprofloxacin and azithromycin.The patient was re-hospitalized 2 wk after discharge for recurrence of R.equi infection.He recovered after another round of adequate abscess drainage and intravenous ciprofloxacin and azithromycin.CONCLUSION Infection with R.equi in renal transplant recipients is rare and complex,and the clinical presentation lacks specificity.Elaborate antibiotic therapy is required,and adequate abscess drainage and surgical excision are necessary.Given the recurrent nature of R.equi,patients need to be followed-up closely.

Clinical profile,etiology,management and outcome of empyema thoracis associated with COVID-19 infection:A systematic review of published case reports

Objective:To explore the clinical features,diagnosis,etiology,treatment,and outcomes of COVID-19 related empyema.Methods:Using PRISMA statement,a systematic search of relevant case reports published between December 2019 and April 2023 was performed through seven databases.The collected data included demographics,clinical manifestations,diagnostic findings,treatment,and outcomes.Results:Thirty-six case reports were identified with 43 cases of empyema.The included cases had a median age of 55 years(range:12-78 years)and 79.1%(34/43)were males.The majority of cases presented during hospitalization for management of acute COVID-19 infection(29/43,67.4%)and Charlson comorbidity index<3(40/43,93.0%).Pseudomonas aeruginosa was the most commonly isolated microorganism from the pleural fluid(9/43,20.9%)and 16.3%of the cases(7/43)had polymicrobial infections.Chest drainage was performed in all cases while surgery was indicated in 24 cases(55.8%).The most common complication of COVID-19-related empyema was broncho-pleural fistula(2/43,4.7%).The mortality rate was 23.3%(10/43).Sepsis and/or multi-organ failure were the most commonly reported causes of death.On univariate analysis,no statistically significant risk factor for mortality was identified.Conclusions:COVID-19-associated empyema has a variety of predisposing factors,time of presentation,clinical features,and causative organisms.Invasive or minimally invasive surgical procedures are performed more frequently than isolated chest drainage.Empyema in COVID-19 patients worsens their prognosis and can lead to serious complications.

Development of subdural empyema from subdural effusion after suppurative encephalitis:A case report

BACKGROUND Chronic subdural effusion is very common in the cranial imaging of middle-aged and older people.Herein,we report a patient misdiagnosed with subdural effusion,who was eventually diagnosed with chronic subdural empyema(SDE)caused by Streptococcus pneumoniae.CASE SUMMARY A 63-year-old man was brought to our emergency room with a headache,vomiting,and disturbed consciousness.Computed tomography(CT)revealed a bilateral subdural effusion at the top left side of the frontal lobe.Cerebrospinal fluid examination after lumbar puncture indicated suppurative meningitis,which improved after anti-infective therapy.However,the patient then presented with acute cognitive dysfunction and right limb paralysis.Repeat CT showed an increase in left frontoparietal subdural effusion,disappearance of the left lateral ventricle,and a shift of the midline to the right.Urgent burr hole drainage showed SDE that was culture-positive for Streptococcus pneumoniae.His condition improved after adequate drainage and antibiotic treatment.CONCLUSION Patients with unexplained subdural effusion,especially asymmetric subdural effusion with intracranial infection,should be assessed for chronic SDE.Early surgical treatment may be beneficial.

Idiopathic colopleural fistula presenting with lung abscess and refractory empyema:A case report

BACKGROUND Colopleural fistula is a rare condition,and only a limited number of cases have been reported.Here,we report a case of idiopathic colopleural fistula in an adult without any known predisposing factors.The patient presented with a lung abscess and refractory empyema and was successfully treated with surgical resection.CASE SUMMARY A 47-year-old man with a history of lung tuberculosis,which had been completely cured 4 years ago,presented to our emergency department with a productive cough and fever for 3 d.Tracing his history,he had undergone left lower lobe segmentectomy of the left lung due to lung abscess one year ago at another hospital.However,he developed refractory empyema postoperatively despite surgical intervention including decortication and flap reconstruction.After admission,we reviewed his previous medical images and noted a fistula tract between the left pleural cavity and splenic flexure.In addition,according to his medical records,bacterial culture of the thoracic drainage showed growth of Escherichia coli and Bacteroides fragilis.Our lower gastrointestinal series and colonoscopy confirmed the diagnosis of colopleural fistula.The patient underwent a left hemicolectomy,splenectomy,and distal pancreatectomy,and the diaphragm was repaired under our care.No further empyema recurrence was noted during follow-up.CONCLUSION Indicative signs of colopleural fistula include refractory empyema accompanied by the growth of colonic flora in the pleural fluid.

Malignant pleural mesothelioma mimics thoracic empyema: A case report

BACKGROUND Thoracic empyema and malignant pleural mesothelioma(MPM)are distinct medical conditions with similar symptoms,including cough,chest pain,and breathing difficulty.We present a rare MPM case mimicking thoracic empyema.Physicians must consider MPM risks for patients exposed to building material who exhibit lobulated pleural effusions,indicating thoracic empyema.CASE SUMMARY A 68-year-old retired male construction worker suffered from shortness of breath and chest tightness over 10 d,particularly during physical activity.A poor appetite and 4 kg weight loss over the past 3 wk were also reported.Chest images and laboratory data concluded a tentative impression of empyema thoracis(right).Video-assisted thoracic surgery with decortication and delobulation(right)was conducted.The pathological report yielded an MPM diagnosis.Refractory pleural bilateral effusions and respiratory failure developed postoperatively,and the patient died three weeks after the operation.CONCLUSION Thoracic empyema and MPM are distinct medical conditions that can present similar symptoms,and video-assisted thoracic surgery facilitates an accurate diagnosis.Empyema-mimicking presentations and postoperative refractory pleural effusion may indicate a poor MPM outcome.

Chronic Empyema: Aetiopathology and Management Challenges in the Developing World

Objectives: Chronic empyema thoracis (CET) is common worldwide despite widespread use of highly effective antibiotics. Also, newer technological armamentaria are available for its diagnosis and treatment. This research was performed to study the aetiopathological profile and the management challenges of CET in view of the background information stated above. Methods: It is a prospective study spanning a period of 62 months in Lagos, Nigeria. Patients’ bio-data, aetiological factors, salient clinical features, management modalities and complications of care were documented and analysed. We excluded patients who were not fit for surgery and those who could not afford surgery. Patients that were initially registered as chronic empyema patients but who later became positive for malignancy were also excluded. Results: There were 93 patients (61 males and 31 females). Age range was 4-72 years but the range 20-49 years constituted 71.0% of the studied population. Poorly treated acute chest infections was the aetiological factor in 49.5% of patients. Tuberculosis was established in 37 patients (39.8%) who were especially in social classes I and II. Decortication and pneumonectomy were done for 52.7% and 16.1% of the patients respectively. Average hospitalisation was prolonged for pneumonectomy because some patients had pneumonectomy space infections. Discusion: CET remains a worldwide problem despite widespread use of potent antibiotics. There are newer diagnostic and therapeutic armamentaria that are not readily available in developing world thereby posing major challenges to practicing surgeons.

Nonsurgical treatment of infratentorial subdural empyema: A case report

Infratentorial subdural empyemas are rare. It is an important neurological infection requiring immediate neurosurgical treatment. The nonsurgical treatment of subdural empyema has been reported sporadically. In this paper the authors report the nonsurgical treatment of a case of infratentorial subdural empyema. The patient with left recurrent otitis was hospitalized with symptoms of headache and fever of 3 weeks duration. Examination revealed that the patient had Glasgow Coma Scale score of 15, fever, mild cerebellar signs, no focal deficit, and abundant suppuration from the left ear. A contrast-enhanced CT scan showed an infratentorial supracerebellar hypodense fluid collection with the peripheral rim enhancement to the left of the midline that mimicked a subdural empyema. Routine hematological investigation revealed polymorphic leukocytosis and elevated erythrocyte sedimentation rate. After the left mastoidectomy and antibiotic treatment, the patient recovered with complete resolution of the subdural empyema on CT scan.

Early Practice of Chinese Europeanized Grammar-Take the Plural of the First-Person Pronoun in The Pilgrim’s Progress in Mandarin as an Example

The Pilgrim’s Progress in Mandarin translated by the British missionary William Chalmers Burns in the 1860s is regarded as one of the typical representatives of the early Europeanized vernacular texts.Compared with the ancient vernacular,the frequency of the inclusive usage of“wǒmen”has increased significantly,which is directly influenced by the plural usage of first-person pronoun in English.Tracking back the origin of Chinese Europeanized grammar is an important part of the study of modern Chinese grammar,which not only is helpful to have a clear understanding of the characteristic of Europeanized grammar in the pre-development stage of modern Chinese,but also can lay a certain foundation for the comparative study of Europeanized grammar in different periods.In addition,this study can also provide linguistic basis for investigating the influence of western missionaries’Chinese translation on the formation of new literature.

The Reflection of Pluralism—Comment on Smuggling Sex Through the Gates:Race,Sexuality,and the Politics of Space in Second Wave Feminism

American studies succeeded in becoming a discipline only after 1920s after overcoming a series of barriers.Not until in the late 1960s did the so-called subcultures,the cultures of the formerly ignored groups or the culture of the minority get the chance to step on the stage of American studies.This article- Smuggling Sex Through the Gates:Race,Sexuality,and the Politics of Space in Second Wave Feminism is a good illustration,or a reflection of the transferring of the subjects for American studies from one-centered to many-faceted.

Dental focal infection-induced ventricular and spinal canal empyema: A case report

BACKGROUND Dental focal infection-induced ventricular and spinal canal empyema is an extremely rare,severe,acute disease that is clinically associated with extremely high morbidity and mortality.Traditional cerebrospinal fluid(CSF)bacterial culture is time-consuming,with a low positive rate,which frequently results in severe irreversible consequences.The next-generation sequencing technique is an emerging pathogenic microorganism detection method that can obtain results in a short time with high accuracy,thus providing great assistance in the clinical diagnosis and treatment of this disease.CASE SUMMARY This paper reports a rare case of dental focal infection-induced ventricular and spinal canal empyema.During the course of treatment at a local hospital,the patient had negative results from repeated CSF bacterial cultures and was empirically given vancomycin treatment.After transfer to our hospital,the nextgeneration sequencing technique was adopted to determine that the pathogenic microorganisms were multiple anaerobic infectious bacteria derived from the oral cavity.The antibiotic therapeutic scheme was adjusted in a timely manner,and the ventricular and spinal canal inflammation was also controlled.However,the antibiotics that had been applied at the local hospital were not able to cover all pathogenic microorganisms,which resulted in irreversible injury to the brain stem,finally leading to patient death.CONCLUSION Dental focal infection-induced ventricular and spinal canal empyema is an extremely rare,severe,acute disease with high morbidity and mortality.Any delay in diagnosis and treatment will result in irreversible consequences.The early application of the next-generation sequencing technique can obtain results in a short time and clarify a diagnosis.Appropriate antibiotic treatment combined with suitable surgical intervention is the key to managing this disease.

Burr hole evacuation for infratentorial subdural empyema

Infratentorial empyema is a life threatening condition and constitutes a neurosurgical emergency. Purulent mastoiditis and medial otitis is the most common origin and a thorough eradication of the purulent foci is mandatory. Decompression craniectomy has been primarily advised in the literature as the gold standard of the surgical treatment but burr hole evacuation when there the lack of cerebellar edema is less invasive and deemed equally efficient in the few reported cases. This is the report of a seventeen year old female who presented in a comatose state due to infratentorial empyema with acute hydrocephalus and who improved immediately after burr hole evacuation. Details of the surgical procedures are given. Mastoidectomy was completed, with the patient under combined antibiotherapy. She leads a normal life now, more than six years after surgery.

Should Empyema with or without Necrotizing Pneumonia in Children Be Managed Differently?

Background: Necrotizing pneumonia (NP) is an increasing lung infection mostly associated with pleural empyema. Objectives: We aimed to compare children with empyema with and without concomitant NP, in terms of risk factors, management and outcome. Methods: We retrospectively included children hospitalized between 2005-2014 with empyema to whom a computed tomography was performed. We recorded patient characteristics, clinical, biological (blood and pleural fluid) and radiological findings, medical and surgical treatments, and clinical, radiological and functional follow-up. Results: 35 children with empyema were included, including 25 with a concomitant NP. Patients with or without NP were undistinguishable, in terms of characteristics, symptoms at admission or detected pathogens. Pleural leucocytes were significantly higher in the empyema group (p = 0.0002) as pleural LDH (p = 0.002), and pleural/blood LDH ratio (p = 0.0005). Medical and surgical managements were similar between both groups. Complications occurred in 1/10 children with empyema alone (pneumatocele) and 5/25 with concomitant NP (bronchopleural fistula (n = 3), lobectomy, pneumothorax). The hospital length of stay and delay for chest X-ray normalization were similar in both groups. Conclusion: Except for minor biological parameters, the presence of concomitant NP in case of empyema does not change the presentation, clinical features, management and outcome, suggesting that the presence of additional NP to empyema should not be managed differently. Therefore, in case of empyema with suspected concomitant NP, chest CT should probably be restricted to abnormal worsening or when mandatory for surgical treatment.

Management for Pediatric Pleural Empyema in Resource-Poor Country: Is Chest Tube Drainage with Antiseptic Lavage-Irrigation Better than Tube Thoracostomy Alone?

Drainage by chest tube thoracostomy is widely used in treatment of early empyema thoracis in children, but drainage with antiseptic lavage-irrigation is more frequent in our context since the last 20 years. This study was to determine which was more effective in our experience comparing chest tube drainage with catheter antiseptic lavage-irrigation versus drainage by chest tube thoracostomy alone in the management of empyema thoracis in children. Patients and Methods: Demographic, clinical and microbiological data on children with thoracic empyema undergoing drainage by chest tube thoracostomy alone or with antiseptic lavage-irrigation were obtained from 2 thoracic surgical centers from September 2008 to December 2014. It was a retrospective study included 246 children (137 boys and 109 girls) who were managed for empyema thoracis at the author’s different department of surgery. Outcomes analysis with respect to treatment efficacy, hospital duration, chest tube duration, hospital costs, and need for subsequent procedures was analyzed and compared in the 2 groups. Results: Drainage of pus and antiseptic irrigation resulted in resolution of pyrexia with improvement in general condition in 85.82% of patients in group 1 and by tube thoracostomy alone in 73.95% in group 2. There are a significant difference in the length of hospital stay (p = 0.022), duration of chest tubes in situ (p = 0.040), treatment coast (p = 0.015) and outcome of stage 2 empyema disease (p = 0.037) between the 2 groups. Conclusion: it seems that chest tube drainage with antiseptic lavage-irrigation method is associated with a higher efficacy, shorter length of hospital stay, shorter duration of chest tube in situ, less cost and better outcome of stage 2 empyema diseases than a treatment strategy that utilizes chest tube thoracostomy alone.

Fatal Legionella pneumophila serogroup 1 pleural empyema:A case report

BACKGROUND Legionella pneumophila(L.pneumophila)is a gram-negative intracellular bacillus composed of sixteen different serogroups.It is mostly known to cause pneumonia in individuals with known risk factors as immunocompromised status,tobacco use,chronic organ failure or age older than 50 years.Although parapneumonic pleural effusion is frequent in legionellosis,pleural empyema is very uncommon.In this study,we report a case of fatal pleural empyema caused by L.pneumophila serogroup 1 in an 81-year-old man with multiple risk factors.CASE SUMMARY An 81-year-old man presented to the emergency with a 3 wk dyspnea,fever and left chest pain.His previous medical conditions were chronic lymphocytic leukemia,diabetes mellitus,chronic kidney failure,hypertension and hyperlipidemia,without tobacco use.Chest X-ray and comouted tomographyscan confirmed a large left pleural effusion,which puncture showed a citrine exudate with negative standard bacterial cultures.Despite intravenous cefotaxime antibiotherapy,patient’s worsening condition after 10 d led to thoracocentesis and evacuation of 2 liters of pus.The patient progressively developed severe hypoxemia and multiorgan failure occurred.The patient was treated by antibiotherapy with cefepime and amikacin and with adequate symptomatic shock treatment,but died of uncontrolled sepsis.The next day,cultures of the surgical pleural liquid samples yielded L.pneumophila serogroup 1,consistent with the diagnosis of pleural legionellosis.CONCLUSION L.pneumophila should be considered in patients with multiple risk factors and undiagnosed pleural empyema unresponsive to conventional antibiotherapy.

Empyema and mediastinal abscess in pyriform sinus f istula: A case report

Dear editor,Though notorious for its tendency to induce recurrent neck abscess,pyriform sinus fistula is of importance despite its rarity.It usually presents diagnostic and therapeutic challenges.Because of post-infectious fi brosis,the embryologic origin of pyriform sinus fi stula is diffi cult to appreciate in certain cases.Here we present a case with empyema and mediastinal abscess caused by pyriform sinus fi stula and share our experience in the treatment of this patient.

Isolated Spinal Subdural Empyema: A Case Report &Review of the Literature

Background: Spinal subdural empyema (SSE) is rare, with less than 70 case reports in adults. The pathomechanism of infection and vulnerable patient populations have yet to be delineated. Reported outcomes are varied. Case Description: Case report of an isolated spinal subdural empyema with no obvious source in a 65-year-old female presenting with an acute neurologic deficit requiring emergent surgical intervention. A Pub Med search of keywords “Spinal Subdural Empyema” and/or “Spinal Subdural Abscess” with review of all associated English language literature was conducted. Pertinent data were compiled, analyzed, and placed into chart and graph format. Conclusions: SSE is rare and often progresses in 3 separate chronologic stages;pain/fever, neurologic deficit, and paralysis. Tenderness to palpation is often absent. 3 methods of spread have been postulated: hematogenous, contiguous, and iatrogenic. Staphylococcus aureus is the most common infecting organism. The lumbar spine, followed closely by the thoracic spine, is most commonly affected. Contrasted MRI is the preferred diagnostic modality. Emergent surgical SSE evacuation followed by parenteral antibiotics is recommended, as surgical outcomes are far superior to non-surgical management. The patient featured in this case made a full neurologic recovery by 6-month follow-up.

Retrospective Comparative Analysis of Thoracic Empyema in Patients Older/Younger than 65

Objectives:Thoracic empyema is characterized by the collection of infected fluid/pus in the pleural space. A multitude of etiologies and surgical approaches exist. The current study aims to assess outcomes in elderly and young patients undergoing surgery for thoracic empyema. Methods: A retrospective comparative analysis was undertaken comparing outcomes in elderly and young patients undergoing surgery with an established diagnosis of empyema. Two groups were generated for comparison 1) patients older than 65 and 2) patients younger than 65. Demographics, comorbidities, post-operative complications, surgical approach and mortalities were compared between groups. Results: 526 patients underwent surgery for empyema during the study period (1993-2016). Group A (65) comprised 108 patients. With respect to group A, the median age at surgery was 45.30 years. Median post-operative stay was 10.50 days (9.10 vs. 11.90 in VATS and open respectively). 30-day mortality in group A was 1.90% (3.30% vs. 0.47% in VATS and open respectively). Group B comprised 108 patients (median age 72.70 years). Median post-operative stay was 14.40 days (11.20 vs. 17.8, VATS vs. open, p = 0.001). Overall 30-day mortality was 8.30 % (7.5% vs. 9% in VATS and open respectively, p = 0.03). Conclusions: The associated mortality and in-patient stay was significantly greater in elderly cohorts when compared to younger. Minimal access approaches confer a number of advantages in elderly patients including shorter hospital stay and reduced mortality.

A Giant Calcified Subdural Empyema, a Complication of Ventriculo Peritoneal Shunt: Surgical Management and Revue of Literature

Subdural empyema is not a usual complication of ventriculo peritoneal shunt and the discovery of his calcified form is much exceptional in young adults. We report the case of a female patient of 17 years old carrying a shunt since 16 years who was received for retro auricular suppuration facing the intra ventricular drain and whom cerebral CT-Scan shows a right hemispheric calcified empyema. A large craniotomy was realized in the same time than an external ventricular drain. Evolution was marked by minor right body motor troubles and seizures. Difficulties we have faced during the management are a reminder about morbidity due to the insertion of a ventriculo peritoneal shunt and the need of and long term follow up for the carriers.

Clinical features, management and outcomes of pediatric pleural empyema: A retrospective, multicenter cross sectional study

Objectives:To evaluate clinical features,treatment strategies,and outcomes of pleural empyema for children who were treated at referral pediatric hospitals in 8 provinces of Iran.Methods:In this retrospective,multicenter cross sectional study,we retrospectively retrieved patients'data from 8 teaching hospitals during 2010 and 2017.A questionnaire was applied and filled,and all data were statistically and descriptively analyzed.Results:In total,191 children(109 males and 82 females)were included.Their mean age was 4.95 years and ranged from 11 months to 16 years.The majority of cases(45.1%)were 1-4 years old.Fever(70.3%),cough(65.6%),tachypnea(53.1%),chest pain(14.6%),and abdominal pain(12%)were the most common manifestations at admission.The mean length of admission in hospital was 16.4 d.Consequently,27 patients(14.1%)were admitted into the pediatric intensive unit because of severe illness,and 15 patients(7.9%)died.Logistic regression analysis showed that younger age(less than 12 months)and presence of underlying diseases(such as cardiovascular disease,immune deficiencies,malignancies,and neuro-developmental delay)significantly increased the mortality rate of patients with pleural empyema(P=0.004 and P=0.001,respectively).Conclusions:Pleural empyema children of younger age and with underlying diseases are at higher risks of death.In addition,guidelines for treating pleural empyema should be developed.

Indwelling Pleural Catheter Insertion Following Inefficient Thoracoscopic Decortication in Postpneumonic Empyema: Beneficial or Contraindicated?

Video assisted thoracic surgery in advanced stage postpneumonic empyema aims for thorough debridement and washout of the pleural space followed by an attempt to release the entrapped lung (decortication). When the latter isn’t successful, and the patient is in a poor performance status, applying tube thoracostomy is the usual routine, to avoid conversion to thoracotomy and open decortication. Tube thoracostomy, however, is associated with complications necessitating further surgery, needs long term follow up and also entails quality of life distorting issues. To overcome these disadvantages, we instead inserted a PleurX&reg indwelling pleural catheter in four patients in the above situation. The method brought success (lung re-expansion and complete or partial pleurodesis) without the need for further surgery or quality of life problems in either patient. Although the use of the indwelling pleural catheter in infected pleural space is not recommended by manufacturers, we noted no complications.