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1.
Khirurgiia (Mosk). 2019;(8):22-28. doi: 10.17116/hirurgia201908122.

[Surgical treatment of tuberculous empyema in children].

[Article in Russian; Abstract available in Russian from the publisher]

Author information

1
Sechenov First Moscow State Medical University, Moscow, Russia.

Abstract

OBJECTIVE:

To analyze surgical treatment of tuberculous pleural empyema in children depending on the stage of the process.

MATERIAL AND METHODS:

There were 82 patients aged 4-17 years with tuberculous pleural empyema. Clinical and X-ray features of different stages of disease are described. Certain types of surgical interventions at each stage of the process are analyzed.

RESULTS:

In 72 children with empyema stage III 76 surgeries were performed. Postoperative complications occurred in 2 (2.6%) cases (delayed lung inflation) that required thoracocentesis with pleural drainage. There was no postoperative mortality.

CONCLUSION:

Complex treatment of tuberculous pleural empyema in children and adolescents with the use of modern surgical methods is followed by satisfactory outcomes in all patients. However, surgical technique, postoperative morbidity and hospital-stay depend on the stage of the process. Unfortunately, almost 90% of patients had empyema stage III. Therefore, minimally invasive surgery was not advisable and extensive, traumatic surgeries were required.

KEYWORDS:

VATS; pediatric surgery; pleural empyema; pleurectomy; tuberculosis

PMID:
31464270
DOI:
10.17116/hirurgia201908122
[Indexed for MEDLINE]
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3.
BMJ Case Rep. 2019 Mar 31;12(3). pii: e229696. doi: 10.1136/bcr-2019-229696.

Expansile cough impulse: a useful clinical sign for empyema necessitans.

Author information

1
Infectious Diseases, All India Institute of Medical Sciences New Delhi, New Delhi, New Delhi, India.
2
Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India.

KEYWORDS:

Tb and other respiratory infections; empyema; infectious diseases

PMID:
30936366
DOI:
10.1136/bcr-2019-229696
[Indexed for MEDLINE]
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4.
QJM. 2019 Jun 1;112(6):471. doi: 10.1093/qjmed/hcy192.

Reply: Atypical manifestations of tuberculous empyema and neutrophil-predominant effusions.

Author information

1
Department of Rehabilitation, Linyi People's Hospital, Linyi, Shandong, China.
2
Department of Lab Medicine, Shandong Provincial Chest Hospital, Jinan, Shandong, China.
PMID:
30165391
DOI:
10.1093/qjmed/hcy192
[Indexed for MEDLINE]
5.
Rev Pneumol Clin. 2018 Feb;74(1):16-21. doi: 10.1016/j.pneumo.2017.12.001. Epub 2017 Dec 28.

[Prognostic factors in pleuropulmonary decortications for tuberculous pyothorax].

[Article in French]

Author information

1
Service de chirurgie thoracique, CHU Hassan II, BP 1893, Km 2.200, route de Sidi-Harazem, 30000 Fès, Maroc. Electronic address: alzoumib84@gmail.com.
2
Service de chirurgie thoracique, CHU Hassan II, BP 1893, Km 2.200, route de Sidi-Harazem, 30000 Fès, Maroc.
3
Service de chirurgie thoracique, CHU Hassan II, BP 1893, Km 2.200, route de Sidi-Harazem, 30000 Fès, Maroc; Université Sidi-Mohamed-Ben-Abdellah, faculté de médecine et de pharmacie, Fès, Maroc.

Abstract

INTRODUCTION:

Tuberculous pyothorax or empyema is one of the serious forms of tuberculosis and still poses public health problems. Through a series of patients who undergone pleuropulmonary decortication, we propose our model of management and determine the main factors prognostic.

METHOD:

We retrospectively retrieved for 8 years 93 cases of patients with pleuropulmonary decortication for tuberculous pyothorax confirmed by histological examination pre- or postoperatively.

RESULTS:

There were 33 women and 60 men with an average age of 28.4 years±10.35. In all cases, the radiological findings showed a pachypleuritis associated with an enclosed pyothorax in 79.6% of cases (n=74), a free cavity pyothorax in 8.6% of cases (n=8) and a passive atelectasis in all these cases. Chest tube was performed before surgery in 91.4% of cases (n=85) until the effusion was completely drained. The univariate analysis of the results of the surgery allowed to determine 4 factors of good prognosis: preoperative preparation (including chest tube with total drying of the empyema, respiratory physiotherapy and weight gain) P=0.04, complete peroperative pulmonary re-expansion P=0.03, the lowest stay in intensive care unit P=0.02 and the follow-up P=0.01.

CONCLUSION:

Pleuropulmonary decortication is a safe therapeutic alternative in the late stages of tuberculous empyema with acceptable morbimortality.

KEYWORDS:

Cavité pleurale; Chest tube; Chirurgie thoracique; Drainage thoracique; Empyema; Empyème; Pleural cavity; Thoracic surgery; Thoracotomi; Thoracotomy; Tuberculose; Tuberculosis

PMID:
29290492
DOI:
10.1016/j.pneumo.2017.12.001
[Indexed for MEDLINE]
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6.
Intern Med. 2018 Apr 15;57(8):1141-1144. doi: 10.2169/internalmedicine.9169-17. Epub 2017 Dec 27.

Salmonella houtenae-induced Empyema Complicated with Chronic Tuberculous Empyema.

Author information

1
Department of Respiratory Medicine, National Hospital Organization Shinshu Ueda Medical Center, Japan.

Abstract

Salmonella spp. are food-borne pathogens that usually cause gastroenteritis, although bacteremia and subsequent focal metastatic infection can also occasionally occur. Of the known Salmonella spp., Salmonella houtenae is a rare subspecies, comprising less than 1% of all Salmonella strains. We herein report the first case of S. houtenae-induced empyema complicated with chronic tuberculous empyema, which was successfully treated by antibacterial agents alone. We wish to highlight the importance of being aware that Salmonella spp. can cause empyema in cases suffering from chronic tuberculous empyema; moreover, despite the successful completion of treatment with antibacterial agents, periodical follow-up is mandatory in such cases.

KEYWORDS:

Salmonella; Salmonella houtenae; chronic tuberculous empyema; empyema

PMID:
29279480
PMCID:
PMC5938507
DOI:
10.2169/internalmedicine.9169-17
[Indexed for MEDLINE]
Free PMC Article
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7.
Zentralbl Chir. 2017 Sep;142(S 01):S53-S65. doi: 10.1055/s-0043-109257. Epub 2017 Oct 4.

[Interdisciplinary Treatment of Patients with Pulmonary Tuberculosis].

[Article in German; Abstract available in German from the publisher]

Abstract

Today surgical procedures for pulmonary tuberculosis are highly selective but owing to the increasing incidence of multidrug resistant tuberculosis has been becoming more and more relevant. Besides the treatment of tuberculosis foci in multidrug resistance tuberculosis to eliminate the source of relapse, complications as sequelae of tuberculosis are among the most frequent indications for surgery. In patients with cavernous lesions, destroyed lobe or lung, bronchiectasis, pleural empyema or hemoptysis thoracic surgical procedures may be warranted. However, in solitary pulmonary nodules operations with diagnostic purpose are necessary, not only to rule out a potential malignancy, but also to identify a so far unidentified tuberculoma. Considering the heterogenous group of patients with tuberculosis, surgical morbidity and mortality are in the known range for surgical resections in lung cancer patients.

PMID:
28977811
DOI:
10.1055/s-0043-109257
[Indexed for MEDLINE]
Icon for Georg Thieme Verlag Stuttgart, New York
8.
Ann Thorac Surg. 2017 Nov;104(5):1688-1694. doi: 10.1016/j.athoracsur.2017.06.038. Epub 2017 Sep 28.

Thoracoscopic Decortication of Stage III Tuberculous Empyema Is Effective and Safe in Selected Cases.

Author information

1
Department of Thoracic Surgery, Sir Ganga Ram Hospital, New Delhi, India. Electronic address: arvindreena@gmail.com.
2
Department of Thoracic Surgery, Sir Ganga Ram Hospital, New Delhi, India.
3
Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York.
4
Department of Anesthesiology, Pain and Perioperative Management, Sir Ganga Ram Hospital, New Delhi, India.

Abstract

BACKGROUND:

Open decortication of advanced tuberculous empyema remains standard of care. As with other aspects of thoracic surgery, minimally invasive approaches are making inroads into procedures traditionally performed open. In this retrospective analysis, we sought to examine feasibility, efficacy, and outcomes of thoracoscopic decortication of stage III tuberculous empyema in our experience.

METHODS:

The records of all patients in whom thoracoscopic decortication of stage III tuberculous empyema was performed between March 2012 and December 2015 were examined. Demographic and perioperative data were analyzed to assess the surgical outcomes of this study group. To assess long-term efficacy, patients were followed for a minimum of 6 months.

RESULTS:

One hundred patients fit the study criteria, of these 67 were men. Ninety cases were successfully completed thoracoscopically. Mean operative time was 204 ± 34.2 minutes with mean blood loss of 384 ± 28 mL. Median chest drain duration and hospital stay was 7 days. There was no perioperative deaths. Morbidity rate was 33%, composed mostly of prolonged air leak (29%). Six-month follow-up revealed completely expanded lung in all patients except one with small apical asymptomatic air space. Intraoperative cultures were positive for mycobacteria in 25% patients. Six (6%) of these patients had multidrug-resistant tuberculosis and required a modification in their antituberculous therapy.

CONCLUSIONS:

Thoracoscopic decortication of advanced tuberculous empyema is feasible, safe, and effective with good short- and long-term results in selected patients. In a substantial portion of patients, operative cultures required modifying drug treatment to treat underlying tuberculosis.

[Indexed for MEDLINE]
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9.
BMJ Case Rep. 2017 Jul 24;2017. pii: bcr-2017-220315. doi: 10.1136/bcr-2017-220315.

Loculated empyema due to tuberculosis in a child.

Author information

1
Department of Paediatrics, Stellenbosch University, Cape Town, South Africa.
2
Paediatrics and Child Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
3
Department of Paediatric Radiology, University of Bristol and Bristol Royal Hospital for Children, Bristol, UK.

Abstract

A 9-year-old girl from black ethnic origin presented with a history of fever, cough, loss of weight and right-sided chest wall pain for 2 weeks. Chest X-ray demonstrated an effusion, which was shown to be loculated on chest CT scan. She was not responding to medical treatment and at thoracotomy loculated pus was drained. Mycobacterium tuberculosis (TB) was cultured from the pus. TB is a rare cause of loculated empyema with an overlapping clinical and radiological picture with pyogenic infections.

KEYWORDS:

Tb and other respiratory infections; infections; paediatrics; radiology

PMID:
28739566
PMCID:
PMC5614269
DOI:
10.1136/bcr-2017-220315
[Indexed for MEDLINE]
Free PMC Article
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10.
J Comput Assist Tomogr. 2017 Sep/Oct;41(5):772-778. doi: 10.1097/RCT.0000000000000608.

Lung Cancer in Patients With Tuberculous Fibrothorax and Empyema: Computed Tomography and 18F-Fluorodeoxyglucose Positron Emission Tomography Findings.

Author information

1
From the *Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea; †Department of Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China; and Departments of ‡Oncology and §Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Abstract

OBJECTIVE:

The aim of this study was to describe the characteristics of lung cancers in patients with tuberculous fibrothorax or empyema.

METHODS:

We retrospectively evaluated 138 consecutive patients with a diagnosis of lung cancer combined with fibrothorax (n = 127) or empyema (n = 11) from January 2005 to May 2015. All patients underwent computed tomography, and 105 underwent F-fluorodeoxyglucose positron emission tomography. Clinical, pathologic, and computed tomography characteristics and maximum standardized uptake values on positron emission tomography of 76 cancers ipsilateral to the fibrothorax or empyema (group 1) were compared with those of 62 contralateral cancers (group 2).

RESULTS:

The median age at diagnosis of patients was 70 years, with a male-to-female ratio of 8.9:1. The most common type was squamous cell carcinoma (41.3%) followed by adenocarcinoma (39.1%). Most were in the peripheral lung (70.3%), and half abutted the pleura. The median maximum standardized uptake value was 8.9. Tumors in group 1 were larger (median, 48.5 vs 42.8 mm, P = 0.036) and more advanced (T3 or T4) (P = 0.014) than those in group 2.

CONCLUSIONS:

Lung cancers ipsilateral to tuberculous fibrothorax or empyema presented larger and advanced T stages, and the diagnosis could be delayed. The most common type cancer was squamous cell carcinoma.

PMID:
28448410
DOI:
10.1097/RCT.0000000000000608
[Indexed for MEDLINE]
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11.
Ann Thorac Surg. 2017 May;103(5):e419-e421. doi: 10.1016/j.athoracsur.2016.10.071.

Tuberculous Empyema Post Bilateral Lung Transplant.

Author information

1
Division of Cardiothoracic Surgery, Tampa General Hospital, Tampa, Florida. Electronic address: gmakdisi@hotmail.com.
2
Tampa Lung Specialists, Tampa, Florida.
3
Mayo Clinic College of Medicine, Rochester, Minnesota.
4
Gulf Coast Cardiothoracic Surgery Institute, Tampa, Florida.

Abstract

Tuberculous empyema in lung transplantation recipients is a rare entity, with only a handful of cases reported in the English-language literature. We are reporting a case of tuberculous empyema 3 months after uncomplicated bilateral lung transplantation. The recipient underwent video-assisted thoracic surgery for diagnosis and decortication. Both the recipient and donor lacked a history of tuberculosis or tuberculosis exposure.

[Indexed for MEDLINE]
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12.
J Bras Pneumol. 2017 Jan-Feb;43(1):71. doi: 10.1590/S1806-37562016000000244.

Primary epithelioid angiosarcoma of the chest wall complicating calcified fibrothorax and mimicking empyema necessitates.

[Article in English, Portuguese]

Author information

1
. Departamento de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España.
2
. Departamento de Cirugía Torácica, Hospital Universitario Ramón y Cajal, Madrid, España.
3
. Departamento de Patología, Hospital Universitario Ramón y Cajal, Madrid, España.
PMID:
28380190
PMCID:
PMC5790678
DOI:
10.1590/S1806-37562016000000244
[Indexed for MEDLINE]
Free PMC Article
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15.
J Bronchology Interv Pulmonol. 2017 Jan;24(1):40-47.

Mixing It Up: Coadministration of tPA/DNase in Complicated Parapneumonic Pleural Effusions and Empyema.

Author information

1
*Department of Internal Medicine, Division of Pulmonary, Critical Care & Sleep Medicine ‡Sealy Center on Aging †Department of Radiology, University of Texas Medical Branch, Galveston, TX.

Abstract

BACKGROUND:

A recent randomized controlled trial showed 12 serial doses of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is safe and effective in managing complicated parapneumonic pleural effusions and empyema (CPEE). However, this regimen is laborious, requiring trained personnel to open/close the chest tube 8 times daily for 3 days. We present our observational data using a simplified regimen of coadministered tPA/DNase.

MATERIALS AND METHODS:

This is a retrospective observational study of patients who received coadministered tPA/DNase for CPEE from January 2012 to April 2015 at the University of Texas Medical Branch. Patient demographics, pleural fluid, radiologic and treatment characteristics, and outcomes were collected. Data are presented as proportions and percentages. Our primary outcome was successful treatment without need of surgery and discharge home alive. Secondary outcomes were dose and length of treatment and hospital stay, treatment complications, and 90-day mortality.

RESULTS:

The study included 39 patients. All pleural effusions were loculated, 59% macroscopically purulent, 50% had a positive organism in Gram stain, and 40% were culture positive. A median of 6 (interquartile range, 3.5 to 6) doses were coadministered mainly via small bore chest tube (≤14 Fr in 79%) with a median of 14.5 (interquartile range, 9.5 to 21.5) hospital days. Overall, 85% were successfully treated without need for surgery. Treatment failures occurred in 15%: 3/39 (7%) received surgery; 3/39 (7%) died. Only 1 (2.5%) complication of hemorrhagic pleural effusion resolved after discontinuation of intrapleural treatment.

CONCLUSIONS:

Our study shows intrapleural coadministration of tPA/DNase was effective and safe in management of CPEE.

PMID:
27984384
DOI:
10.1097/LBR.0000000000000334
[Indexed for MEDLINE]
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16.
Pan Afr Med J. 2016 May 9;24:26. doi: 10.11604/pamj.2016.24.26.8675. eCollection 2016.

[Tuberculous pyopneumothorax: about 18 cases].

[Article in French]

Author information

1
Service de Pneumologie de l'Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc.

Abstract

Tuberculous pyopneumothorax is a rare but serious complication of evolutive pulmonary tuberculosis. We report a series of 18 cases with tuberculous pyopneumothorax admitted to the Pneumo-Phthisiology Department of the Mohammed V Military Teaching Hospital in Rabat between January 2005 and December 2009. Our study included 15 men and 3 women, the average age was 35 ± 7 years. 4 patients were diabetic. Smoking was found in 9 cases. Right-sided pneumothorax was found in 13 cases. Chest radiograph showed cavitary lesions in 15 patients and extensive bilateral lesions in 8 cases. The search for Mycobacterium tuberculosis in the fluid from the gastric tube was positive in 16 cases. Chest drainage associated with antituberculosis treatment according to the 2SRHZ/7RH regimen and respiratory kinesitherapy were performed in all cases. The average duration of pleural drainage was 4 weeks. In 3 cases we noted persistent pleural suppuration requiring pleural toilet using thoracoscopy with pleurectomy and limited pulmonary resection to eliminate tuberculous parenchymal lesions and the persistence of a large pleural pocket with restrictive ventilatory defect that required surgery for pleural decortication in two cases. The outcome was favorable with minimal pachypleuritis as sequelae in the remaining cases. Tuberculous pyopneumothorax is a severe form, which is often associated with active cavitary tuberculosis. Evolution is generally progressive despite antituberculosis treatment and thoracic drainage, hence the need for early diagnosis and treatment of all forms of tuberculosis.

KEYWORDS:

Pyothorax; pneumothorax; tuberculosis

PMID:
27583090
PMCID:
PMC4992394
DOI:
10.11604/pamj.2016.24.26.8675
[Indexed for MEDLINE]
Free PMC Article
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17.
Intern Med. 2016;55(15):2055-9. doi: 10.2169/internalmedicine.55.6672. Epub 2016 Aug 1.

Endoscopic Bronchial Occlusion with Silicon Spigots for the Treatment of an Alveolar-pleural Fistula during Anti-tuberculosis Therapy for Tuberculous Empyema.

Author information

1
Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Japan.

Abstract

A prolonged air leak caused by pulmonary tuberculosis is difficult to treat, and little is known about optimal treatment strategies. We herein report the case of a 60-year-old man who demonstrated tuberculous empyema with a fistula. An air leak from a tuberculous cavity in his left upper lobe persisted for approximately 4 months; surgical repair could not be performed due to a poor physical status and undernourishment. However, the air leak was successfully treated with endobronchial occlusion using two silicone spigots in left B3b and B4, without any adverse effects or aggravation of the infection.

[Indexed for MEDLINE]
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18.
Mediators Inflamm. 2016;2016:3068103. doi: 10.1155/2016/3068103. Epub 2016 Feb 29.

Analysis of Cytokine Levers in Pleural Effusions of Tuberculous Pleurisy and Tuberculous Empyema.

Author information

1
Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China.
2
Tuberculosis Immunology Department, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China.

Abstract

The aim is to examine whether the interleukin-1β (IL-1β), IL-2, IL-6, tumor necrosis factor-α (TNF-α), plasminogen activator inhibitor type-1 (PAI-1), and tissue plasminogen activator (t-PA) levels were different in pleural effusions of tuberculous pleurisy and tuberculous empyema. IL-1β, IL-2, IL-6, TNF-α, PAI-1, and t-PA levels in pleural fluids of 40 patients with tuberculous pleurisy and 38 patients with tuberculous empyema were measured. The levels of IL-1β, PAI-1, and t-PA in the pleural effusions were different between tuberculous pleurisy and tuberculous empyema; it could be helpful to differentiate the two diseases. The levels of PAI-1, IL-1β were higher and t-PA, IL-6 were lower in pleural effusions of the patients with tuberculous empyema and who must undergo operation than the patients who could be treated with closed drainage and anti-TB chemotheraphy. These indications may be helpful to evaluate whether the patient needs the operation.

PMID:
27034588
PMCID:
PMC4789481
DOI:
10.1155/2016/3068103
[Indexed for MEDLINE]
Free PMC Article
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19.
Asian Cardiovasc Thorac Ann. 2016 Mar;24(3):245-9. doi: 10.1177/0218492316629281. Epub 2016 Jan 18.

Effect of decortication and pleurectomy in chronic empyema patients.

Author information

1
Cardiothoracic Surgery & Transplant Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran bagherir@mums.ac.ir.
2
Cardiothoracic Surgery & Transplant Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
3
Lung Disease Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

Abstract

BACKGROUND:

Fibrosis that occurs in the chronic phase of pleural empyema restricts lung movement and impairs pulmonary function. It also leads to asymmetry of the chest wall. We evaluated the efficacy of decortication and pleurectomy in improving these adverse consequences.

METHODS:

Data of 50 patients (42 males, mean age 49.1 ± 19.46 years) with chronic empyema who underwent lung decortication via a posterolateral thoracotomy between 2004 and 2014 were reviewed in this study. All patients had pulmonary function tests before and after surgery. Computed tomography was used to determine transverse and anteroposterior diameters of the chest before and after surgery.

RESULTS:

The patients were followed up for 11.5 ± 4.5 months. Mean forced expiratory volume in 1 s was 62.5% ± 13.61% before surgery vs. 77.3% ± 13.31% after surgery (p < 0.001). Mean forced vital capacity was 60.6% ± 14.38% before surgery vs. 78.5% ± 12.64% after surgery (p < 0.001). The improvement in patients with reduced chest wall diameters was significant (p < 0.001). Improvements in pulmonary function tests and chest wall diameters were not significantly different between patients with tuberculosis (n = 10) and those with other diseases (n = 40; p < 0.05).

CONCLUSION:

Decortication and pleurectomy via a posterolateral thoracotomy significantly improves pulmonary function and chest wall diameters in patients with chronic empyema due to tuberculosis or other diseases.

KEYWORDS:

Chronic disease; Debridement; Empyema; Respiratory function tests; Thoracic wall; pleural; tuberculous

PMID:
26787536
DOI:
10.1177/0218492316629281
[Indexed for MEDLINE]
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20.
BMJ Case Rep. 2016 Jan 4;2016. pii: bcr2015212311. doi: 10.1136/bcr-2015-212311.

Unusual cause of chest pain: empyema necessitans and tubercular osteomyelitis of the rib in an immunocompetent man.

Author information

1
Department of Respiratory Medicine, Milton Keynes University Hospital, Buckinghamshire, Milton Keynes, UK.
2
Department of Thoracic and Transplant Pathology, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

Abstract

A 33-year-old man, born in India but resident in the UK for 5 years, presented to the emergency department with a 4-week history of a dry cough and right-sided pleuritic chest pain. He reported systemic features, including fever and unintentional weight loss. His medical history included vitamin D deficiency. He had travelled to India 10 months previously and denied any exposure to tuberculosis (TB). He was an ex-smoker with a 20 pack history. Respiratory examination confirmed decreased air entry of the right lower lobe and stony dullness on percussion. His C reactive protein was 178 mg/L. A chest radiograph identified a moderate-sized right-sided pleural effusion and destruction of the lateral aspect of the right fifth rib, strongly suggestive of underlying malignancy. Further investigation with a CT of the thorax identified a focal lytic lesion in the right fifth rib, at its lateral aspect, with expansion of the rib observed. Ultrasound-guided pleural aspiration confirmed an exudative pleural effusion. Gram stain revealed no organisms or polymorphs. Four days post admission, the patient was transferred to the regional thoracic surgery unit and underwent video-assisted thoracic surgery, bronchoscopy and drainage of his empyema. His Mantoux tuberculin skin test and his TB Elispot were negative, suggesting that TB infection was unlikely. Culture confirmed no growth after 48 h incubation. Histology of his pleural biopsy identified multiple non-confluent necrotising granulomatous inflammation with very occasional acid-alcohol-fast bacilli-like organisms, highly suspicious for mycobacterial infection. The isolate, Mycobacterium tuberculosis, was identified by Accuprobe and HAIN tests, respectively. MPT64 erythrocyte sedimentation rate (ESR) results from the fifth rib were positive for M. tuberculosis. This case report discusses the aetiology, clinical presentation and pathophysiology of both empyema necessitans and tubercular osteomyelitis of the rib.

PMID:
26729824
PMCID:
PMC4716320
DOI:
10.1136/bcr-2015-212311
[Indexed for MEDLINE]
Free PMC Article
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