CTV01 - Empyema Necessitans in an Immunosuppressed Patient Following Tube Thoracostomy

Introduction/Purpose: Empyema necessitans is a rare thoracic disease process that results from an infected pleural effusion, or empyema, extending through the chest wall to involve the surrounding soft tissue. This process is typically associated with Mycobacterium tuberculosis and Actinomyces israelii, but a variety of microbial culprits have been documented. Clinical presentation can mimic that of a pleural effusion or empyema, with pleuritic chest pain, dyspnea, fever, or respiratory compromise commonly seen. Additionally, this process can develop following post-obstructive pneumonia with secondary lung abscess formation. With progression of subcutaneous tissue involvement along the chest wall, cellulitis can ensue, and even can be the herald symptom. The typical patient profile is not well documented, but in one case series of 350 patients, all afflicted patients were male, immunocompromised, and had either HIV or drug abuse history. Lastly, although documented only once before, this can occur secondary to tube thoracostomy. Here, we discuss a rare presentation empyema necessitans that developed following tube thoracostomy in an immunocompromised patient with pleural effusion.

Methods or Case Description: A 52-year-old male with autosomal dominant polycystic kidney disease status post renal transplantation maintained on immunosuppression presented with dyspnea. At time of presentation, patient was afebrile with hypoxia. Physical exam was remarkable for decreased breath sounds over the left thorax. Laboratory results showed a leukocytosis of 12,000 and a lactic acid of 12. Computed tomography (CT) revealed a left apical pneumothorax with a loculated pleural effusion. A 14Fr chest tube was placed with return of 1,200mL of grossly purulent material. Aerobic fluid cultures grew Streptococcus anginosus and Streptococcus constellatus. The patient was commenced on broad spectrum antibiotics upon admission. He was resumed on immunosuppressive regimen on hospital day 6. Repeat chest CT showed no significant decrease in volume of empyema, but newly noted extrathoracic soft tissue gas as seen in Image 1. Given these findings, he was taken for left thoracoscopy which revealed dense adhesions and frank pus with poor visualization prompting conversion to an open thoracotomy. Upon dissection into the subcutaneous tissue and muscular compartments, we noted frank necrosis with turbid fluid consistent with necrotizing soft tissue infection. We performed wide local debridement prior to drainage of empyema and full pulmonary decortication. A large-bore chest tube was left and the thoracic cavity closed with pericostal sutures. The soft tissues were left open and negative pressure dressing was placed.

Post operatively, the patient improved with antibiotic therapy and did not require further debridement. Delayed primary closure was performed on postoperative day 13. The latter part of his postoperative course was uneventful, and he was discharged home following subacute rehabilitation.

Outcomes: Empyema necessitans is a complication of pleural effusion that is not often seen. As expected, this pathology is more commonly seen in elderly male patients who are immunosuppressed, consistent with our patient’s demographics. Our patient presented with dyspnea and was found to have a complex left-sided pleural effusion for which a thoracostomy tube was immediately placed. Thoracostomy tube, in addition to broad spectrum antibiotics, is commonly the initial management of choice for parapneumonic infections, but often leads to inadequate source control. Such as in our patient, thoracostomy tube was inadequate despite appropriate antibiotic regimen. Additionally, placement ultimately resulted in the progression to empyema necessitans. Similar reports have concluded that decortication is superior to intercostal tube drainage in chronic empyema. In this case, performing a thoracotomy and decortication with debridement of the chest wall soft tissue was adequate to obtain source control. We successfully utilized negative pressure wound therapy for wound management and as a bridge until delayed primary closure could be performed after clearance of bacterial infection.

Conclusion: In patients with Empyema Necessitans early and aggressive surgical approach should be taken and has been shown to improve outcomes. Although a rare diagnosis, physicians must remain cognizant of the diagnosis and treatment strategies.