Thoracic empyema is a disease of substantial morbidity and mortality, mainly in the developing world where tuberculosis remains a common cause. It is known to be associated with prolonged respiratory symptoms requiring longer times for drainage due to excessive fibrosis and pleural thickening. Suppurative bacterial infections are also an important cause of empyema, which if not diagnosed and treated early by antibiotics alone or with early under water seal intercostal tube, may result in to chronic empyema or even empyema thoracis necessitans requiring open drainage and decortication. Empyema necessitans is spillover of pleural space infection or pus in to soft tissue of the thoracic wall. It may burst out via weak part of the chest wall to skin and start discharging pus; otherwise it may involve surrounding structures in any direction. After Streptococcus pneumonia, Staphylococcus aureus, is the commonest cause of empyema in children, but it is not uncommon in adults either. Chronic suppurative empyema is more common and even recurrent in patients with past history of poly trauma or chest surgery. Chronic empyema treated with decortications results in rapid resolution of infection and better re-expansion of the lung as compared to only under water seal intercostal tube. We report 55 years old Saudi male with history of road traffic accident, poly trauma, chest surgery and paraplegia admitted for rehabilitation in Sultan Bin Abduaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia and diagnosed with empyema thoracis necessitans due to Staphylococcus aureus, treated initially with under water seal intercostal intubation and antibiotics but subsequently required decortication.
A Saudi male 55 years of age suffered poly trauma in a road traffic accident including chest two years ago and was admitted in SBAHC for rehabilitation for having paraplegia on 16-6-2013. Three days since admission he was running fever and his chest x-ray on admission being abnormal was referred a bit late for pulmonary consultation on 19-6-2013, he was being treated by the primary team as pneumonia. He had mild cough, feeling of heaviness and discomfort on the left lateral chest without significant expectoration. He had poor oral hygiene, malodorous fetor with pyorrhea and dark brown deposits on the teeth. On systemic examination his BP was 120/70, HR = 88, RR = 19, T = 38.5, O2 Saturation = 95% at room air, Weight = 78 Kg. There were obvious old thoracostomy scars (Figure 1) performed two years ago on the left chest wall. Percussion note was dull and reduced breath sounds on the ipsilateral side. Percussion note was stony dull. There was no paradoxical, respirartion and heart rate pattern on clinical examination as well as on electrocardiogram. Echo cardiac examination was unremarkable with no out flow obstruction apart from mild left ventricular diastolic dysfunction consistant with his age. His chest x-ray (Figure 2) showed left sided thick biconvex opacity occupying left lower and middle zone. Lab works showed Hb = 12gm, RBC = 3.6, WBC = 12.6, N = 88, L = 10, M = 1, E = 1, PLT = 366, ESR = 32, BU = 6.2, SCR = 76, LDH = 40, CRP = 16, PPD = 5mm. Under the provisional diagnosis of chronic empyema patient was started on empirical injection clindamycin 600 mg iv q8hrs. Culture on blood, urine and sputum was awaited. After having CT scan chest (Figure 3) an urgent external thoracic surgical consultation was requested as our hospital is a rehabilitation facility there is no thoracic surgical specialty. The color of an old thoracostomy scar started changing dark brown to red color and in next 24-48 hours it became umblicated and yellow (Figure 4). On the 7th day of admission on 23-6-2013 while he was being examined by the thoracic surgeon he had an intractable bout of cough which lead to spontaneous rupture with pouring out of frank pus. A specimen of the pus was sent for bacterial and mycobacterial culture besides Acid Fast Bacteria (AFB) direct smear microscopy. Patient felt relieved and had no adverse events like breathlessness or pain. He was taken to the operation room and was inserted underwater intercostal tube as part of traditional thoracostomy.
Patient was sent back to the unit where he felt better his temperature became less but his lung remained unexpanded with residual loculations and still residual pus on post intercostal tube (ICT) chest x-ray (Figure 5). Culture on the pus, was reported heavy growth of Staphylococcus aureus, sensitive to clindamycin so same antibiotic was continued. Pus was reported AFB negative on direct smear microscopy. Blood and urine culture were reported negative. Next day the patient was taken for decortication and was kept subsequently in the high dependency unit (HDU). He remained stable initially on ventilator for 48 hours, then on spontaneous breathing and oxygen subsequently maintaining normal range O2 saturation at room air. His lung remained well anchored and expanded with no complications, hence all three one anterior apical, and two posterior apical and basal under water seal drainage tubes along with Robert's pump application were removed one by one. Culture on pus for Mycobacteria was reported negative. Patient remained stable made good uneventful recovery and was discharged home on 16-7-2013, his last chest x-ray shown (Figure 6). There was complete re-expansion of the lung with no residual collection. He was advised OPD follow up which he failed.
(a and b) CT scan chest showing left sided chronic empyema.