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CASE REPORT
Year : 2016  |  Volume : 13  |  Issue : 2  |  Page : 125-127

Massive pleural empyema in infancy


1 Department of Radiology, Federal Neuropsychiatric Hospital, Maiduguri, Nigeria
2 Department of Radiology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Paediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria

Date of Web Publication1-Aug-2016

Correspondence Address:
Abubakar Ahmad
Department of Radiology, Federal Neuropsychiatric Hospital, Maiduguri
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-8540.181231

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  Abstract 

Pleural empyema is an emergency clinical condition characterised by presence of purulent organisms within the pleural fluid. It is associated with significant morbidity and consumption of scarce resources. It is a rare clinical condition but constitute a serious thoracic emergency despite advances in management. Imaging plays an important role in the diagnosis and management of pleural empyema. We present an 11 month old infant with a month history of fever, cough, shortness of breath and weight loss. Clinical diagnosis of bronchopneumonia with pleural effusion was made. Chest radiograph revealed right opaque hemithorax with central mediastinum. Computed tomography (CT) of the chest showed extensive right pleural effusion with compression of viable lung tissue. Ultrasound guided thoracocentesis drained about one litre of pus. Intravenous antibiotics were also administered. Repeat chest radiograph a week after the drainage showed marked reduction in the size of the previously noted opaque right hemithorax with remarkable improvement of the clinical condition.

Keywords: Chest radiograph, opaque right hemithorax, pleural empyema, thoracocentesis


How to cite this article:
Ahmad A, Adamu YM, Dambatta A H, Lawan B. Massive pleural empyema in infancy. Niger J Basic Clin Sci 2016;13:125-7

How to cite this URL:
Ahmad A, Adamu YM, Dambatta A H, Lawan B. Massive pleural empyema in infancy. Niger J Basic Clin Sci [serial online] 2016 [cited 2021 Dec 2];13:125-7. Available from: https://www.njbcs.net/text.asp?2016/13/2/125/181231


  Introduction Top


Pleural empyema is an emergency clinical condition characterised by the presence of purulent organisms within the pleural fluid or when the fluid has a white blood cell count of >5 × 109 cells/L.[1],[2] In childhood, it usually follows an acute bacterial pneumonia. Rarer causes include spread from other sites of sepsis such as from septic emboli, lung abscess, subphrenic abscess, osteomyelitis of a rib or as a result of a missed inhaled foreign body.[1],[2],[3] It is associated with significant morbidity and consumption of scarce hospital resources.[3] It is a rare clinical condition but constitute a serious thoracic emergency despite advances in management.[1],[2],[3],[4] The overall incidence of pleural empyema in children has decreased significantly due to availability of sensitive antibiotic therapy, widespread immunisation programmes and improved infant nutrition.[2],[3]

Imaging plays an important role in the diagnosis and management of pleural empyema. While a gamut of different imaging modalities may be used, the chest radiograph remains the first examination in the initial assessment of pleural empyema. Depending on the clinical context, the optimal imaging technique for further evaluation may be conventional computed tomography (CT), high-resolution CT and ultrasound scan. Magnetic resonance imaging currently plays a very limited role.[1],[2],[3],[4]

Studies regarding empyema in the paediatric literature are limited; below is a case of massive pleural empyema in 11 months old infant.


  Case Report Top


AR was an 11-month-old infant referred to the respiratory unit, Department of Paediatrics, University of Maiduguri Teaching Hospital with 2 weeks fever, chronic cough, shortness of breath and weight loss. Obstetrics and prior infancy history were unremarkable. On examination, he was febrile, dyspnoeic, not pale, anicteric, cyanosis, no peripheral lymphadenopathy and no pedal oedema. The respiratory rate was 53/min; dull percussion and decrease breath sound were noted over the entire right hemithorax. Other systemic examinations were essentially normal. A clinical diagnosis of bronchopneumonia with pleural effusion was made.

Full blood count showed pack cell volume of 38%, neutrophils of 50%, monocyte of 5%, lymphocyte of 45%, eosinophils count of 0% and erythrocyte sedimentation rate of 110 mm/h. Liver function tests, serum electrolytes, urea and creatinine were all within normal limit. Retroviral screening was negative.

Anterior-posterior chest radiograph [Figure 1] revealed a complete right opaque hemithorax with central mediastinum. However, the left lung zones and the thoracic cage were normal. CT scan of the chest [Figure 2] shows extensive right pleural effusion; with marked compression of the lung tissue (only a small part of the lung tissue was seen anterosuperiorly). No evidence of collapse was noted. Ultrasound scan guided thoracocentesis drained turbid pus. Routine bacterial cultures and acid-fast bacilli smear were both negative, and cytology of the fluid shows red blood and inflammatory cells. An assessment of massive right pleural empyema was made, and closed drainage under local anaesthesia yielded about a litre of pus from the thorax. The patient received intravenous ceftriaxone and metronidazole. Repeat chest radiograph [Figure 3] a week after the procedure revealed some improvement as evidenced by a reduction in the size of the previously noted opaque right hemithorax. However, the resolution was not complete. Multiple attempts to re-drain with various sizes of catheters did not yield any pus and clinical condition improved remarkably. The patient was discharged 2 weeks after the procedure but lost to follow-up thereafter.
Figure 1: Chest radiograph at presentation showing complete right opaque hemithorax with central mediastinum. The left lung field is normal

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Figure 2: High-resolution computed tomography scan of the chest showing a hyperdense collection in the right hemithorax suggestive of massive pleural effusion; with mark compression of lung tissue. The left lung field is normal

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Figure 3: Repeat chest radiograph showing some improvement as evidenced by reduction in size of previously noted opaque right hemithorax and re-expansion of the lung

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  Discussion Top


Empyema thoracis (pleural empyema) is an unusual manifestation of a long-standing pulmonary infection, but it may also occur secondary to a systemic infection or by the direct extension of infectious processes in the abdomen, the mediastinum, or the chest wall such as subdiaphragmatic abscess, liver abscess and post-thoracotomy.[1] The documented predisposing factors include malnutrition, immunosuppression, prematurity, congenital heart disease and cerebral palsy.[2] None of the predisposing factors was noted in the index case, and the exact focus and route of the infection were not established.

Staphylococcus aureus is the most common causative organism in the paediatric age group, occurring in about 77%.[4],[5] Other documented organisms include Streptococcus pneumoniae,  Escherichia More Details coli, Haemophilus influenzae, Mycobacterium tuberculosis and Candida albican.[4],[5] Pleural culture is positive only in 32–48% and in the index patient culture is negative for mycobacterium and other bacteria.[2],[4],[5],[6]

Chest radiographic features include homogeneous opacity with positive meniscus sign which is usually unilateral and move with a change in posture of the child.[4],[6],[7] The diagnosis can be confirmed by thoracocentesis, culture and pleural fluid analysis.[4],[6],[7]

A CT scan of the chest is not necessary due to its high radiation dose if the diagnosis can be made with plain radiography, ultrasound scan and thoracocentesis.[1] However, it is essential if there is suspected underlying lung disorders which are not clear on the radiograph. In the case cited above CT scan was done for the assessment of underlying lung pathology.[1]

Empyema can be nonloculated or loculated, the former is usually homogeneous in opacity, change with patient position and have a meniscus sign. Loculated effusions are those that do not shift freely in the pleural space and occur in children with empyema when there are adhesions between the visceral and parietal pleura.[4],[6],[8]

Optimal management in children is controversial, but it includes parenteral antibiotics, limited thoracotomy, open drainage, fibrinolysis, video-assisted thoracoscopic surgery and fluoroscopy, CT and US-guided percutaneous catheter drainage.[9] Traditionally, empyema thoracis has been treated by means of conventional surgical chest tube drainage guided only by the findings on the chest radiograph. The recorded success rate is about 35–71% and our patient similarly responded favourably to the ultrasound-guided drainage.[9]

Greater success rate has been obtained with image-guided chest tube drainage compared to tubes inserted blindly in most series; hence, image-guided drainage is currently recommended as the primary method for treating empyema.[2],[8],[9]

Chronic pleural thickening and entrapment of the lung are the potential complications of empyema thoracis, which do not resolve immediately after chest tube drainage. The surgery literature has traditionally recommended decortication in patients with empyema associated with these complications.[10] However, other studies have recently demonstrated that the pleural thickening seen with empyema usually resolves after 12 weeks.[9]


  Conclusion Top


Pleural empyema is a rare paediatric emergency which shows decrease in incidence in the recent years, this is a severe case in an 11-month-old infant who presented radiologically with complete opaque right hemithorax and responded favourably to ultrasound-guided thoracocentesis and drainage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
King S, Thomson A. Radiological perspectives in empyema. Br Med Bull 2002;61:203-14.  Back to cited text no. 1
    
2.
DeLuca A, Kurland G. Empyema in children: Epidemiology, diagnosis and management. Semin Pediatr Infect Dis 1998;9:205-11.  Back to cited text no. 2
    
3.
Schultz KD, Fan LL, Pinsky J, Ochoa L, Smith EO, Kaplan SL, et al. The changing face of pleural empyemas in children: Epidemiology and management. Pediatrics 2004;113:1735-40.  Back to cited text no. 3
    
4.
Baranwal AK, Singh M, Marwaha RK, Kumar L. Empyema thoracis: A 10-year comparative review of hospitalised children from south Asia. Arch Dis Child 2003;88:1009-14.  Back to cited text no. 4
    
5.
Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyema thoracis: An emerging clinical entity. Chest 2000;117:1672-8.  Back to cited text no. 5
    
6.
Chaplin AE. Empyema thoracis in infants and children. Arch Dis Child 1947;22:91-105.  Back to cited text no. 6
    
7.
Osaki S, Nakanishi Y, Andou K, Takano K, Takayama K, Hirota N, et al. A case of extrapleural empyema. Respirology 2002;7:83-5.  Back to cited text no. 7
    
8.
Calder A, Owens CM. Imaging of parapneumonic pleural effusions and empyema in children. Pediatr Radiol 2009;39:527-37.  Back to cited text no. 8
    
9.
Davies CW, Gleeson FV, Davies RJ; Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the management of pleural infection. Thora×2003;58 Suppl 2:ii18-28.  Back to cited text no. 9
    
10.
Neff CC, vanSonnenberg E, Lawson DW, Patton AS. CT follow-up of empyemas: Pleural peels resolve after percutaneous catheter drainage. Radiology 1990;176:195-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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