Analysis of thirty-seven cases of pleural empyema

Paediatric thoracic tumours presenting as empyema

Ultrasonography (US) is considered to be adequate for the preoperative evaluation of childhood empyema. This study was aimed to improve awareness that paediatric intra-thoracic tumours can mimic childhood post-pneumonic empyema and highlights the value of computed tomogram (CT) scan with intravenous (IV) contrast in preoperative evaluation of childhood empyema. The data were analysed on eight children (four boys and four girls) presented at the median age of 6.2 years (1.8-15 years) for the management of empyema and later confirmed to have intra-thoracic tumours. Intra-thoracic tumours in 8 (5.3%) children out of 150 cases of post-pneumonic empyema were managed during the study period. All eight had clinical features, increased white cell count, raised inflammatory markers and biochemical parameters suggestive of childhood empyema. Chest X-ray showed localised opacity in 3/8 while in other five suggested significant pleural collection with mediastinal shift. Additional investigations in referring hospital were suggestive of empyema in four children; US in three, CT scan without IV contrast in one. Referring hospital carried out non-diagnostic thoracocentesis in four children with blood stained pleural tap in two. In four children corroborative evidence suggestive of infection within pleural cavity and acute respiratory distress led to an emergency mini-thoracotomy resulting in significant intra-operative bleeding in two children. Histology on biopsy of the infected material showed primitive neuroectodermal tumour (PNET) in one, pleuropulmonary blastoma in one, metastatic malignant melanoma in one and cytology of pleural fluid diagnosed lymphoma in one. Pre-operative CT scan with IV contrast in four children correctly identified underlying intra-thoracic tumour (two benign teratoma, two PNET). In two cases CT with IV contrast was performed because chest X-ray suggested mediastinal loculated empyema while in other two high clinical index of suspicion prompted preoperative evaluation with CT scan with IV contrast. We advocate caution and increased awareness before considering therapeutic options in childhood empyema and recommend preoperative CT scan with IV contrast in some selected and unusual cases.

Unusual manifestations of invasive pneumococcal infection

Unusual pneumococcal infections occurred frequently in the preantibiotic age but rapidly declined with the advent of the antibiotic era. Unfortunately, the morbidity and mortality associated with invasive pneumococcal disease remain high despite antibiotic therapy and monumental advances in medical technology. The incidence of invasive pneumococcal disease has increased recently because of the onset of the human immunodeficiency virus (HIV) epidemic and the emergence of antibiotic-resistant pneumococcus. Robert Austrian described the clinical triad of pneumococcal pneumonia, meningitis, and endocarditis, a syndrome that now bears his name. Although seen infrequently today, unusual manifestations of pneumococcal infection such as those Austrian reported still occur. A review of these cases is warranted because, as drug-resistant organisms continue to emerge worldwide, more unusual pneumococcal infections will be seen. Streptococcus pneumoniae is responsible for a remarkable array of disease processes; our literature review uncovered 95 different types of unusual pneumococcal infections representing 2,064 cases. Examples of these infections included pancreatic and liver abscesses, aortitis, gingival lesions, phlegmonous gastritis, inguinal adenitis, testicular and tubo-ovarian abscesses, and necrotizing fasciitis. We also reviewed predisposing underlying illnesses and conditions. Alcoholism, HIV infection, splenectomy, connective tissue disease, steroid use, diabetes mellitus, and intravenous drug use remain common risk factors for invasive pneumococcal infections. Currently, multidrug-resistant S. pneumoniae remains susceptible to vancomycin and several new third-generation fluoroquinolones. As what some fear will be a possible postantibiotic era approaches, clinicians must be able to recognize and manage unusual pneumococcal infections.

Gas chromatographically quantitated lactate in empyema and other pleural effusions

To determine the value of gas chromatographically measured lactate in distinguishing between empyema and other causes of pleural effusion, consecutively collected samples of pleural fluid were studied. In 15 cases of empyema the mean lactate concentration was 11.60 mM and higher than in 41 patients with other diagnoses (mean 3.98 mM). The concentration of lactate remained unchanged during storage at 4 degrees C for two years. Gas chromatographic quantitation of lactate is useful in the presumptive diagnosis of empyema, and stability of the lactate concentration allows retrospective analyses.