Parapneumonic Effusion and Empyema

Utilizing Telemedicine in Public Health Services for the Treatment of Patients with Thoracic Surgical Conditions

Background: Telemedicine has been safely used across various surgical specialties at different stages of outpatient care, with effectiveness measured by clinical outcomes, cost savings, and user satisfaction. When employed for communication between physicians at a referral center and lower-complexity hospitals, it enables quick specialist evaluations for patients with relative emergencies. This study describes the experience of a tertiary care service in managing thoracic surgical conditions through telemedicine case discussions. Methods: This prospective study, from March 2022 to February 2023, focused on teleconsultations with hospitals in the referral area of a public academic hospital. Consultations were conducted synchronously and asynchronously via a proprietary platform. Data were collected on the originating hospital, patient demographics, admission date, diagnosis, and clinical summary. Cost savings were calculated by estimating avoided round-trip ambulance transportation. The analysis included data from the public health system's referral records. Results: Out of 4,386 evaluation requests, 341 (7.7%) were discussed with a thoracic surgery specialist. Of these, 181 (53%) were managed without patient transfer, and 53 required rediscussion to revisit the initial medical approach. Immediate transfer, outpatient evaluation, or surgery was recommended in 160 cases. Conclusion: The incorporation of telemedicine into interhospital regulation of thoracic surgical diseases effectively reduced unnecessary patient transfers while providing the originating service with valuable information for managing specialty-specific situations.

Evaluation of cytomorphological examination in the diagnosis of pleural effusion

Cytological examination serves as a crucial diagnostic tool for pleural effusion, with its diagnostic efficacy influenced by variations in specimen processing and staining techniques. Cellular morphological analysis of pleural effusions was performed using Wright-Giemsa staining to assess its diagnostic accuracy and clinical utility in differentiating the various etiologies of exudative pleural effusion. A routine examination was conducted on 2305 cases of unexplained pleural effusion, followed by cellular classification and morphological analysis in 1376 cases identified as exudative effusion. Among the 479 patients with malignant tumors, cytomorphological examination identified malignant cells in 295 patients, resulting in a clinical diagnosis coincidence rate of 98.6%. Abnormal cells, including malignant and heterogeneous nuclear cells, were observed in 364 cases, yielding a detection rate of 76.0%. The proportion of positive malignant cells in the newly diagnosed patient group was significantly higher than that in the previously diagnosed group (P < 0.01). Cytological analysis revealed the presence of bacteria, fungi, and phagocytes in 51 out of 1376 cases. The positivity rate for multiple bacterial infections detected through cytology was significantly greater than that identified by culture (P < 0.01). Additionally, various special morphologies and pathogens, which are rare in clinical practice, were detected, including mixed metastasis of small cell lung carcinoma and adenocarcinoma cells, as well as concurrent infections with Talaromyces marneffei and Pneumocystis jirovecii. This method enables the rapid and comprehensive differentiation between malignant tumors, tuberculosis, pneumonia, and rare exudative pleural effusions resulting from specific clinical conditions.

Pleural Space Diseases and Their Management: What is the Role of Intrapleural Fibrinolytic Therapy?

Pleural space diseases are a significant cause of morbidity in the United States with a reported 25% mortality rate within a year of diagnosis. Pleural space diseases, including intrapleural infections, retained hemothorax (RH), and malignant pleural effusions (MPE), often indicate advanced disease. Despite options like video-assisted thoracoscopy (VATS), tube thoracostomy, and intrapleural fibrinolytic therapy (IPFT), treatment remains a significant clinical challenge. IPFT, which describes a combination of administrating tissue plasminogen activator (tPA) and DNase through a chest tube, has shown effectiveness in improving fluid drainage and reducing surgery frequency in a large, randomized control trial and is widely used. However, the success of IPFT varies based on infection severity, patient health, and treatment timing, with a failure rate around 20-25%. This highlights the need for further research to enhance the therapy's efficacy, investigating both disease mechanisms and optimizing treatment protocols. This review seeks to provide a comprehensive overview of IPFT, highlighting recent advancements, current trends, and existing research gaps.

Fusobacterium nucleatum-Induced Empyema Masquerading as Lung Cancer: A Diagnostic Challenge

A 73-year-old man, an ex-smoker with a history of asbestos exposure and hypertension, presented with progressive shortness of breath, weight loss, loss of appetite, and fatigue. He was referred by a general practitioner for evaluation of a round lesion in the right lung. Chest computed tomography (CT) revealed a pleural-based mass and small right-sided pleural effusion that was not amenable to aspiration. Routine blood investigations revealed elevated levels of the inflammatory markers. He was discharged with a course of oral antibiotics, levofloxacin, and scheduled for a two-week follow-up on the lung cancer pathway. The patient returned with worsening shortness of breath and enlarged pleural effusion. Ultrasound-guided diagnostic aspiration yielded purulent fluid, with cultures identifying Fusobacterium nucleatum. Cytological examination of the pleural fluid yielded negative results for malignant cells. Further investigations ruled out septic thrombophlebitis of the internal jugular vein (Lemierre syndrome) and septic mediastinitis. After excluding all other possible infection sites and conducting an oral examination, the pleural infection was attributed to periodontal disease. Empyema was effectively managed with antibiotics and drainage. However, empyema resulted in a visceral pleural rind, leading to an unexpandable lung. Surgical intervention was not pursued because of the patient's comorbidities and clinical and biochemical resolution of the infection. This case highlights the importance of considering rare pathogens, such as Fusobacterium nucleatum, in pleural infections, particularly when linked to oral sources.

Severe pneumonia with empyema due to multiple anaerobic infections: case report and literature review

Background

Cases of severe pneumonia complicated by empyema due to normal anaerobic flora from the oral cavity are infrequent. Diagnosing anaerobic infections through conventional microbiological test (CMT) is often challenging.

Case presentation

This study describes the case of a 67-year-old man, bedridden long-term, who developed severe pneumonia with empyema caused by multiple anaerobic bacterial infections. The patient was hospitalized with a 5-day history of cough, sputum and fever, accompanied by a 2-day history of dyspnea. Despite CMT, the specific etiology remained elusive. However, metagenomic next-generation sequencing (mNGS) identified various anaerobic bacteria in bronchoalveolar lavage fluid (BALF), blood and pleural effusion. The patient was diagnosed with a polymicrobial infection involving multiple anaerobic bacteria. Following treatment with metronidazole and moxifloxacin, the patient's pulmonary symptoms improved.

Conclusion

mNGS serves as a valuable adjunctive tool for diagnosting and managing patients whose etiology remains unidentified following CMT.

Case report of parapneumonic effusion and mesothelial subdiaphragmatic cyst: relationship or coincidence?

Parapneumonic pleural effusions are common in patients with pneumonia. When colonized by pathogenic bacteria or other microorganisms, these effusions can progress to empyema. Additionally, empyema formation may result in extension of the infection into the infradiaphragmatic region, further complicating the clinical scenario. Many subphrenic collections are found to be mesothelial cysts, which are congenital in origin. However, data regarding the potential association between mesothelial diaphragmatic cysts and parapneumonic effusions are limited. We herein describe a toddler with pneumonia complicated by parapneumonic effusion and a lung abscess with a subphrenic collection. After abscess drainage and a full course of antibiotics, imaging revealed clear lung parenchyma with an interval resolution of the effusion and a persistent unchanged subphrenic collection that was confirmed to be mesothelial diaphragmatic cyst. This case highlights the fact that not every subphrenic collection associated with parapneumonic effusion is a communicated collection formed by seeding. Such a collection can instead be an incidental cyst, which is congenital in origin and known as a mesothelial diaphragmatic cyst. A diaphragmatic mesothelial cyst is an uncommon benign congenital cyst that is unrelated to an adjacent parapneumonic effusion. It is usually incidental and can be monitored without invasive intervention.

Successful Interventional Treatment of Pyopneumothorax Caused by Streptococcus constellatus Associated with Hashimoto's Thyroiditis: A Case Report and Literature Review

Background

Streptococcus constellatus rarely causes pyopneumothorax, which is a serious state and requires a surgery. However, not every patient can tolerate surgery and individualized solutions are needed. Furthermore, many known situations are risk factors of S. constellatus infection, but S. constellatus pyopneumothorax associated with Hashimoto's thyroiditis has not been reported.

Case Presentation

We present the case of a 74-year-old male with multiple encapsulated pyopneumothorax caused by S. constellatus. Given his respiratory failure, we provided two-stage percutaneous right empyema radiography for catheter drainage in the radiology interventional department instead of surgery. Moreover, an occult Hashimoto's thyroiditis was discovered in the patient, which was possibly associated with S. constellatus pyopneumothorax. Levothyroxine was administered to improve his situation.

Conclusion

To our knowledge, it is the first case described in this context. We provided an alternative treatment for S. constellatus encapsulated pyopneumothorax in patient who might not tolerate surgery. We also revealed the possible relationship between S. constellatus pyopneumothorax and Hashimoto's thyroiditis.

Severe pneumonia with empyema caused by Parvimonas micra and Streptococcus constellatus co-infection: a case report

Empyema is a common complication of pneumonia, caused by the accumulation of purulent exudate due to pathogenic bacteria invading the pleural cavity. Parvimonas micra and Streptococcus constellatus are pathogens that rarely cause pneumonia with empyema. Herein, a case of severe empyema caused by these two pathogens, confirmed by metagenomic next-generation sequencing (mNGS) of pleural effusion cultures, is reported. A male Chinese patient in his late sixties presented with wheezing, cough, sputum expectoration, and fever. Blood and sputum cultures were negative for pathogens, but the pleural effusion culture was positive for S. constellatus, and was also found to contain P. micra, confirmed by mNGS. The patient's symptoms improved after treatment with cefoperazone/sulbactam and moxifloxacin. Pneumonia caused by P. micra and S. constellatus is rare; however, coinfection with these pathogens may cause severe pneumonia, with or without empyema.

Video-Assisted-Thoracoscopic-Surgery Pleural Decorticator for Emergency Empyema Surgery

BACKGROUND/NEED

Pleural empyemas carry a high morbidity and mortality. Some can be managed with medical treatment but most require some form of surgery with the goals to remove the infected material from the pleural space and to help re-expand the collapsed lung. Keyhole surgery by Video Assisted Thoracoscopy Surgery (VATS) is rapidly becoming a common approach to deal with early stage empyemas to avoid larger, more painful thoracotomies that hinder recovery. However, the ability to achieve those aforementioned goals is often hindered by VATS surgery due to the instruments available.

METHODOLOGY AND DEVICE DESCRIPTION

We have developed a simple instrument called the "VATS Pleural Debrider" to achieve those goals in empyema surgery that can be used in keyhole surgery.

PRELIMINARY RESULTS

We have used this device in over 90 patients with no peri-operative mortality and a low re-operation rate.

CURRENT STATUS

Used in routine urgent/emergency pleural empyema surgery across 2 cardiothoracic surgery centres.

The diagnostic value of interleukin-36 cytokines in pleural effusions of varying etiologies

BACKGROUND

The clinical management of pleural effusion (PE) poses challenges due to its diverse etiologies. The objective of this research was to investigate the concentrations of interleukin-36 (IL-36) cytokines in pleural fluid (PF) from different etiologies and assess their diagnostic efficacy in distinguishing the causes of PE.

METHODS

This study enrolled 89 patients with confirmed PE, comprising 11 cases classified as transudate, 24 cases as malignant pleural effusion (MPE), 24 cases as tuberculous pleural effusion (TPE), and 30 cases as parapneumonic pleural effusion (PPE). The PPE group was further subdivided into 20 cases of uncomplicated parapneumonic effusion (UPPE) and 10 cases of complicated parapneumonic effusion (CPPE)/empyema. The concentrations of IL-36 cytokines in the PF of all 89 patients were quantified by the enzyme-linked immunosorbent assay (ELISA).

RESULTS

IL-36α exhibited excellent diagnostic accuracy in TPE, achieving a sensitivity of 91.7 % and specificity of 83.1 %, along with a cut-off value of 435.3 pg/ml. IL-36Ra also demonstrated relatively favorable diagnostic performance in PPE, with a sensitivity of 80.0 % and specificity of 76.3 %, along with a cut-off value of 390.8 pg/ml. Multivariable logistic regression models were successfully developed for both TPE and PPE, confirming their diagnostic utility. Furthermore, the levels of IL-36Ra were notably elevated in CPPE/empyema in comparison to UPPE. Moreover, in PF, IL-36γ exhibited positive associations with both IL-36α and IL-36Ra.

CONCLUSION

IL-36α and IL-36Ra may serve as novel biomarkers for diagnosing TPE and PPE, respectively. The multivariate models established significantly enhance the diagnostic efficacy of both TPE and PPE. Furthermore, IL-36Ra can function as an indicator for assessing the extent of pleural inflammation. Additionally, the interaction among IL-36 cytokines in PF may contribute to their expression modulation.

Point-of-Care Thoracic Ultrasound in Children: New Advances in Pediatric Emergency Setting

Point-of-care thoracic ultrasound at the patient's bedside has increased significantly recently, especially in pediatric settings. Its low cost, rapidity, simplicity, and repeatability make it a practical examination to guide diagnosis and treatment choices, especially in pediatric emergency departments. The fields of application of this innovative imaging method are many and include primarily the study of lungs but also that of the heart, diaphragm, and vessels. This manuscript aims to describe the most important evidence for using thoracic ultrasound in the pediatric emergency setting.

Diagnostic value of soluble biomarkers for parapneumonic pleural effusion

Parapneumonic pleural effusion (PPE) is a common complication in patients with pneumonia. Timely and accurate diagnosis of PPE is of great value for its management. Measurement of biomarkers in circulating and pleural fluid have the advantages of easy accessibility, short turn-around time, objectiveness and low cost and thus have utility for PPE diagnosis and stratification. To date, many biomarkers have been reported to be of value for the management of PPE. Here, we review the values of pleural fluid and circulating biomarkers for the diagnosis and stratification PPE. The biomarkers discussed are C-reactive protein, procalcitonin, presepsin, soluble triggering receptor expressed on myeloid cells 1, lipopolysaccharide-binding protein, inflammatory markers, serum amyloid A, soluble urokinase plasminogen activator receptor, matrix metalloproteinases, pentraxin-3 and cell-free DNA. We found that none of the available biomarkers has adequate performance for diagnosing and stratifying PPE. Therefore, further work is needed to identify and validate novel biomarkers, and their combinations, for the management of PPE.

Diagnostic accuracy of pleural fluid to serum carcinoembryonic antigen ratio and delta value for malignant pleural effusion: findings from two cohorts

BACKGROUND

Pleural fluid (PF) carcinoembryonic antigen (CEA) is a widely used diagnostic marker for malignant pleural effusion (MPE). Recent studies revealed that PF to serum CEA was also a promising diagnostic parameter for MPE.

OBJECTIVE

We aimed to investigate whether PF to serum CEA ratio and delta CEA (PF minus serum CEA) provided added value to PF CEA in diagnosing MPE.

METHODS

Patients with pleural effusion in a retrospective cohort (BUFF) and a prospective cohort (SIMPLE) were included. The clinical characteristics of the patients were extracted from their medical records. The diagnostic value of CEA ratio and delta CEA was estimated by a receiver operating characteristics (ROC) curve, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

RESULTS

A total of 148 patients in the BUFF cohort and 164 patients in the SIMPLE cohort were enrolled. The BUFF cohort had 46 MPE patients and 102 benign pleural effusion (BPE) patients, and the SIMPLE cohort had 85 MPE patients and 79 BPE patients. In both cohorts, MPE patients had significantly higher PF CEA, serum CEA, CEA ratio, and delta CEA. The area under ROC curves (AUCs) of PF CEA, CEA ratio, and delta CEA were 0.78 (95% CI: 0.67-0.88), 0.80 (95% CI: 0.72-0.89) and 0.83 (95% CI: 0.75-0.91) in the BUFF cohort, and 0.89 (95% CI: 0.83-0.94), 0.86 (95% CI: 0.80-0.92), and 0.84 (95% CI: 0.78-0.91) in the SIMPLE cohort. The differences between the AUCs of PF CEA, CEA ratio, and delta CEA did not reach statistical significance. The continuous NRI and IDI of CEA ratio and delta CEA were <0.

CONCLUSION

CEA ratio and delta value cannot provide added diagnostic value to PF CEA. The simultaneous determination of serum and PF CEA should not be adopted in clinical practice.

A novel biomarker for pleural effusion diagnosis: Interleukin-36γ in pleural fluid

BACKGROUND

Numerous studies have described the critical importance of interleukin (IL) -36γ in host defense against lung infections, but it is unknown whether it plays a role in infectious pleural effusion (IPE). This study aimed to examine the levels of IL-36γ in pleural effusions of different etiologies and evaluate the diagnostic accuracy of IL-36γ in the differential diagnosis of IPE.

METHODS

A total of 112 individuals was enrolled in this research. IL-36γ levels in pleural fluids of all 112 patients were measured by enzyme-linked immunosorbent assay (ELISA). We also characterized these markers' diagnostic values across various groups.

RESULTS

Patients with tuberculous pleural effusion (TPE) and parapneumonic effusion (PPE) had exhibited markedly higher IL-36γ levels in their pleural fluid than the malignant pleural effusion (MPE) and transudative effusion patients. Furthermore, the IL-36γ concentrations in TPE patients were evidently higher than in uncomplicated parapneumonic effusion (UPPE) patients but significantly lower than in complicated parapneumonic effusion (CPPE)/empyema patients. Pleural fluid IL-36γ is a useful marker to differentiate TPE from UPPE, at a cut-off value for 657.5 pg/ml (area under the curve = 0.904, p < 0.0001) with 70.0% sensitivity and 95.7% specificity.

CONCLUSIONS

The elevated IL-36γ in pleural effusion may be used as a novel biomarker for infectious pleural effusion diagnosis, particularly in patients with CPPE/empyema, and is a potentially promising biomarker to differentiate between TPE and UPPE.

Pleural fluid biochemical analysis: the past, present and future

Identifying the cause of pleural effusion is challenging for pulmonologists. Imaging, biopsy, microbiology and biochemical analyses are routinely used for diagnosing pleural effusion. Among these diagnostic tools, biochemical analyses are promising because they have the advantages of low cost, minimal invasiveness, observer independence and short turn-around time. Here, we reviewed the past, present and future of pleural fluid biochemical analysis. We reviewed the history of Light’s criteria and its modifications and the current status of biomarkers for heart failure, malignant pleural effusion, tuberculosis pleural effusion and parapneumonic pleural effusion. In addition, we anticipate the future of pleural fluid biochemical analysis, including the utility of machine learning, molecular diagnosis and high-throughput technologies. Clinical Chemistry and Laboratory Medicine (CCLM) should address the topic of pleural fluid biochemical analysis in the future to promote specific knowledge in the laboratory professional community.

Implementation of evidence on management of pleural diseases: insights from a territory-wide survey of clinicians in Hong Kong

BACKGROUND

Major advances in management of common pleural diseases have taken place in the past decade. However, pleural diseases are often managed by physicians of diverse training background and research on implementation of new knowledge is scanty. We aim to evaluate the practice pattern in pleural medicine among physicians in Hong Kong, for identification of possible gaps for clinical service improvement.

METHODS

The Hong Kong Thoracic Society undertook a cross-sectional questionnaire survey in 2019, targeting clinicians of various subspecialties in internal medicine and levels of experience (basic and higher trainees, specialists) from twelve regional hospitals of diverse service scopes throughout Hong Kong. Respondents were selected by non-probability quota sampling. The questionnaire tool consisted of 46 questions covering diagnostic and therapeutic aspects of common pleural diseases. The responses were anonymous, and analysed independently using SPSS statistics software.

RESULTS

The survey collected 129 responses, 47(36%) were from clinicians specialized in respiratory medicine. Majority of the respondents (98%) managed pleural diseases, including performing pleural procedures in their practice. Fifty-five percent of all the respondents had not received any formal training in transthoracic ultrasonography. A significant proportion of clinicians were unaware of pleuroscopy for investigation of exudative pleural effusion, indwelling pleural catheter for recurrent malignant pleural effusion, and combined intra-pleural Alteplase plus DNase for treatment of pleural infection (30%, 15% and 70% of non-respiratory clinicians respectively). Significant heterogeneity was found in the management of pleural infection, malignant pleural effusion and pneumothorax among respiratory versus non-respiratory clinicians. Contributing factors to the observed heterogeneity included lack of awareness or training, limited accessibility of drugs, devices, or dedicated service support.

CONCLUSION

Significant heterogeneity in management of pleural diseases was observed among medical clinicians in Hong Kong. Continuous medical education and training provision for both specialists and non-specialists has to be strengthened to enhance the implementation of advances, improve quality and equity of healthcare provision in pleural medicine.

DNase inhibits early biofilm formation in Pseudomonas aeruginosa- or Staphylococcus aureus-induced empyema models

Anti-infection strategies against pleural empyema include the use of antibiotics and drainage treatments, but bacterial eradication rates remain low. A major challenge is the formation of biofilms in the pleural cavity. DNase has antibiofilm efficacy in vitro, and intrapleural therapy with DNase is recommended to treat pleural empyema, but the relevant mechanisms remain limited. Our aim was to investigate whether DNase I inhibit the early biofilm formation in Pseudomonas aeruginosa- or Staphylococcus aureus-induced empyema models. We used various assays, such as crystal violet staining, confocal laser scanning microscopy (CLSM) analysis, peptide nucleic acid-fluorescence in situ hybridization (PNA-FISH), and scanning electron microscopy (SEM) analysis. Our results suggested that DNase I significantly inhibited early biofilm formation in a dose-dependent manner, without affecting the growth of P. aeruginosa or S. aureus in vitro. CLSM analysis confirmed that DNase I decreased the biomass and thickness of both bacterial biofilms. The PNA-FISH and SEM analyses also revealed that DNase I inhibited early (24h) biofilm formation in two empyema models. Thus, the results indicated that DNase inhibited early (24h) biofilm formation in P. aeruginosa- or S. aureus-induced rabbit empyema models and showed its therapeutic potential against empyema biofilms.

Analysis of antibiotic use and clinical outcomes in adults with known and suspected pleural empyema

Background

There is not a prevailing consensus on appropriate antibiotic choice, route, and duration in the treatment of bacterial pleural empyema after appropriate source control. Professional society guidelines note the lack of comparative trials with which to guide recommendations. We assessed clinical outcomes in the treatment of known and suspected empyema based upon three aspects of antibiotic use: (1) total duration, (2) duration of intravenous (IV) antibiotics, and (3) duration of anti-anaerobic antibiotics.

Methods

We performed a hypothesis-generating retrospective chart review analysis of 355 adult inpatients who had pleural drainage, via either chest tube or surgical intervention, for known or suspected empyema. The primary outcome variable was clinician assessment of resolution or lack thereof. The secondary outcomes were death within 90 days, hospital readmission within 30 days for empyema, and all-cause hospital readmission within 30 days. Mann-Whitney U test was used to compare outcomes with regard to these variables.

Results

None of the independent variables was significantly associated with a difference in clinical resolution rate despite trends for total antibiotic duration and anti-anaerobic antibiotic duration. None of the independent variables was associated with mortality. Longer total antibiotic duration was associated with lower readmission rate for empyema (median 17 [interquartile range 11–28] antibiotic days in non-readmission group vs. 13 [6-15] days in readmission group), with a non-significant trend for all-cause readmission rate (17 [11–28] days vs. 14 [9–21] days). IV antibiotic duration was not associated with a difference in any of the defined outcomes. Longer duration of anti-anaerobic antibiotics was associated with both lower all-cause readmission (8.5 [0–17] vs. 2 [0–11]) and lower readmission rate for empyema (8 [0–17] vs. 2 [0–3]).

Conclusion

Our data support the premise that routine use of anti-anaerobic antibiotics is indicated in the treatment of pleural empyema. However, our study casts doubt on the benefits of extended IV rather than oral antibiotics in the treatment of empyema. This represents a target for future investigation that could potentially limit complications associated with the excessive use of IV antibiotics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07759-8.