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Carneiro DC, Duarte D'Ambrosio P, Mariani AW, Fonini JS, Aguirre GKZ, Carneiro Leão JP, Schmidt Júnior AF, Bedawi EO, Rahman NM, Manuel Pêgo-Fernandes P. Evaluation of the RAPID score as a predictor of postoperative morbidity and mortality in patients undergoing pulmonary decortication for stage III pleural empyema. Clinics (Sao Paulo) 2024; 79:100356. [PMID: 38608555 PMCID: PMC11019092 DOI: 10.1016/j.clinsp.2024.100356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/22/2024] [Accepted: 03/24/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE This study aims to correlate the RAPID score with the 3-month survival and surgical results of patients undergoing lung decortication with stage III pleural empyema. METHODS This was a retrospective study with the population of patients with pleural empyema who underwent pulmonary decortication between January 2019 and June 2022. Data were collected from the institution's database, and patients were classified as low, medium, and high risk according to the RAPID score. The primary outcome was 3-month mortality. Secondary outcomes were the length of hospital stay, readmission rate, and the need for pleural re-intervention. RESULTS Of the 34 patients with pleural empyema, according to the RAPID score, patients were stratified into low risk (23.5 %), medium risk (47.1 %), and high risk (29.4 %). The high-risk group had a 3-month mortality of 40 %, while the moderate-risk group had a 6.25 % and the low-risk group had no deaths within 90 days, confirming a good correlation with the RAPID score (p < 0.05). Sensitivity and specificity for the primary outcome in the high-risk score were 80.0 % and 79.3 %, respectively. The secondary outcomes did not reach statistical significance. CONCLUSIONS In this retrospective series, the RAPID score had a good correlation with 3-month mortality in patients undergoing lung decortication. The morbidity indicators did not reach statistical significance. The present data justifies further studies to explore the capacity of the RAPID score to be used as a selection tool for treatment modality in patients with stage III pleural empyema.
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Affiliation(s)
- Danilo Caribé Carneiro
- Thoracic Surgery Resident, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Paula Duarte D'Ambrosio
- Thoracic Surgery Departament, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Alessandro Wasum Mariani
- Thoracic Surgery Departament, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Jaqueline Schaparini Fonini
- Thoracic Surgery Resident, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Gabriela Ketherine Zurita Aguirre
- Thoracic Surgery Resident, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - João Pedro Carneiro Leão
- Thoracic Surgery Resident, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Aurelino Fernandes Schmidt Júnior
- Thoracic Surgery Departament, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Eihab O Bedawi
- Department of Infection, Immunity and Cardiovascular Disease (IICD), University of Sheffield, Sheffield, United Kingdom of Great Britain and Northern Ireland United Kingdom; Department of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom of Great Britain and Northern Ireland United Kingdom
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom of Great Britain and Northern Ireland United Kingdom; Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom of Great Britain and Northern Ireland United Kingdom
| | - Paulo Manuel Pêgo-Fernandes
- Thoracic Surgery Departament, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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Hammoud M, Ammoury C, Iskandar C, Aoun E, Eid R, Sayad E. Case report of parapneumonic effusion and mesothelial subdiaphragmatic cyst: relationship or coincidence? J Int Med Res 2024; 52:3000605241235026. [PMID: 38497143 PMCID: PMC10946073 DOI: 10.1177/03000605241235026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/08/2024] [Indexed: 03/19/2024] Open
Abstract
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.
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Affiliation(s)
- Mohamad Hammoud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Carl Ammoury
- Department of Pediatrics, Gilbert and Rose-Marie Chagoury School of Medicine and LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon
| | - Charbel Iskandar
- Department of Pediatrics, Gilbert and Rose-Marie Chagoury School of Medicine and LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon
| | - Eliane Aoun
- Department of Pediatrics, Gilbert and Rose-Marie Chagoury School of Medicine and LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon
| | - Reem Eid
- Department of Pediatrics, Gilbert and Rose-Marie Chagoury School of Medicine and LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon
| | - Edouard Sayad
- Department of Pediatrics, Gilbert and Rose-Marie Chagoury School of Medicine and LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon
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Emmanuel GM, Chady A, Antony S. Fusobacterium/Peptostreptococcus - A Case Report of Community- Acquired Empyema Resulting in Surgical Decortication with Prolonged Antibiotic Therapy: A Case Series and Review of the Literature. Infect Disord Drug Targets 2024; 24:53-57. [PMID: 38178665 DOI: 10.2174/0118715265255809231107100450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/28/2023] [Accepted: 09/01/2023] [Indexed: 01/06/2024]
Abstract
Background: Infections caused by anaerobic bacteria occur frequently and can be serious and life-threatening. Anaerobes are a rare cause of community-acquired pneumonia with Streptococcus pneumonia and respiratory viruses being the most frequently detected pathogens. We, herein, report a case of Fusobacterium/Peptostreptococcus parapneumonic effusion with empyema in a patient without risk factors for aspiration pneumonia. This case presents an opportunity to discuss an unusual case of community-acquired empyema secondary to anaerobic infection in a patient without the common risk factors for aspiration. Case Presentation: A 59-year-old male patient without significant past medical history apart from a twenty-five-year history of smoking presented due to left flank pain and shortness of breath. Findings of a complicated parapneumonic effusion were found on imaging, resulting in surgical decortication and prolonged antibiotic therapy. Discussion: Parapneumonic effusions and empyema are relatively common complications of pneumonia. It is important to note that the incidence of anaerobic empyema has been on the rise due to more modern culturing techniques. Conclusion: This case highlights an unusual presentation of community-acquired empyema secondary to anaerobes without any risk factors for aspiration pneumonia. Therefore, clinicians should consider the possibility of anaerobic coverage in the treatment of community-acquired empyema in the appropriate setting. .
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Affiliation(s)
- Garrastegui-Mercado Emmanuel
- Department of Internal Medicine, HCA Healthcare Las Palmas/Del Sol Internal Medicine Program, El Paso, Texasc, USA
| | - Awad Chady
- Department of Internal Medicine, HCA Healthcare Las Palmas/Del Sol Internal Medicine Program, El Paso, Texasc, USA
| | - Suresh Antony
- Department of Internal Medicine, HCA Healthcare Las Palmas/Del Sol Internal Medicine Program, El Paso, Texasc, USA
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Papachristidou S, Lapea V, Charisi M, Kourkouni E, Kousi D, Xirogianni A, Dedousi O, Papaconstadopoulos I, Eleftheriou E, Krepis P, Pasparaki S, Pantalos G, Doudoulakakis A, Bozavoutoglou E, Daskalaki M, Kostaridou-Nikolopoulou S, Tzanakaki G, Spoulou V, Tsolia M. A multicenter study on the epidemiology of complicated parapneumonic effusion in the era of currently available pneumococcal conjugate vaccines. Vaccine 2023; 41:6727-6733. [PMID: 37805358 DOI: 10.1016/j.vaccine.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Parapneumonic effusion (PPE) is a common complication of pneumonia. Streptococcus pneumoniae is the most common cause of bacterial pneumonia. A reduction in pneumonia hospitalizations has been observed since the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). Despite this apparent benefit, an increase in the incidence of PPE was recorded in some countries following PCV7 implementation. As the 13-valent pneumococcal conjugate vaccine (PCV13) was expected to provide a wider protection against PPE, the aim of the present study was to evaluate the impact of PCV13 introduction on the epidemiology of complicated parapneumonic effusion (c-PPE) among children in the Athens greater area. METHODS All cases of community-acquired pneumonia (CAP) with PPE requiring chest tube insertion (complicated PPE, c-PPE) hospitalized in the 3 public Children's hospitals in Athens between 01/01/2004 and 31/12/2019 were included in the study. RESULTS A total of 426 cases of c-PPE associated with pneumonia were recorded of which 198 were admitted during 2004-2010 (period A, prePCV13/PCV -7 introduction period) and 228 during 2011-2018 (period B, post - PCV13 period). A definite bacterial etiology was established in 44.4 % of all cases and of those 25.4 % were caused by S. pneumoniae. An increasing trend in c-PPE incidence was observed during period A; although, a significant decrease on c-PPE annual rates was observed during the period B (p = 0.011), a remarkable increase in serotype 3 cases was recorded. CONCLUSION A decreasing time trend in c-PPE cases among children was shown after the introduction of PCV13 in our area. However, serotype 3 is nowadays a common cause of PPE. Hence, continuous surveillance is imperative in order to follow c-PPE epidemiology over time.
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Affiliation(s)
- Smaragda Papachristidou
- Second Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), P.& A. Kyriakou Children's Hospital, Athens, Greece.
| | - Vasiliki Lapea
- First Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), Aghia Sophia Children's Hospital, Athens, Greece
| | - Martha Charisi
- Department of Paediatrics, Penteli Children's Hospital, Athens, Greece
| | - Eleni Kourkouni
- Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece
| | - Dimitra Kousi
- Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece
| | - Athanasia Xirogianni
- National Meningitis Reference Laboratory, Dept of Public Health Policy, School of Public Health, University of West Attica, Athens, Greece
| | - Olga Dedousi
- Second Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), P.& A. Kyriakou Children's Hospital, Athens, Greece
| | - Irene Papaconstadopoulos
- First Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), Aghia Sophia Children's Hospital, Athens, Greece
| | - Eirini Eleftheriou
- Second Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), P.& A. Kyriakou Children's Hospital, Athens, Greece
| | - Panagiotis Krepis
- Second Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), P.& A. Kyriakou Children's Hospital, Athens, Greece
| | - Sophia Pasparaki
- Second Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), P.& A. Kyriakou Children's Hospital, Athens, Greece
| | - Georgios Pantalos
- Pediatric Intensive Care Unit, Penteli's Children Hospital, Penteli, Greece
| | | | | | - Maria Daskalaki
- Microbiology Laboratory, Penteli Children's Hospital, Athens, Greece
| | | | - Georgina Tzanakaki
- National Meningitis Reference Laboratory, Dept of Public Health Policy, School of Public Health, University of West Attica, Athens, Greece
| | - Vana Spoulou
- First Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), Aghia Sophia Children's Hospital, Athens, Greece
| | - Maria Tsolia
- Second Department of Paediatrics, School of Medicine, National and Kapodistrian University of Athens (NKUA), P.& A. Kyriakou Children's Hospital, Athens, Greece
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Tsukamoto Y, Odaka M, Nakada T, Yabe M, Harada E, Akiba T, Toya N, Ohtsuka T. Comparative study of local versus general anesthesia in video-assisted thoracoscopic surgery for empyema. Asian J Surg 2023; 46:4208-4214. [PMID: 36504150 DOI: 10.1016/j.asjsur.2022.11.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/17/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This study evaluated the feasibility of performing non-intubated video-assisted thoracoscopic surgery (VATS) with local anesthesia for parapneumonic effusion and empyema resistant to conservative treatment. METHODS We retrospectively reviewed 80 patients who underwent surgery for parapneumonic effusions and empyema between 2015 and 2021. Patients were divided into those who received non-intubated local anesthesia and general anesthesia during surgery. Patient demographics, characteristics, laboratory findings, treatment progress, and treatment outcomes were compared. The primary outcomes were duration of postoperative drainage, postoperative complication rate, and postoperative mortality rate within 30 days. RESULTS Among patients who received local (n = 21) and general anesthesia (n = 59), there was a significant difference in age (median 79.0 years [interquartile range (IQR) 77.0-80.0] vs. 68.0 years [IQR 54.5-77.5]; p < 0.001), preoperative performance status (3.0 [IQR 2.0-4.0] vs. 2.0 [IQR 1.0-3.0]; p < 0.001), and operative time (69 min [IQR 50-128] vs. 150 min [IQR 107-198]; p < 0.001) but not in preoperative white blood cell count (12,100/μL [IQR 8,400-18000] vs. 12,220/μL [IQR 8,950-16,724]; p = 0.840), C-reactive protein (15.2 mg/dL [8.8-21.3] vs. 17.9 mg/dL [IQR 9.5-23.6]; p = 0.623), postoperative drainage period (11 days [IQR 7-14] vs. 9 days [7-13]; p = 0.216), postoperative hospital stay (22 days [IQR 16-53] vs. 18 days [IQR 12-26]; p = 0.094), reoperation rate (9.5% vs. 15.3%; p = 0.775), postoperative complication rate (19.0% vs. 18.6%; p = 0.132), or postoperative 30-day mortality rate (4.8% vs. 0%; p = 0.587). CONCLUSIONS VATS using local anesthesia is feasible for patients with treatment-resistant parapneumonic effusion and empyema with poor general condition.
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Affiliation(s)
- Yo Tsukamoto
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan.
| | - Makoto Odaka
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Takeo Nakada
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Mitsuo Yabe
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Eriko Harada
- Department of Surgery, The Jikei University Hospital, Nishishinbashi 3-19-18, Minatoku, Tokyo, 105-8471, Japan
| | - Tadashi Akiba
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Naoki Toya
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Takashi Ohtsuka
- Department of Surgery, The Jikei University Hospital, Nishishinbashi 3-19-18, Minatoku, Tokyo, 105-8471, Japan
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Johansson N, Andersson Ydsten K, Backman-Johansson C, Vondracek M, Hedlund J. Measurement of lactate in pleural fluid rapidly identify infection and guide therapy. Infect Dis (Lond) 2023; 55:396-404. [PMID: 37021765 DOI: 10.1080/23744235.2023.2192278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Measurements of pleural fluid biomarkers for rapid identification of complicated parapneumonic effusion (CPPE) are crucial for optimal management. Previous studies for biomarker evaluation were however based on pleura culture, not modern DNA technique. Lactate has not been thoroughly studied earlier as a potential biomarker in this regard. OBJECTIVES To evaluate whether the routine biomarkers pH, glucose, lactate dehydrogenase (LDH) measured in pleural fluid in a microbiological well characterised cohort could differentiate simple parapneumonic effusion (SPPE) from CPPE and if pleural fluid lactate could be of additional use in this discrimination. METHODS Pleural fluid prospectively collected from adult patients (n = 112) with PPE admitted to the Departments of Infectious Diseases (DIDs) at four Stockholm County hospitals were characterised microbiologically with bacterial culture and 16S rDNA sequencing, and biochemically with pH, glucose, LDH and lactate. RESULTS Forty and seventy two patients were categorised as SPPE/CPPE. The median values between SPPE/CPPE differed significantly for all biomarkers with varying overlap. Receiver operating characteristics (ROC) curves showed the area under the curve (AUC) for pH 0.905 (CI 0.847-0.963), glucose 0.861 (CI 0.79-0.932), LDH 0.917 (CI 0.860-0.974) and lactate 0.927 (CI 0.877-0.977), corresponding to best cut-off levels and sensitivity/specificity for pH of 7.255, 0.819/0.9, glucose 5.35 mmol/L, 0.847/0.775, LDH 9.8 µcat/L, 0.905/0.825 and lactate 4.9 mmol/L, 0.875/0.85. CONCLUSIONS To distinguish between SPPE/CPPE, pH and LDH performed well, but optimal cut-off values differed from earlier established recommendations. Pleura lactate had the largest AUC of the investigated biomarkers and may be used in the analyses of PPE-staging.
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Affiliation(s)
- Niclas Johansson
- Department of Medicine, Karolinska Institutet, Division of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Solna, Sweden
| | - Karin Andersson Ydsten
- Department of Medicine, Karolinska Institutet, Division of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Solna, Sweden
| | | | - Martin Vondracek
- Department of Clinical Microbiology, Karolinska University Hospital, Solna, Sweden
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Hedlund
- Department of Medicine, Karolinska Institutet, Division of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Solna, Sweden
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Yukumi S, Ishimaru K, Suzuki H, Abe M, Morimoto M, Senba M, Yamamoto T, Mori Y, Sakao N, Sano Y. Duration of antimicrobial therapy after video-assisted thoracoscopic surgery for thoracic empyema and complicated parapneumonic effusion: A single-center study. Respir Investig 2023; 61:110-5. [PMID: 36470803 DOI: 10.1016/j.resinv.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/08/2022] [Accepted: 11/02/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND There are no evidence-based reports on the proper duration of antimicrobial therapy following video-assisted thoracoscopic surgery debridement (VATS-D) in thoracic empyema (TE) or complicated parapneumonic effusion (PPE). This study aimed to investigate the optimal duration of antimicrobial therapy after VATS-D. METHODS Between January 2011 and December 2019, 33 patients corresponding to American College of Chest Physicians (ACCP) category 3 or 4 undergoing VATS-D were included. The times until the body temperature (BT) was confirmed to be less than 37.5 °C and 37.0 °C, white blood cell count (WBC) less than 10,000/μl, segmented neutrophils (seg) less than 80%, and C-reactive protein (CRP) level less than 25% of the preoperative value were retrospectively analyzed. RESULTS The median time from the onset of TE/PPE to surgery was 13 days. The median durations of preoperative and postoperative antibiotic use were five and seven days, respectively. Major complications occurred in four cases (three and one cases of respiratory failure and cerebral infarction, respectively). The median postoperative hospital stay was 14 days. Recurrence or progression to chronic empyema was seen in four cases. The median numbers of days until the conditions were met were three days for BT < 37.5 °C, six days for BT < 37.0 °C, four days for WBC<10,000, seven days for seg<80% and seven days for CRP<25%. CONCLUSIONS The proper duration of antimicrobial therapy after VATS-D for TE/PPE is approximately three to seven days. Urgent VATS-D may shorten the total antibiotic usage.
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Townsend A, Raju H, Serpa KA, Pruett R, Razi SS, Tarrazzi FA, Tami CM, Block MI. Tissue plasminogen activator with prolonged dwell time effectively evacuates pleural effusions. BMC Pulm Med 2022; 22:464. [PMID: 36471325 PMCID: PMC9724361 DOI: 10.1186/s12890-022-02261-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/24/2022] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Fibrinolytic therapy can be effective for management of complex pleural effusions. Tissue plasminogen activator (tPA, 10 mg) and deoxyribonuclease (DNAse) every 12 h with a dwell time of one hour is a common strategy based on published data. We used a simpler protocol of tPA (4 mg) without DNAse but with a longer dwell time of 12 h, repeated daily. We reviewed our results. METHODS Charts were reviewed and demographics, clinical data and treatment information were abstracted. Outcomes were assessed based on radiographic findings and need for surgery. RESULTS Two hundred and fifteen effusions in 207 patients (8 bilateral) were identified. 85% were either infectious or malignant. Two hundred and forty nine chest tubes were used: 84% were 10 Fr or 12 Fr and 7% were PleurX®. Five hundred and thirty one doses of tPA were given. The median number of doses per effusion was 2 (range 1-10), and 84% of effusions were treated with three or fewer doses. There were no significant bleeding complications. Median time to chest tube removal was 6 days (range 1 to 98, IQR 4 to 10). Drainage was considered complete for 78% of effusions, while 6% required decortication. CONCLUSIONS Low dose tPA daily with a 12 h dwell time may be as effective as the standard regimen of tPA and DNAse twice daily with one hour dwell. For most patients only three doses were required, and small pigtail catheters were sufficient. This regimen uses less medication and is logistically much easier than the current standard.
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Affiliation(s)
- Alexandra Townsend
- grid.65456.340000 0001 2110 1845Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Harsha Raju
- grid.65456.340000 0001 2110 1845Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Krystina A. Serpa
- grid.489080.d0000 0004 0444 4637Division of Thoracic Surgery, Memorial Healthcare System, 1150 N. 35th Ave., Suite 660, Hollywood, FL 33026 USA
| | - Rachel Pruett
- grid.489080.d0000 0004 0444 4637Division of Thoracic Surgery, Memorial Healthcare System, 1150 N. 35th Ave., Suite 660, Hollywood, FL 33026 USA
| | - Syed S. Razi
- grid.489080.d0000 0004 0444 4637Division of Thoracic Surgery, Memorial Healthcare System, 1150 N. 35th Ave., Suite 660, Hollywood, FL 33026 USA
| | - Francisco A. Tarrazzi
- grid.489080.d0000 0004 0444 4637Division of Thoracic Surgery, Memorial Healthcare System, 1150 N. 35th Ave., Suite 660, Hollywood, FL 33026 USA
| | - Catherine M. Tami
- grid.489080.d0000 0004 0444 4637Division of Thoracic Surgery, Memorial Healthcare System, 1150 N. 35th Ave., Suite 660, Hollywood, FL 33026 USA
| | - Mark I. Block
- grid.489080.d0000 0004 0444 4637Division of Thoracic Surgery, Memorial Healthcare System, 1150 N. 35th Ave., Suite 660, Hollywood, FL 33026 USA
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James CA, Lewis PS, Moore MB, Wong K, Rader EK, Roberson PK, Ghaleb NA, Jensen HK, Pezeshkmehr AH, Stroud MH, Ashton DJ. Efficacy of standardizing fibrinolytic therapy for parapneumonic effusion. Pediatr Radiol 2022; 52:2413-2420. [PMID: 35451632 PMCID: PMC9023697 DOI: 10.1007/s00247-022-05365-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/15/2021] [Accepted: 03/21/2022] [Indexed: 10/25/2022]
Abstract
BACKGROUND While chest tube placement with pleural fibrinolytic medication is the established treatment of pediatric empyema, treatment failure is reported in up to 20% of these children. OBJECTIVE Standardizing fibrinolytic administration among interventional radiology (IR) physicians to improve patient outcomes in pediatric parapneumonic effusion. MATERIALS AND METHODS We introduced a hospital-wide clinical pathway for parapneumonic effusion (1-2 mg tissue plasminogen activator [tPA] twice daily based on pleural US grade); we then collected prospective data for IR treatment May 2017 through February 2020. These data included demographics, co-morbidities, pediatric intensive care unit (PICU) admission, pleural US grade, culture results, daily tPA dose average, twice-daily dose days, skipped dose days, pleural therapy days, need for chest CT/a second IR procedure/surgical drainage, and length of stay. We compared the prospective data to historical controls with IR treatment from January 2013 to April 2017. RESULTS Sixty-three children and young adults were treated after clinical pathway implementation. IR referrals increased (P = 0.02) and included higher co-morbidities (P = 0.005) and more PICU patients (P = 0.05). Mean doses per day increased from 1.5 to 1.9 (P < 0.001), twice-daily dose days increased from 38% to 79% (P < 0.001) and median pleural therapy days decreased from 3.5 days to 2.5 days (P = 0.001). No IR patients needed surgical intervention. No statistical differences were observed for gender/age/weight, US grade, need for a second IR procedure or length of stay. US grade correlated with greater positive cultures, need for chest CT/second IR procedure, and pleural therapy days. CONCLUSION Interventional radiology physician standardization improved on a clinical pathway for fibrinolysis of parapneumonic effusion. Despite higher patient complexity, pleural therapy duration decreased. There were no chest tube failures needing surgical drainage.
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Affiliation(s)
- Charles A James
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA.
| | - P Spencer Lewis
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Mary B Moore
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Kevin Wong
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Emily K Rader
- Quality, Risk, and Safety Department, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Paula K Roberson
- Biostatistics Department, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nancy A Ghaleb
- Anesthesia Department, Detroit Medical Center and Wayne State University, Detroit, MI, USA
| | - Hanna K Jensen
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Amir H Pezeshkmehr
- Radiology Department, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Michael H Stroud
- Pediatrics Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Daniel J Ashton
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
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10
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Abstract
The rising incidence and high morbidity of pleural infection remain a significant challenge to health care systems worldwide. With distinct microbiology and treatment paradigms from pneumonia, pleural infection is an area in which the evidence base has been rapidly evolving. Progress in recent years has revolved around characterizing the microbiome of pleural infection and the addition of new strategies such as intrapleural enzyme therapy to the established treatment pathway of drainage and antibiotics. The future of improving outcomes lies with personalizing treatment, establishing optimal timing of intrapleural agents and surgery, alongside wider use of risk stratification to guide treatment.
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Affiliation(s)
- Dinesh N Addala
- Oxford University Hospitals NHS Foundation Trust; Department of Respiratory Medicine, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK.
| | - Eihab O Bedawi
- Oxford University Hospitals NHS Foundation Trust; Department of Respiratory Medicine, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, Headington OX3 9DU, UK
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11
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Hao J, Liu J, Pereira E, Liu R, Zhang J, Zhang Y, Yan K, Gong Y, Zheng J, Zhang J, Liu Y, Zhao Y. Uncertainty-guided graph attention network for parapneumonic effusion diagnosis. Med Image Anal 2021; 75:102217. [PMID: 34775280 DOI: 10.1016/j.media.2021.102217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 01/08/2023]
Abstract
Parapneumonic effusion (PPE) is a common condition that causes death in patients hospitalized with pneumonia. Rapid distinction of complicated PPE (CPPE) from uncomplicated PPE (UPPE) in Computed Tomography (CT) scans is of great importance for the management and medical treatment of PPE. However, UPPE and CPPE display similar appearances in CT scans, and it is challenging to distinguish CPPE from UPPE via a single 2D CT image, whether attempted by a human expert, or by any of the existing disease classification approaches. 3D convolutional neural networks (CNNs) can utilize the entire 3D volume for classification: however, they typically suffer from the intrinsic defect of over-fitting. Therefore, it is important to develop a method that not only overcomes the heavy memory and computational requirements of 3D CNNs, but also leverages the 3D information. In this paper, we propose an uncertainty-guided graph attention network (UG-GAT) that can automatically extract and integrate information from all CT slices in a 3D volume for classification into UPPE, CPPE, and normal control cases. Specifically, we frame the distinction of different cases as a graph classification problem. Each individual is represented as a directed graph with a topological structure, where vertices represent the image features of slices, and edges encode the spatial relationship between them. To estimate the contribution of each slice, we first extract the slice representations with uncertainty, using a Bayesian CNN: we then make use of the uncertainty information to weight each slice during the graph prediction phase in order to enable more reliable decision-making. We construct a dataset consisting of 302 chest CT volumetric data from different subjects (99 UPPE, 99 CPPE and 104 normal control cases) in this study, and to the best of our knowledge, this is the first attempt to classify UPPE, CPPE and normal cases using a deep learning method. Extensive experiments show that our approach is lightweight in demands, and outperforms accepted state-of-the-art methods by a large margin. Code is available at https://github.com/iMED-Lab/UG-GAT.
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12
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Nasralla A, Laing B, Turner SR. The use of fibrinolytic therapy for parapneumonic effusion in pregnancy: a case report and a review. J Cardiothorac Surg 2021; 16:236. [PMID: 34419110 DOI: 10.1186/s13019-021-01619-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/11/2021] [Indexed: 02/05/2023] Open
Abstract
The use of intrapleural fibrinolytics for complicated parapneumonic effusion has been shown to be an effective and safe alternative to surgery. However, there is limited evidence about its use during pregnancy. We present a case and a review of the literature of pregnant women who had successful treatment of their complicated parapneumonic effusion with intrapleural fibrinolytics. To our knowledge this is the first review of cases of pregnant women with parapneumonic effusion managed with intrapleural fibrinolytic.
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13
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Mondoni M, Saderi L, Trogu F, Terraneo S, Carlucci P, Ghelma F, Centanni S, Sotgiu G. Medical thoracoscopy treatment for pleural infections: a systematic review and meta-analysis. BMC Pulm Med 2021; 21:127. [PMID: 33879116 PMCID: PMC8056545 DOI: 10.1186/s12890-021-01492-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background Complicated parapneumonic effusions and empyema represent advanced stages of pleural infections and are characterized by a high mortality. Medical thoracoscopy is a safe and minimally invasive endoscopic technique prescribed to treat severe pleural infections. However, only a few studies evaluated its success rate. A systematic review of observational studies was performed to assess the efficacy of medical thoracoscopy in patients with complicated parapneumonic effusions and empyema, as well as its predictive factors. Methods A search of the scientific evidence was carried out using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials. Articles describing observational studies on medical thoracoscopy in patients with parapneumonic effusions and empyema were selected. Results Eight studies met the inclusion criteria. The pooled treatment success rate of thoracoscopy was 85% (95% CI 80.0–90.0%; I2: 61.8%) when used as first-line intervention or after failure of chest tube. The pooled complication rate was 9.0% (95% CI 6.0–14.0%; I2: 58.8%). A pooled difference of treatment success of 9.0% (95% CI 1.0–18.0%) was found when post-thoracoscopy intra-pleural fibrinolysis was prescribed. Pooled success rate was higher in cases with pleural fluid culture negativity (pooled difference: 14.0%; 95% CI 4.0–24.0%). Conclusions Medical thoracoscopy is effective and safe when prescribed for complicated parapneumonic effusions and empyema. Bacteriological negativity of pleural effusion specimens and administration of adjuvant intra-pleural fibrinolysis after the procedure are associated with a higher success rate. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01492-9.
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Affiliation(s)
- Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi Di Milano, Via Di Rudinì n. 8, 20142, Milan, Italy.
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Federica Trogu
- Clinical Epidemiology and Medical Statistics Unit, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Silvia Terraneo
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi Di Milano, Via Di Rudinì n. 8, 20142, Milan, Italy
| | - Paolo Carlucci
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi Di Milano, Via Di Rudinì n. 8, 20142, Milan, Italy
| | - Filippo Ghelma
- Disabled Advanced Medical Assistance Unit, Department of Health Sciences, San Paolo Hospital, Università Degli Studi Di Milano, Milan, Italy
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi Di Milano, Via Di Rudinì n. 8, 20142, Milan, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
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14
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Gayaf M, Anar C, Canbaz M, Tatar D, Güldaval F. Value of Cancer Ratio plus and Cancer Ratio Formulation in Distinguishing Malignant Pleural Effusion from Tuberculosis and Parapneumonic Effusion. Tanaffos 2021; 20:221-231. [PMID: 35382086 PMCID: PMC8978044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 04/17/2021] [Indexed: 11/03/2022]
Abstract
Background The aim of our study is to determine the clinical availability accessibility of cancer ratio and cancer ratio plus formulations, previously validated and reported to have clinical value in distinguishing malignant pleural effusion from tuberculosis pleurisy and parapneumonic effusion. Materials and Methods Retrospective study of patients hospitalized with Malignant Pleural Effusion (MPE), tuberculosis (TPE) and pararapneumonic effusion (PPE) between 2009 and 2018. Results Totally 232 patients, 101(43.5 %) having MPE, 86 (37.1 %) having PPE and 45 (19.4 %) TPE were examined. When compared with each other, "serum LDH / PS Lymphocyte %", "Cancer ratıo" and "Cancer ratıo plus" values were statistically different between the groups (p = 0.021, p <0.001 and p = 0.015, respectively). In multivariate logistic regression analysis, cancer ratio, serum LDH: pleural fluid lymphocyte count ratio was in positive correlation with MPE. The sensitivity and specificity of "cancer ratio", "cancer ratio plus" and "ratio of serum LDH: pleural fluid lymphocyte count" were 84.2 % (95% CI 75.6- 90.7) and 52.7 (95% CI 43.8- 61.5), and 82.2 % (95% CI 73.3- 89.1) and 45.8 (95%CI 37.1- 54.7), 53.5% (95% CI 43.3- 63.5) and 67.2% (95% CI 0.68-0.94) at the cut-off level of >14.25, >28.7, and >636, respectively. When considering only MPE and TPE patients, the specificity of cancer ratıo and cancer ratıo plus increased. Conclusion The cancer ratio plus rate (the ratio of "cancer ratio"formulation to the percentage of differential pleural lymphocyte count) was almost the same as the cancer ratio in separating the malignant pleural effusion from the TPE and PPE, while it has better specificity only in differentiating malignant effusions from tuberculosis effusions.
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Affiliation(s)
| | - Ceyda Anar
- Correspondence to: Anar C, Address: Department of Chest Diseases, Health Sciences University İzmir Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey, Email address:
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15
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Shiu SI. Parapneumonic Effusion and Tension Pneumothorax after Diverticular Peroral Endoscopic Myotomy in a Woman with Large Epiphrenic Diverticulum: A Case Report and Literature Review. Clin Endosc 2021; 54:275-279. [PMID: 33445820 PMCID: PMC8039732 DOI: 10.5946/ce.2020.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/25/2020] [Indexed: 11/14/2022] Open
Abstract
Esophageal diverticula (ED) represents a group of rare conditions that warrant intervention when they are symptomatic or coexisting with pulmonary disorders. Few literature reviews have described this patient entity or discussed the postoperative outcome. Therefore, I present the case of a 59-year-old woman with symptoms of dysphagia who was significantly underweight, which was conducive to the diagnosis of symptomatic ED. Because she was a poor candidate for surgery, she received a diverticular peroral endoscopic myotomy. She subsequently developed parapneumonic effusion and tension pneumothorax after the procedure. She was finally discharged on postoperative day 23. I also performed the first known comprehensive literature review of 34 published cases (including my patient) from PubMed and have addressed the demography, intervention, and prognosis for symptomatic ED after the procedure. Prompt treatment as well as prognostic measurement are crucial to successful outcomes.
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Affiliation(s)
- Sz-Iuan Shiu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Evidence-based Practice and Policymaking Committee, Taichung Veterans General Hospital, Taichung, Taiwan
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16
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Galliguez T, Tsou PY, Cabrera A, Fergie J. Next-generation sequencing-based clinical metagenomics identifies Prevotella pleuritidis in a diabetic adolescent with large parapneumonic effusion and negative growth of pleural fluid culture: a case report. Br J Biomed Sci 2021; 78:101-105. [PMID: 32993476 DOI: 10.1080/09674845.2020.1827846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We report a 12-year-old diabetic boy with a right-sided parapneumonic effusion and pneumonia who failed initial empirical antibiotics. Prevotella pleuritidis was identified from the pleural fluid using next-generation sequencing-based clinical metagenomics with cultures of pleural fluid and blood resulting negative. The patient responded well to intravenous meropenem followed by oral metronidazole.
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Affiliation(s)
- T Galliguez
- Department of Pediatrics, Driscoll Children's Hospital and College of Medicine, Texas A&M University , Corpus Christi, TX, USA
| | - P Y Tsou
- Department of Pediatrics, Driscoll Children's Hospital and College of Medicine, Texas A&M University , Corpus Christi, TX, USA
| | - A Cabrera
- Department of Pediatrics, Driscoll Children's Hospital and College of Medicine, Texas A&M University , Corpus Christi, TX, USA
| | - J Fergie
- Department of Pediatrics, Driscoll Children's Hospital and College of Medicine, Texas A&M University , Corpus Christi, TX, USA
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17
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Rafailidis V, Andronikou S, Mentzel HJ, Piskunowicz M, Squires JH, Barnewolt CE. Contrast-enhanced ultrasound of pediatric lungs. Pediatr Radiol 2021; 51:2340-2350. [PMID: 33978798 PMCID: PMC8566417 DOI: 10.1007/s00247-020-04914-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/14/2020] [Accepted: 11/09/2020] [Indexed: 12/14/2022]
Abstract
In addition to radiography, ultrasound (US) has long proved to be a valuable imaging modality to evaluate the pediatric lung and pleural cavity. Its many inherent advantages, including real-time performance, high spatial resolution, lack of ionizing radiation and lack of need for sedation make it preferable over other imaging modalities such as CT. Since the introduction of ultrasound contrast agents (UCAs), contrast-enhanced ultrasound (CEUS) has become a valuable complementary US technique, with many well-established uses in adults and evolving uses in children. Lung CEUS applications are still not licensed and are performed off-label, although the added value of CEUS in certain clinical scenarios is increasingly reported. The limited evidence of CEUS in the evaluation of pediatric lungs focuses primarily on community-acquired pneumonia and its complications. In this clinical setting, CEUS is used to confidently and accurately diagnose necrotizing pneumonia and to delineate pleural effusions and empyema. In addition to intravenous use, UCAs can be administered directly into the pleural cavity through chest catheters to improve visualization of loculations within a complex pleural effusion, which might necessitate fibrinolytic therapy. The purpose of this paper is to present the current experience on pediatric lung CEUS and to suggest potential additional uses that can be derived from adult studies.
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Affiliation(s)
- Vasileios Rafailidis
- Department of Radiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Savvas Andronikou
- Department of Radiology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, University Hospital, Jena, Germany
| | | | - Judy H. Squires
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Carol E. Barnewolt
- Department of Radiology, Boston Children’s Hospital, Harvard University, Boston, MA USA
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18
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Diez JRV, Perez MLM, Malayan GV, Cenabre MVL. Loculated empyema in a neonate successfully treated with chest tube thoracostomy and antibiotics. Respir Med Case Rep 2020; 31:101274. [PMID: 33209575 DOI: 10.1016/j.rmcr.2020.101274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/01/2020] [Accepted: 11/01/2020] [Indexed: 11/20/2022] Open
Abstract
Empyema thoracis, defined as the accumulation of pus in the pleural space, is a rare entity in the neonatal period. There are very few cases described in the medical literature and there are still no treatment protocols in the management of empyema in neonates. In older infants and children, intrapleural fibrinolytics and surgery are often utilized since treatment of complicated parapneumonic effusions with chest tube and antibiotics alone often fail due to the viscous fluid and presence of loculations. Presented here is a case of a term neonate who exhibited symptoms of respiratory distress on the sixth day of life. Imaging modalities revealed massive left sided pleural effusion with loculations and mass effects. Pleural fluid was grossly pus and exudative in nature. Gram stain revealed gram-positive cocci but culture was negative. Empiric broad-spectrum antibiotics and chest tube drainage were utilized and patient was discharged after forty-seven days of hospital admission. In spite of prolonged hospital stay, patient survived with no complications. Therefore, nonoperative therapy could still be an option for neonates with loculated empyema. The key to success in treatment is immediate identification of effusion, prompt initiation of antibiotics, and early effective chest tube drainage.
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19
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Hsueh PC, Wu KA, Yang CY, Hsu CW, Wang CL, Hung CM, Chen YT, Yu JS, Wu CC. Metabolomic profiling of parapneumonic effusion reveals a regulatory role of dipeptides in interleukin-8 production in neutrophil-like cells. Anal Chim Acta 2020; 1128:238-250. [PMID: 32825908 DOI: 10.1016/j.aca.2020.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/24/2020] [Accepted: 06/09/2020] [Indexed: 11/16/2022]
Abstract
Bacterial pneumonia is a lethal condition, and approximately 40% of bacterial pneumonia patients experience parapneumonic effusion (PPE). Based on the severity of inflammation, PPEs can be categorized as early-stage uncomplicated PPE (UPPE), advanced-stage complicated PPE (CPPE) and, most seriously, thoracic empyema. Appropriate antibiotic treatment at the early stage of PPE can prevent PPE progression and reduce mortality, indicating that understanding PPE generation and components can help researchers develop corresponding treatment strategies for PPE. To this end, metabolomes of 73 PPE (38 UPPE and 35 CPPE samples) and 30 malignant pleural effusion (MPE) samples were profiled with differential 12C2-/13C2-isotope dansylation labeling-based mass spectrometry. We found that PPE is characterized by elevated levels of dipeptides, especially for PPEs at advanced stages. Furthermore, with integrated proteomic and transcriptomic analyses of PPEs, the levels of dipeptides were strongly associated with the production of interleukin-8 (IL-8), an inflammation-associated cytokine. The production of IL-8 indeed increased upon the treatment of HL-60-derived neutrophilic cells with dipeptides, Gly-Val and Gly-Tyr. Our findings help to elucidate the metabolic perturbations present in PPE and indicate for the first time that dipeptides may be involved in the immune regulation observed during PPE progression.
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Affiliation(s)
- Pei-Chun Hsueh
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuo-An Wu
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan; School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Chia-Yu Yang
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology-Head & Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Department of Microbiology and Immunology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Wei Hsu
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei, Taiwan
| | - Chih-Liang Wang
- Division of Pulmonary Oncology and Interventional Bronchoscopy, Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chu-Mi Hung
- Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Ting Chen
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan; Department of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jau-Song Yu
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Ching Wu
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology-Head & Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Research Center for Emerging Viral Infections, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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20
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Jiang C, Xie M, Cervellione K, Thurm C. Clinical efficacy and bleeding outcomes of tissue plasminogen activator and dornase alfa in pleural space infection with once daily concurrent administration: a retrospective cohort study. BMC Res Notes 2020; 13:368. [PMID: 32746902 PMCID: PMC7398294 DOI: 10.1186/s13104-020-05210-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/28/2020] [Indexed: 12/02/2022] Open
Abstract
Objective The use of intrapleural tissue plasminogen activator (tPA) and dornase alfa (DNase) is common in the management of pleural space infection. We review our experience with the efficacy and safety of this therapy. We performed a single center, retrospective study of consecutive patients with complicated parapneumonic effusion or empyema who received tPA/DNase therapy. Treatment success was defined as radiographic and clinical improvement in pleural space infection that precluded the need for surgical intervention, and the absence of mortality related to pleural infection. Results Fifty-six patients received concurrent once daily tPA/DNase therapy (median 3 days) from July 2014 to July 2019. Fifty-two patients (92.9%) had treatment success. Median duration of chest tube therapy was 10 days and length of stay was 15 days. Significant pleural bleeding requiring transfusion therapy occurred in five patients (8.9%). Of these, three patients (5.4%) required operative intervention. Concurrent once daily administration of tPA/DNase in patients with pleural infection yielded comparable rates of treatment success as compared to twice daily concurrent or sequential administration. However, adverse events highlight potential safety concerns with using once daily concurrent administration of tPA/DNAse.
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Affiliation(s)
- Chuan Jiang
- Department of Medicine-Division of Pulmonary Medicine, Jamaica Hospital Medical Center, Jamaica, NY, 11418, USA.
| | - Meng Xie
- Department of Clinical Research, Jamaica Hospital Medical Center, Jamaica, NY, 11418, USA
| | - Kelly Cervellione
- Department of Clinical Research, Jamaica Hospital Medical Center, Jamaica, NY, 11418, USA
| | - Craig Thurm
- Department of Medicine-Division of Pulmonary Medicine, Jamaica Hospital Medical Center, Jamaica, NY, 11418, USA
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21
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Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins University, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 7353, Baltimore, MD 21287, USA.
| | - Charles M Leys
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, 600 Highland Avenue, H4/740 CSC, Madison, WI 53792-7375, USA
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Ayuk AC, Gray D, Vanker A, Zampoli M. Tuberculosis in children presenting with chylothorax - Report of two cases and review of the literature. Respir Med Case Rep 2019; 27:100848. [PMID: 31049284 DOI: 10.1016/j.rmcr.2019.100848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 12/03/2022] Open
Abstract
One third of the world's population is estimated to be infected with Mycobacterium tuberculosis. Tuberculosis (TB) is endemic in many sub-Saharan African counties. The burden is further made worse by the HIV scourge. The number of children with TB and its attendant complications, is equally on the rise. TB can mimic many diseases ranging from infections to malignancies. Among pleuro-pulmonary TB complications, exudative effusion is more common while chylothorax is rare and thus easily missed especially if not the classical milky appearance. We present two children from a TB endemic region, with microbiologically-confirmed TB presenting with chylothoraces that were initially misdiagnosed as pleural empyema. Tuberculosis in children presenting as chylothorax is uncommon. These cases are instructive as they bring to the fore the importance of a full investigation of pleural effusions in children, to ensure a correct diagnosis and prompt effective management.
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Azzari C, Serranti D, Nieddu F, Moriondo M, Casini A, Lodi L, de Benedictis FM, De Vitis E, Cavone F, Cortimiglia M, Indolfi G, Lombardi E, Carloni I, Cutrera R, Lucenteforte E, Resti M, Ricci S. Significant impact of pneumococcal conjugate vaccination on pediatric parapneumonic effusion: Italy 2006-2018. Vaccine 2019; 37:2704-2711. [PMID: 30981627 DOI: 10.1016/j.vaccine.2019.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 10/27/2022]
Abstract
Etiology and serotyping of parapneumonic effusion (PPE) and the impact of vaccination was evaluated over a 12-year period, before and after the PCV13 introduction (2011) for Italian children From 0 to 16 years of age. Five hundred and two children were evaluated; 226 blood and 356 pleural fluid samples were obtained and tested using Realtime-PCR and culture. In the pre-PCV13 era S. pneumoniae was the most frequent pathogen identified (64/90; 71.1%) with a large predominance of serotypes 1 (42.4%), 3 (23.7%), 7F (5.1%) and 19A (11.9%). The impact of vaccination, calculated on children 0-8 years of age, demonstrated a significant reduction of PPE: with an incidence rate of 2.82 (95%CL 2.32-3.41) in the pre-PCV13 era and an age-standardized rate (ASR) of 0.66 (95% CL 0.37-1.99) in the post-PCV13 era, p < 0.0001. No increase in non-PCV13 serotypes was recorded. S. pneumoniae remained the most frequent pathogen identified in the post-PCV13 era in unvaccinated children with an unchanged serotype distribution: respectively 26/66 (39.4%), 25/66 (37.9%), 5/66 (7.6%), and 4/66 (6.1%) for 1, 3, 7F and 19A. On the other hand 7F and 19A disappeared in vaccinated children and serotype 1 and 3 decreased by 91.8% and 31.5%, respectively. Realtime PCR was significantly more sensitive than culture both in pleural fluid (79.7% vs 12.5%) and in blood (17.8% vs 7.4%). In conclusion, our findings indicate that routine immunization with PCV13 has significantly reduced the burden of childhood PPE in vaccinated children, without increasing PPE due to other bacteria and without serotype shift. Moreover, the impact of PCV13 may be underestimated due to the increase in pneumococcal surveillance in Italy. Data has also shown that Real-time PCR is an essential tool to better define the etiology of PPE and to monitor vaccination plans. Longer studies will be necessary to evaluate the role of herd protection in PPE prevention.
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Affiliation(s)
- Chiara Azzari
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Daniele Serranti
- Department of Pediatrics, Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Francesco Nieddu
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Maria Moriondo
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Arianna Casini
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Lorenzo Lodi
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | | | - Elisa De Vitis
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Federica Cavone
- Department of Pediatrics, Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Martina Cortimiglia
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Giuseppe Indolfi
- Department of Pediatrics, Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Enrico Lombardi
- Department of Pediatrics, Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Ines Carloni
- Pediatric Unit, Salesi Childrens Hospital, Department of Mother and Child Health, Via Filippo Corridoni 10, 60123 Ancona, Italy.
| | - Renato Cutrera
- Ospedale Bambino Gesù, Pediatrics - Respiratory Unit, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Ersilia Lucenteforte
- Medical Statistics, Department of Clinical and Experimental Medicine, University of Pisa, Italy.
| | - Massimo Resti
- Department of Pediatrics, Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
| | - Silvia Ricci
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy.
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Johansson N, Vondracek M, Backman-Johansson C, Sköld MC, Andersson-Ydsten K, Hedlund J. The bacteriology in adult patients with pneumonia and parapneumonic effusions: increased yield with DNA sequencing method. Eur J Clin Microbiol Infect Dis 2018; 38:297-304. [PMID: 30547334 DOI: 10.1007/s10096-018-3426-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/06/2018] [Indexed: 12/25/2022]
Abstract
The aim of this study was to use a 16S rDNA sequencing method in combination with conventional culture in patients with parapneumonic effusions (PPE) to evaluate the methods, study the microbiological spectrum, and examine the presence of bacteria within the different stages of PPE. Adults with community-acquired pneumonia (CAP) and PPE (n = 197) admitted to the Departments of Infectious Diseases at four hospitals in Stockholm County during 2011-2014 were prospectively studied. All patients underwent thoracentesis. Twenty-seven non-infectious pleural effusions were used as controls. The pleural samples were analyzed with culture, 16S rDNA sequencing, pH, glucose, and lactate dehydrogenase. Microbiological etiology was found in 99/197 (50%) of the patients with mixed infections in 20 cases. The most common pathogens were viridans streptococci (n = 37) and anaerobic bacteria (n = 40). Among the 152 patients with both methods performed, 26/152 (17%) and 94/152 (62%) had bacteria identified with culture and 16S rDNA sequencing respectively (p < 0.001). In 24/26 (92%) culture-positive cases, the same organism was identified by 16S rDNA. All controls were negative in both methods. Among the patients with complicated PPE and complete sampling, bacteria were found in 69/74 patients (93%), all detected with 16S rDNA sequencing, compared to 23/74 (31%) culture-positive samples (p < 0.001). Compared with culture, 16S rDNA sequencing substantially improved the microbiological yield, a microbiological diagnosis was achieved in almost all patients with complicated PPE, and the specificity seemed to be high. 16S rDNA sequencing should be used together with culture in patients with PPE to guide antibiotic therapy.
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Affiliation(s)
- Niclas Johansson
- Department of Medicine, Solna, Infectious Diseases Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden. .,Department of Infectious Diseases, Karolinska University Hospital Solna, SE-171 76, Stockholm, Sweden.
| | - Martin Vondracek
- Department of Clinical Microbiology, Department of Microbiology, Tumor and Cell Biology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | | | - Magnus C Sköld
- Respiratory Medicine Unit, Department of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Lung-Allergy Clinic, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Karin Andersson-Ydsten
- Department of Medicine, Solna, Infectious Diseases Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital Solna, SE-171 76, Stockholm, Sweden
| | - Jonas Hedlund
- Department of Medicine, Solna, Infectious Diseases Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden. .,Department of Infectious Diseases, Karolinska University Hospital Solna, SE-171 76, Stockholm, Sweden.
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25
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Griffith D, Boal M, Rogers T. Evolution of practice in the management of parapneumonic effusion and empyema in children. J Pediatr Surg 2018; 53:644-646. [PMID: 28781127 DOI: 10.1016/j.jpedsurg.2017.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/22/2017] [Accepted: 07/09/2017] [Indexed: 10/19/2022]
Abstract
AIM To assess the evolution in management of children with parapneumonic effusion and empyema in a tertiary referral centre. METHOD We conducted a retrospective case note review of paediatric patients with parapneumonic effusion, pleural effusion and pleural empyema between December 2006 and December 2015. Digital database searches were performed to identify demographic data, referring hospital, radiological and microbiological investigations. Length of stay and morbidity were analysed. RESULTS One hundred fifteen patients had 159 interventions over the study period. Fifty-four children were successfully treated with intercostal drainage (ICD) and urokinase fibrinolysis alone. There were 19 primary video assisted thoracoscopic surgeries (VATS) and 12 VATS after initial intercostal drains. Thirty-three children required a thoracotomy, a reduction of 26% from the previous era (p=0.009). The median length of stay was 9days (range 2-54). CONCLUSION Parapneumonic effusion can be successfully treated with intercostal drainage and intrapleural fibrinolytics, but a proportion requires further surgical intervention. In our hospital, increased utilisation of fibrinolysis and VATS occurred with a corresponding decrease in the need for thoracotomy. Patients needing thoracotomy all had severe disease on ultrasound, but ultrasound did not reliably predict failure of fibrinolytic therapy. LEVEL OF EVIDENCE III.
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Affiliation(s)
- D Griffith
- Department of Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS28BJ, UK.
| | - M Boal
- Department of Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS28BJ, UK
| | - T Rogers
- Department of Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS28BJ, UK
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Bueno Fischer G, Teresinha Mocelin H, Feijó Andrade C, Sarria EE. When should parapneumonic pleural effusions be drained in children? Paediatr Respir Rev 2018; 26:27-30. [PMID: 28673835 DOI: 10.1016/j.prrv.2017.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
Pneumonia is an important health problem in children, and parapneumonic pleural effusion (PPE) is a frequent complication. There is no standard strategy for treating PPE, reflected in the few international guidelines that have been published on the issue. Compared to adults, there is no consensus on the utility of pleural fluid analysis in paediatric PPE. This is because of the lack of good evidence either in favour or against it and the risks of procedural sedation for acquiring pleural fluid for analysis to guide management. In this paper we provide a succinct review of the different approaches to the management of PPE, including diagnosis, pleural fluid analysis (Light's criteria) and treatment, both medical and surgical.
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Affiliation(s)
| | | | - Cistiano Feijó Andrade
- Department of Paediatric Thoracic Surgery, Hospital da Criança Santo Antônio, Porto Alegre and Post-Graduate Program in Pulmonology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Edgar E Sarria
- Department of Biology and Pharmacy, School of Medicine, Universidade de Santa Cruz do Sul (UNISC), Santa Cruz do Sul, Brazil
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27
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Lewis MR, Micic TA, Doull IJM, Evans A. Real-time ultrasound-guided pigtail catheter chest drain for complicated parapneumonic effusion and empyema in children - 16-year, single-centre experience of radiologically placed drains. Pediatr Radiol 2018; 48:1410-1416. [PMID: 29951836 PMCID: PMC6105150 DOI: 10.1007/s00247-018-4171-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/29/2018] [Accepted: 04/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chest tube drainage with fibrinolytics is a cost-effective treatment option for parapneumonic effusion and empyema in children. Although the additional use of ultrasound (US) guidance is recommended, this is rarely performed in real time to direct drain insertion. OBJECTIVE To evaluate the effectiveness and safety of real-time US-guided, radiologically placed chest drains at a tertiary university hospital. MATERIALS AND METHODS This was a retrospective review over a 16-year period of all children with parapneumonic effusion or empyema undergoing percutaneous US-guided drainage at our centre. RESULTS Three hundred and three drains were placed in 285 patients. Treatment was successful in 93% of patients after a single drain (98.2% success with 2 or 3 drains). Five children had peri-insertion complications, but none was significant. The success rate improved with experience. Although five patients required surgical intervention, all children treated since 2012 were successfully treated with single-tube drainage only and none has required surgery. CONCLUSION Our technique for inserting small-bore (≤8.5 F) catheter drains under US guidance is effective and appears to be a safe procedure for first-line management of complicated parapneumonic effusion and empyema.
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Affiliation(s)
- Megan R. Lewis
- Department of Postgraduate Medical and Dental Education at Cardiff University, Heath Park Way, Cardiff, UK CF14 4YU
| | - Thomas A. Micic
- Department of Paediatric Radiology, Children’s Hospital for Wales, Heath Park, Cardiff, UK CF14 4XW
| | - Iolo J. M. Doull
- Department of Paediatric Respiratory Medicine, Children’s Hospital for Wales, Cardiff, UK CF14 4XW
| | - Alison Evans
- Department of Paediatric Radiology, Children’s Hospital for Wales, Heath Park, Cardiff, UK CF14 4XW
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Bajantri B, Danial S, Duncalf R, Khaja M. Rare complicated parapneumonic effusion, Mycoplasma pneumoniae with new-onset lupus flare: Case report and literature review. Respir Med Case Rep 2017; 22:287-291. [PMID: 29124008 PMCID: PMC5671404 DOI: 10.1016/j.rmcr.2017.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 12/01/2022] Open
Abstract
Mycoplasma pneumoniae has been associated with respiratory tract infections. Mycoplasma pneumoniae pneumonia–related pleural effusion is rarely reported. Extra-pulmonary abnormalities such as encephalitis, myocarditis, glomerulonephritis, and myringitis have been reported. However pulmonary manifestations in systemic lupus erythematosus include pneumonitis, pleurisy, interstitial lung disease, and thromboembolic disease. We present the case of a 26-year-old male who came for evaluation of fever, cough, and shortness of breath with right-sided chest pain. He was found to have right-side loculated complicated parapneumonic effusion and underwent drainage with a pleural catheter followed by fibrinolytic therapy. He was then found to have new-onset systemic lupus erythematosus concomitant with Mycoplasma pneumonia, leading to lupus flare and lupus nephritis. He responded well to levofloxacin, steroids, hydroxychloroquine, and mycophenolate, with complete resolution of loculated pleural effusion and symptom improvement. Our case describes the rare combination of Mycoplasma pneumoniae pneumonia, parapneumonic pleural effusion, and lupus flare with lupus nephritis. Early identification and treatment can lead to better out come in young patients.
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Affiliation(s)
- Bharat Bajantri
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Affiliated with Icahn School of Medicine at Mount Sinai, 1650 Grand Concourse, Bronx, NY 10457, USA
| | - Shaik Danial
- Department of Medicine, Bronx Lebanon Hospital Center, Affiliated with Icahn School of Medicine at Mount Sinai, 1650 Grand Concourse, Bronx, NY 10457, USA
| | - Richard Duncalf
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Affiliated with Icahn School of Medicine at Mount Sinai, 1650 Grand Concourse, Bronx, NY 10457, USA
| | - Misbahuddin Khaja
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Affiliated with Icahn School of Medicine at Mount Sinai, 1650 Grand Concourse, Bronx, NY 10457, USA
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Chang CJ, Chiu NC, Huang FY, Tsung-Ning Huang D, Chang L, Huang CY, Kung YH, Chi H. Predictive value of Thomsen-Friedenreich antigen activation for Streptococcus pneumoniae infection and severity in pediatric lobar pneumonia. J Microbiol Immunol Infect 2017; 52:571-577. [PMID: 28918242 DOI: 10.1016/j.jmii.2017.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/28/2017] [Accepted: 08/17/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Most cases of complicated pneumonia in children are caused by pneumococcal infections. Thomsen-Friedenreich antigen (TA) is present on erythrocytes, platelets and glomeruli, and it can be activated during pneumococcal infection. The aim of this study was to investigate the predictive value of TA activation for pneumococcal infection and association with the severity of complicated pneumonia. MATERIALS AND METHODS Patients with lobar pneumonia were routinely tested for TA at the Department of Pediatrics, Mackay Memorial Hospital from January 2010 to December 2015. We retrospectively reviewed and analyzed their charts and data including age, sex, etiology of infection, chest tube insertion or video-assisted thoracoscopic surgery, length of hospital stay, TA activation, white blood cell count and level of C reactive protein. RESULTS A total of 142 children with lobar pneumonia were enrolled, including 35 with empyema, 31 with effusion, 11 with necrotizing pneumonia and four with lung abscess. Streptococcus pneumoniae was the most commonly identified pathogen. Twenty-two patients (15.4%) had activated TA, all of whom were infected with S. pneumoniae. TA activation had 100% specificity and 100% positive predictive value for pneumococcal infection. In the multivariate analysis in lobar pneumonia, TA activation (OR, 15.8; 95% CI, 3.0-83.5; p = 0.001), duration of fever before admission (OR, 1.2; 95% CI, 1.1-1.5; p = 0.013) and initial CRP level (OR, 1.1; 95% CI, 1.0-1.1; p = 0.004) were independent predictors of empyema. CONCLUSIONS TA activation is a specific marker for pneumococcal pneumonia and might indicate higher risk for complicated pneumonia.
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Affiliation(s)
- Chia-Jung Chang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Nan-Chang Chiu
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Fu-Yuan Huang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Daniel Tsung-Ning Huang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Lung Chang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Ching-Ying Huang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsin Kung
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Hsin Chi
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medicine College, New Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.
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Asai N, Suematsu H, Hagihara M, Nishiyama N, Kato H, Sakanashi D, Koizumi Y, Yamagishi Y, Mikamo H. The etiology and bacteriology of healthcare-associated empyema are quite different from those of community-acquired empyema. J Infect Chemother 2017; 23:661-667. [PMID: 28751154 DOI: 10.1016/j.jiac.2017.04.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/22/2017] [Accepted: 04/21/2017] [Indexed: 11/29/2022]
Abstract
OBJECTS Changes in patients' background and life environment could contribute to increase healthcare-associated (HCA) empyema. There are no guidelines and statements for HCA empyema. METHODS We retrospectively reviewed all patients with empyema who were admitted to the Aichi Medical University Hospital, Japan between 2008 and 2015. We evaluated patients' characteristics, microbial profiles, treatment and outcomes, and analyzed prognostic factors for 90-day mortality. RESULTS A total of 48 patients were enrolled in this study. They were categorized into community-acquired (CA) empyema (16 patients) and healthcare-associated (HCA) empyema (32 patients). HCA empyema patients had higher Charlson comorbidity index (CCI) scores, and poorer performance status (PS) than CA empyema patients. Potentially-drug resistant (PDR) pathogens were seen more frequently in HCA empyema than in CA empyema. Compared with survival and death groups, the death group showed higher CCI scores and poorer PSs than the survival group. The death group had more malignancy than the survival group. PDR pathogens were detected more frequently in the death group than in the survival group. Multivariate analysis showed that emergence of PDR pathogens and malignancies were independent poor prognostic factors for 90-days mortality among empyema. CONCLUSION The etiology and bacteriology of HCA empyema are quite different from those of CA empyema. Especially, the mortality of HCA empyema was higher than the one of CA empyema. Emergence of PDR pathogens in the pleural fluid detected by culture, pulmonary disease and malignancies were independent poor prognostic factors among CA and HCA empyema by multivariate logistic regression analysis.
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Affiliation(s)
- Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan; Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
| | - Hiroyuki Suematsu
- Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
| | - Mao Hagihara
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan; Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
| | - Naoya Nishiyama
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan; Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
| | - Hideo Kato
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan; Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
| | - Daisuke Sakanashi
- Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
| | - Yusuke Koizumi
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan; Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan; Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan; Department of Infection Control and Prevention, Aichi Medical University Hospital, Japan.
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Diawara I, Zerouali K, Elmdaghri N, Abid A. A case report of parapneumonic pleural effusion caused by Streptococcus pneumoniae serotype 19A in a child immunized with 13-valent conjugate pneumococcal vaccine. BMC Pediatr 2017; 17:114. [PMID: 28449653 PMCID: PMC5408360 DOI: 10.1186/s12887-017-0872-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 04/25/2017] [Indexed: 01/09/2023] Open
Abstract
Background Simple parapneumonic effusion is a pleural effusion associated with lung infection (i.e., pneumonia). Streptococcus pneumoniae remains the most common pathogen causing parapneumonic effusions. In Morocco, the pneumococcal conjugate vaccine 13-valent (PCV13) was introduced in the national immunization program in October 2010 in 2 + 1 schedule for prevention of pneumococcal disease, and replaced by the PCV10 in July 2012 in the same schedule. We report a case of parapneumonic pleural effusions caused by S. pneumoniae serotype 19A in a child immunized with 3 doses of PCV13. Case presentation This is a 2.5 years old previously healthy Moroccan female, fully vaccinated by PCV13 and immunocompetent, admitted to a private medical clinic with a six months history of persistent asthma. On arrival (7 February 2015), she was febrile to 40.3 °C with a brutal flu syndrome, chills, dry cough and serous rhinitis, for which she received symptomatic treatment. A biological assessment was done that confirmed the clinical diagnosis of flu. Seven days after, she presented a progressive deterioration of its general condition and the onset of severe abdominal pain. She was hospitalized and a second biological assessment, computed tomography scans and chest radiography were done that confirmed a diagnosis of a pneumococcal parapneumonia with abscess of the left lower lobe with encysted empyema. Microbiological analysis of the pleural fluid showed a S. pneumoniae serotype 19A with susceptibility intermediate to penicillin. The patient was treated by antibiotics including amoxicillin, cefixime ceftriaxone and vancomycin. Conclusions We reported a case of parapneumonic pleural effusions caused by a vaccine serotype pneumococcal 19A occurring in an immunocompetent child immunized with 3 doses of PCV13.
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Affiliation(s)
- Idrissa Diawara
- Laboratoire de Microbiologie, Faculté de Médecine et de Pharmacie, Hassan II University of Casablanca, B.P 5696, Casablanca, Morocco. .,Service de Microbiologie, CHU Ibn Rochd, B.P 2698, Casablanca, Morocco.
| | - Khalid Zerouali
- Laboratoire de Microbiologie, Faculté de Médecine et de Pharmacie, Hassan II University of Casablanca, B.P 5696, Casablanca, Morocco.,Service de Microbiologie, CHU Ibn Rochd, B.P 2698, Casablanca, Morocco
| | - Naima Elmdaghri
- Laboratoire de Microbiologie, Faculté de Médecine et de Pharmacie, Hassan II University of Casablanca, B.P 5696, Casablanca, Morocco.,Service de Microbiologie, CHU Ibn Rochd, B.P 2698, Casablanca, Morocco.,Institut Pasteur du Maroc, 1 Louis Pasteur place, Casablanca, Morocco
| | - Abderrahman Abid
- Service des Maladies Infectieuses Pédiatriques, Hôpital d'Enfants Abderrahim Harouchi, CHU Ibn Rochd, Casablanca, Morocco
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James CA, Braswell LE, Pezeshkmehr AH, Roberson PK, Parks JA, Moore MB. Stratifying fibrinolytic dosing in pediatric parapneumonic effusion based on ultrasound grade correlation. Pediatr Radiol 2017; 47:89-95. [PMID: 27709281 DOI: 10.1007/s00247-016-3711-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/29/2016] [Accepted: 09/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Complicated pleural effusion prolongs the hospital course of pneumonia. Chest tube placement with instillation of fibrinolytic medication allows efficient drain output and decreases hospital stay. OBJECTIVE To evaluate experience with lower fibrinolytic dose for parapneumonic effusions and to assess potential dose stratification based on a simple ultrasound grading system. MATERIALS AND METHODS We retrospectively reviewed the medical record to identify children and young adults who received fibrinolytic therapy for parapneumonic effusion and had chest tube placement by an interventional radiology service at a single children's hospital. We assessed tissue plasminogen activator (tPA) dosing and treatment duration, as well as the need for a second pleural procedure or surgical drainage. Diagnostic US images were classified as showing less than 50% pleural echogenicity (grade 1) or greater than 50% pleural echogenicity (grade 2) and were correlated with clinical parameters. RESULTS Of 32 patients with parapneumonic effusion, all except one received at least some 1-mg tPA doses. Dosing was solely 1-mg tPA in 81% of subjects; 19% of subjects also received 2-mg tPA doses. Mean fibrinolytic duration was 3.1 days for grade 1 effusions compared to 5.4 days for grade 2 effusions. A second pleural procedure was required in 15.6% of children. Pleural drainage with fibrinolytic therapy was successful in 97%; only one child required surgical drainage. Grade 2 US differed significantly from grade 1 US, with grade 2 occurring in younger patients (P < 0.0001), smaller patients (P < 0.0001), those needing a second procedure (P = 0.001), those with positive pleural culture or polymerase chain reaction test (P = 0.006), and those with longer treatment duration (P = 0.03). CONCLUSION A lower 1-mg dosing regimen of tissue plasminogen activator was effective in all children with less complex (grade 1 US imaging) parapneumonic effusions. Grade 2 US images correlated with younger and smaller children, presence of a pleural organism, and longer or more complicated chest tube duration.
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Affiliation(s)
- Charles A James
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA.
| | - Leah E Braswell
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
| | - Amir H Pezeshkmehr
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
| | - Paula K Roberson
- Biostatistics Department, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - James A Parks
- Pharmacy Department, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Mary B Moore
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
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Basille D, Plouvier N, Trouve C, Duhaut P, Andrejak C, Jounieaux V. Non-steroidal Anti-inflammatory Drugs may Worsen the Course of Community-Acquired Pneumonia: A Cohort Study. Lung 2016; 195:201-208. [PMID: 28005149 DOI: 10.1007/s00408-016-9973-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 12/16/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed or used as self-medication in cases of community-acquired pneumonia (CAP). Nevertheless, the consequences of such medication on the risk of pleuroparenchymal complications are not well known. The aim was to investigate whether exposure to NSAIDs prior to hospital admission among patients suffering from CAP is associated with the development of pleural complications or a lung abscess. METHODS All consecutive non-immunocompromised patients with CAP and admitted to a university hospital were prospectively included (2-year period). The risk of pleuropulmonary complications was analyzed according to previous exposure to NSAIDs. RESULTS Of the 221 included patients, 40 (18.1%) had developed a pleuropulmonary complication. NSAIDs intake prior to admission was reported for 24 patients (10.9%) who were younger (50.6 ± 18.5 vs. 66.5 ± 16.4 years; p = 0.001), had less comorbidities (60 vs. 25.1%; p = 0.001), had a longer duration between the first symptoms of CAP and the start of an antibiotic therapy (6.1 ± 7.6 vs. 2.8 ± 3.8 days; p = 0.001), and who had a higher incidence of pleuropulmonary complications (33.3 vs. 16.2%; p = 0.048). In multivariate analyses, two factors were independently associated with the development of pleuroparenchymal complications: NSAIDs intake [Odds Ratio (OR) = 2.57 [1.02-6.64]; p = 0.049] and alcohol abuse (OR = 2.68 [1.27-5.69]; p = 0.01). CONCLUSIONS Our findings suggest that NSAIDs, often taken by young and healthy patients, may worsen the course of CAP with delayed therapy and a higher rate of pleuropulmonary complications.
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Affiliation(s)
- Damien Basille
- Respiratory and Intensive Care Unit, University Hospital Amiens, Amiens, 80054, France. .,Recif Unit, University Hospital Amiens, Amiens, France.
| | - Nathalie Plouvier
- Respiratory and Intensive Care Unit, University Hospital Amiens, Amiens, 80054, France
| | - Charlotte Trouve
- Respiratory and Intensive Care Unit, University Hospital Amiens, Amiens, 80054, France
| | - Pierre Duhaut
- Recif Unit, University Hospital Amiens, Amiens, France.,Internal Medicine, University Hospital Amiens, Amiens, France
| | - Claire Andrejak
- Respiratory and Intensive Care Unit, University Hospital Amiens, Amiens, 80054, France.,Recif Unit, University Hospital Amiens, Amiens, France
| | - Vincent Jounieaux
- Respiratory and Intensive Care Unit, University Hospital Amiens, Amiens, 80054, France
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Porcel JM, Valencia H, Bielsa S. Manual Intrapleural Saline Flushing Plus Urokinase: A Potentially Useful Therapy for Complicated Parapneumonic Effusions and Empyemas. Lung 2017; 195:135-8. [PMID: 27866276 DOI: 10.1007/s00408-016-9964-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 11/09/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE We sought to evaluate the safety profile and effectiveness of manual pleural saline flushing, in addition to urokinase, for managing complicated parapneumonic effusions and empyemas. METHODS Retrospective comparative review of 23 consecutive patients with complicated parapneumonic effusions or empyemas who received saline flushing plus urokinase through small-bore chest catheters, and 39 who were only treated with fibrinolytics. Both groups had similar baseline characteristics and treatments were mostly protocol-driven. RESULTS As compared with patients only receiving urokinase, those additionally treated with saline flushing needed less fibrinolytic doses (a single dose being sufficient in 15 vs 44%, p = 0.019), chest tube duration (5 vs 2 days, p < 0.01), and length of hospital stay (8 vs 6 days, p = 0.011). There were no adverse events attributed to saline therapy. CONCLUSIONS Manual pleural saline flushing via chest tube, in addition to urokinase, is a safe and potentially beneficial therapy in patients with pleural infection.
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Lee J, Yoo SS, Lee SY, Cha SI, Park JY, Kim CH. Pleural fluid adenosine deaminase/serum C-reactive protein ratio for the differentiation of tuberculous and parapneumonic effusions with neutrophilic predominance and high adenosine deaminase levels. Infection 2016; 45:59-65. [PMID: 27488820 DOI: 10.1007/s15010-016-0928-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Tuberculous pleural effusion (TPE) and parapneumonic effusion (PPE) are usually distinguished by cellular predominance and pleural fluid adenosine deaminase (ADA) levels. However, both diseases may occasionally show similar neutrophilic predominance and high ADA levels. In such cases, the differential diagnosis between TPE and PPE is challenging and has been rarely investigated. METHODS A retrospective study was conducted on TPE and PPE patients with neutrophilic exudate and pleural fluid ADA levels ≥40 U/L. Individual and combined parameters of routine blood and pleural fluid tests were compared between the two groups, and receiver operating characteristic (ROC) curves were constructed for identifying TPE. RESULTS Thirty-six TPE and 41 PPE patients were included. White blood cell counts, serum C-reactive protein (S-CRP), and pleural fluid pH, lactate dehydrogenase, and ADA levels showed significant difference between the two groups (p < 0.001). Among multiple parameters, pleural fluid ADA/S-CRP ratio, which best reflected different local and systemic characteristics between TPE and PPE, provided the highest diagnostic accuracy with an area under the ROC curve of 0.93. At a cutoff value of 5.62, ADA/S-CRP ratio had a sensitivity of 89 %, specificity of 88 %, positive likelihood ratio of 7.29, and negative likelihood ratio of 0.13 for identifying TPE. Additionally, more than half of TPE patients had a ratio above 15.82, while none of PPE patients showed such findings. CONCLUSIONS Pleural fluid ADA/S-CRP ratio, as a simple method using routine laboratory tests, may be helpful in discriminating between TPE and PPE patients with neutrophilic predominance and ADA ≥40 U/L.
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Affiliation(s)
- Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 700-842, Republic of Korea
| | - Seung Soo Yoo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 700-842, Republic of Korea
| | - Shin Yup Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 700-842, Republic of Korea
| | - Seung Ick Cha
- Department of Internal Medicine, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 700-842, Republic of Korea
| | - Jae Yong Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 700-842, Republic of Korea
| | - Chang Ho Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 700-842, Republic of Korea.
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Corral-Gudino L, García-Zamalloa A, Prada-González C, Bielsa S, Alexis D, Taboada-Gómez J, Dos-Santos-Gallego PR, Alonso-Fernández MA, Porcel JM. Development and Validation of the COMPLES Score for Differentiating Between Tuberculous Effusions with Low Pleural pH or Glucose and Complicated Parapneumonic Effusions. Lung 2016; 194:847-54. [PMID: 27401009 DOI: 10.1007/s00408-016-9923-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The frequency of "complicated" pleural effusions (CPE) (i.e., pleural fluid pH ≤ 7.2 and/or glucose ≤60 mg/dL) of tuberculous origin (CTPE) is not well reported. This study aims to quantify their prevalence, and develop a score to differentiate CTPE from complicated parapneumonic effusions (CPPE). METHODS Retrospective analysis of databases from three Spanish hospitals which included patients with CTPE and CPPE. Forty percent of the study population served to generate a scoring system (COMPLES, COMplicated PLeural Effusion Score) that was further validated in the remaining 60 %. RESULTS During the study period (1992-2015) 549 patients were diagnosed with tuberculous effusions and 434 parapneumonic effusions, of whom 25 and 64 %, respectively, had CPE. COMPLES was based on the combination of pleural fluid adenosine deaminase (ADA), the percentage of mononuclear cells (MNC %), pH, and age. The cutoff values and assigned scores were: ADA (<46 IU/L [0 points], 46-100 IU/L [4 points], ≥100 IU/L [6 points]), MNC % (<10 % [0 points], 10-50 [3 points], >50 [8 points]), pH (<7.07 [0 points], 7.07-7.20 [3 points], >7.20 [5 points]), and age (≥30 [0 points], <30 years [3 points]). A sum of 12 or more points had 97 % sensitivity, 92 % specificity, likelihood ratio positive 12.3, likelihood ratio negative 0.03, and area under the curve of 0.947 for identifying CTPE versus CPPE in the validation set. CONCLUSIONS CPE is not an unusual presentation of tuberculosis. A simple new scoring system provides a reliable tool for differentiating between CTPE and CPPE.
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Dorman RM, Vali K, Rothstein DH. Trends in treatment of infectious parapneumonic effusions in U.S. children's hospitals, 2004-2014. J Pediatr Surg 2016; 51:885-90. [PMID: 27032611 DOI: 10.1016/j.jpedsurg.2016.02.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/26/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to examine trends in the treatment of patients with infectious parapneumonic effusions in U.S. children's hospitals over the past decade. METHODS The PHIS database was queried for patients younger than 18years old with pneumonia and pleural effusion in three yearlong periods over the past decade. Variables included age, gender, payer, race/ethnicity, hospital region, hospital type, markers of illness severity, and treatment group (antibiotics alone, chest tube thoracostomy±thrombolytics, video-assisted thoracoscopy (VATS), or thoracotomy). RESULTS 5569 patients were included in the final analysis. The proportion of patients treated with antibiotics alone increased from 62% to 74% from 2004 to 2014 (p<0.001). Among patients requiring pleural space drainage, the frequency of VATS peaked in 2009 (50.8%), dropping to 36.4% in 2014 (p<0.001), while tube thoracostomy, usually with fibrinolytics, rose from 39.0% in 2009 to 53.2% in 2014 (p<0.001). CONCLUSION In a select cohort of free-standing, tertiary care U.S. children's hospitals, antibiotic administration alone remains the most common treatment approach to infectious parapneumonic effusions. VATS treatment for those patients requiring pleural space drainage is being gradually supplanted by thoracostomy tube placement with instillation of fibrinolytics.
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Affiliation(s)
- Robert M Dorman
- Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY
| | - Kaveh Vali
- Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY
| | - David H Rothstein
- Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY.
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Porcel JM, Valencia H, Bielsa S. Factors influencing pleural drainage in parapneumonic effusions. Rev Clin Esp 2016; 216:361-6. [PMID: 27161381 DOI: 10.1016/j.rce.2016.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/02/2016] [Accepted: 04/06/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The identification of parapneumonic effusions (PPE) requiring pleural drainage is challenging. We aimed to determine the diagnostic accuracy of radiological and pleural fluid findings in discriminating between PPE that need drainage (complicated PPE (CPPE)) and those that could be resolved with antibiotics only (uncomplicated PPE (UPPE)). SUBJECTS AND METHODS A retrospective review of 641 consecutive PPE, of which 393 were categorized as CPPE and 248 as UPPE. Demographics, radiological (size and laterality on a chest radiograph) and pleural fluid parameters (pus, bacterial cultures, biochemistries) were compared among groups. Logistic regression was performed to determine variables useful for predicting chest drainage, and receiver-operating characteristic curves assisted in the selection of the best cutoff values. RESULTS According to the likelihood ratios (LR), findings increasing the probability of chest tube usage the most were: effusions occupying ≥1/2 of the hemithorax (LR 13.5), pleural fluid pH ≤7.15 (LR 6.2), pleural fluid glucose ≤40mg/dL (LR 5.6), pus (LR 4.8), positive pleural fluid cultures (LR 3.6), and pleural fluid lactate dehydrogenase >2000U/L (LR 3.4). In the logistic regression analysis only the first two were selected as significant predictors of CPPE. In non-purulent effusions, the effusion's size and pleural fluid pH retained their discriminatory properties, in addition to a pleural fluid C-reactive protein (CRP) level >100mg/L. CONCLUSION Large radiological effusions and a pleural fluid pH ≤7.15 were the best predictors for chest drainage in patients with PPE. In the subgroup of patients with non-purulent effusions, pleural fluid CRP also contributed to CPPE identification.
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Long AM, Smith-Williams J, Mayell S, Couriel J, Jones MO, Losty PD. 'Less may be best'-Pediatric parapneumonic effusion and empyema management: Lessons from a UK center. J Pediatr Surg 2016; 51:588-91. [PMID: 26382287 DOI: 10.1016/j.jpedsurg.2015.07.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/31/2015] [Accepted: 07/31/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Children with empyema are managed at our center using a protocol-driven clinical care pathway. Chemical fibrinolysis is deployed as first-line management for significant pleural disease. We therefore examined clinical outcome(s) to benchmark standards of care while analyzing disease severity with introduction of the pneumococcal conjugate vaccine. METHODS Medical case-records of children managed at a UK pediatric center were surveyed from Jan 2006 to Dec 2012. Binary logistic regression was utilized to study failure of fibrinolytic therapy. The effects of age, comorbidity, number of days of intravenous antibiotics prior to drainage and whether initial imaging showed evidence of necrotizing disease were also studied. RESULTS A total of 239 children were treated [age range 4months-19years; median 4years]. A decreasing number of patients presenting year-on-year since 2006 with complicated pleural infections was observed. The majority of children were successfully managed without surgery using antibiotics alone (27%) or a fine-bore chest-drain and urokinase (71%). Only 2% of cases required primary thoracotomy. 14.7% cases failed fibrinolysis and required a second intervention. The only factor predictive of failure and need for surgery was suspicion of necrotizing disease on initial imaging (P=0.002, OR 8.69). CONCLUSION Pediatric patients with pleural empyema have good outcomes when clinical care is led by a multidisciplinary team and protocol driven care pathway. Using a 'less is best' approach few children require surgery.
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Affiliation(s)
- Anna-May Long
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Sarah Mayell
- Department of Respiratory Medicine, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Jon Couriel
- Department of Respiratory Medicine, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Matthew O Jones
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Paul D Losty
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK; Academic Department of Paediatric Surgery, University of Liverpool, Liverpool, UK.
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Birkenkamp K, O'Horo JC, Kashyap R, Kloesel B, Lahr BD, Daniels CE, Nichols FC, Baddour LM. Empyema management: A cohort study evaluating antimicrobial therapy. J Infect 2016; 72:537-43. [PMID: 26987740 DOI: 10.1016/j.jinf.2016.02.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/16/2016] [Accepted: 02/19/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Empyemas require aggressive antimicrobial and surgical management. However, the specifics of antimicrobial therapy have not been studied in clinical trials. The present study examines management and outcomes among a cohort of patients with empyema cared for in a tertiary-care referral hospital over a decade. METHODS We retrospectively identified patients hospitalized with empyema from January 2000 through December 2010 at one institution. Patient demographics, laboratory findings, treatments, and patient outcomes were abstracted using a standard form. Data were summarized with standard descriptive statistics. RESULTS A total of 91 patients were identified. The predominant organisms were viridans group streptococci, which were isolated in 64% of cases with cultures. The median length of hospitalization was 9 days. Length of antimicrobial therapy from time of source control was variable, with a median (interquartile range) duration of 27 (15-31) days. Of note, longer courses of parenteral, but not oral, therapy were associated with fewer cases of clinical failure. CONCLUSIONS This descriptive analysis demonstrated a higher rate of viridans group streptococci than expected. Three weeks of therapy was generally adequate and prevented clinical failure, but further study is needed with a much larger cohort to better define the optimal drug regimen, route, and duration of antimicrobial therapy for empyema.
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Affiliation(s)
- Kate Birkenkamp
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John C O'Horo
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA.
| | - Rahul Kashyap
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Ben Kloesel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Craig E Daniels
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francis C Nichols
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Santotoribio JD, Cabrera-Alarcón JL, Batalha-Caetano P, Macher HC, Guerrero JM. Pleural fluid cell-free DNA in parapneumonic pleural effusion. Clin Biochem 2015; 48:1003-5. [PMID: 26234638 DOI: 10.1016/j.clinbiochem.2015.07.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/15/2015] [Accepted: 07/27/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To measure the accuracy of pleural fluid cell-free DNA (cfDNA) concentration for diagnosis of parapneumonic pleural effusions (PPE). DESIGN AND METHODS We studied pleural fluids obtained by thoracocentesis in patients with pleural effusion. DNA was automatically extracted from pleural fluid using the MagNa Pure Compact instrument (Roche Diagnostics), and was measured by a real-time quantitative PCR assay for the β-globin gene using a Light-Cycler 480 Real-Time PCR instrument (Roche Diagnostics). Patients were classified into two groups according to the etiology of pleural effusion: PPE and NOT PPE. The diagnostic accuracy was determined using receiver operating characteristic (ROC) techniques by analyzing the area under the ROC curve (AUC). RESULTS We studied 78 patients with ages between 1 and 86 years old (median=64). Sixteen patients were PPE and 62 were NOT PPE (24 transudative, 30 malignant and 8 other etiology). Pleural fluid cfDNA concentration was higher in patients with PPE (median=46,240 ng/mL) than in those with NOT PPE (median=224 ng/mL). The AUC value was 0.907 (p<0.0001) and the optimal cut-off value was 6740 ng/mL exhibiting 87.5% sensitivity and 80.6% specificity. Also, there were significant differences between transudative and exudative effusions according to pleural fluid cfDNA concentration (p<0.0001). The AUC value was 0.994 and the optimal cut-off value was 162ng/mL exhibiting 100% sensitivity and 96.3% specificity. CONCLUSIONS Pleural fluid cfDNA concentration showed high accuracy for diagnosis of PPE and to discriminate between transudative and exudative effusions.
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Abstract
Parapneumonic effusions complicating pneumonia are associated with increased morbidity and mortality. Along with increased mortality, complicated parapneumonic effusion and empyema often necessitate prolonged treatment, longer hospital stay and interventions. Parapneumonic effusions arise from inflammation in the lungs and pleural space from direct invasion of bacteria, cascade of inflammatory events and bacteriologic virulence features. Patient factors and comorbidities also contribute to the pathophysiology of parapneumonic effusion development. The evolution of parapneumonic effusion can be divided into three progressive stages: (I) exudative stage; (II) fibrinopurulent stage; and (III) organizing stage with pleural peel formation. These stages can help categorize effusions into groups in order to evaluate the risk of a complicated course requiring intervention. We recommend that clinical data be evaluated and a stepwise approach be taken in management of these patients. This review article discusses current understanding of the development and relationship of parapneumonic effusions with pneumonia.
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Affiliation(s)
- Lindsay McCauley
- 1 Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Pulmonary Division, University of Utah, Salt Lake City, USA ; 2 Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Salt Lake City, USA
| | - Nathan Dean
- 1 Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Pulmonary Division, University of Utah, Salt Lake City, USA ; 2 Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Salt Lake City, USA
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Abstract
Multidisciplinary management of thoracic infection, including experts in thoracic surgery, pulmonology, infectious disease, and radiology, is ideal for optimal outcomes. Initial assessment of parapneumonic effusion and empyema requires computed tomographic evaluation and consideration for fluid sampling or drainage. Goals for the treatment of parapneumonic effusion and empyema include drainage of the pleural space and complete lung reexpansion. Pulmonary abscess is often successfully treated with antibiotics and observation. Surgical intervention for the treatment of fungal or tuberculous lung disease should be undertaken by experienced surgeons following multidisciplinary assessment. Sternoclavicular joint infection often requires joint resection.
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Affiliation(s)
- Daniel Raymond
- Thoracic & Cardiovascular Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, J4-1, Cleveland, OH 44195, USA.
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Gümüs A, Ozkaya S, Ozyurt S, Cınarka H, Kirbas A, Sahin U, Ece F. A novel biomarker in the diagnosis of parapneumonic effusion: neutrophil gelatinase-associated lipocalin. Multidiscip Respir Med 2014; 9:49. [PMID: 25243068 PMCID: PMC4169811 DOI: 10.1186/2049-6958-9-49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 09/01/2014] [Indexed: 11/14/2022] Open
Abstract
Background The protein neutrophil gelatinase-associated lipocalin (NGAL) is a mediator synthesized and released by neutrophils. Its physiological function is as yet unclear. Levels in blood increase in several inflammatory diseases. High serum values indicate poor prognosis for several diseases. Pleural effusion may appear as the result of various pathologies. The most common cause is heart failure (HF). Other common causes include parapneumonic (PPE) and malignant (MPE) pleural effusions, and pulmonary embolism. Tubercular effusion (TE) is commonly encountered in Turkey and similar developing countries. The purpose of this study was to investigate the effectiveness of NGAL, a current inflammation marker, in discriminating between different etiological diseases that cause pleural effusion. Methods The study was performed at the Recep Tayyip Erdoğan University Faculty of Medicine Chest Diseases Clinic. One hundred patients were included in the study, 25 with parapneumonic effusion, 25 with heart failure-related effusion, 25 with tubercular effusion and 25 with cancer-related effusion. NGAL was measured in patients’ serum and pleural fluids. Results Serum NGAL levels in PPE (171 ± 56 ng/ml) were significantly higher (p < 0.001) than those in HF (86 ± 31 ng/ml), CA (103 ± 42 ng/ml) and TE (63 ± 19 ng/ml). Pleural NGAL levels were also significantly higher in PPE compared to HF, MPE and TE (p < 0.001). Serum NGAL levels exhibited a positive correlation with white blood cell (WBC), neutrophil, C-reactive protein (CRP), sedimentation, serum LDH, creatinine, pleural leukocyte and pleural neutrophil numbers. The most significant correlation was between NGAL level and WBC (p < 0.001, r = 0.579). Both serum and pleural NGAL levels are highly effective in differentiating patients with PPE from those without PPE (AUC: 0.910 and 0.790, respectively). Conclusions NGAL can be used in the diagnosis of diseases with an acute inflammatory course. Serum and pleural NGAL levels can differentiate PPE from other diseases causing pleural fluid with high sensitivity and specificity.
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Affiliation(s)
- Aziz Gümüs
- Department of Pulmonary Medicine, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Sevket Ozkaya
- Department of Pulmonary Medicine, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey
| | - Songul Ozyurt
- Department of Pulmonary Medicine, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Halit Cınarka
- Department of Pulmonary Medicine, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Aynur Kirbas
- Department of Biochemistry, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Unal Sahin
- Department of Pulmonary Medicine, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Ferah Ece
- Department of Pulmonary Medicine, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey
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Le Mée A, Mordacq C, Lagrée M, Deschildre A, Martinot A, Dubos F. Survey of hospital procedures for parapneumonic effusion in children highlights need for standardised management. Acta Paediatr 2014; 103:e393-8. [PMID: 24862230 DOI: 10.1111/apa.12702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 04/30/2014] [Accepted: 05/20/2014] [Indexed: 11/26/2022]
Abstract
AIM This study sought to evaluate the initial management of children with parapneumonic effusion admitted to all French university hospitals. METHODS A nationwide survey of all 35 university hospitals took place in 2011 to assess practices for children with parapneumonic effusion, using a hypothetical clinical vignette and a standardised questionnaire. Two to four paediatricians per hospital were interviewed and asked about their initial management, probabilistic antibiotic therapy and its adaptation to microbiological results and subsequent course. Answers from paediatricians working in emergency departments, intensive care units and conventional paediatric units were compared. RESULTS Of the 100 paediatricians contacted, 95 responded. Of these, 98% would order an initial blood test, 70% would order diagnostic thoracentesis, and all would start immediate antibiotic therapy: 31% with a single drug, 67% with two drugs and 2% with three drugs. The most frequent initial choices were third-generation cephalosporin alone (17%) or combined with rifampicin (34%) or vancomycin (24%). Adaptation varied according to drug used, dose and duration, especially when the microorganism was not Streptococcus pneumoniae. Practices did not differ significantly among the different groups of paediatricians. CONCLUSION Standardised management of parapneumonic effusion, including routine thoracentesis and more consistent prescription of antibiotics, is needed.
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Affiliation(s)
- A Le Mée
- Pediatric Pulmonology Unit; Jeanne de Flandre Hospital; CHRU Lille; Lille France
| | - C Mordacq
- Pediatric Pulmonology Unit; Jeanne de Flandre Hospital; CHRU Lille; Lille France
| | - M Lagrée
- Pediatric Emergency Unit & Infectious Diseases; R. Salengro Hospital; CHRU Lille; UDSL, Lille-2 Nord-de-France University; Lille France
| | - A Deschildre
- Pediatric Pulmonology Unit; Jeanne de Flandre Hospital; CHRU Lille; Lille France
| | - A Martinot
- Pediatric Emergency Unit & Infectious Diseases; R. Salengro Hospital; CHRU Lille; UDSL, Lille-2 Nord-de-France University; Lille France
- EA2694, Public Health: Epidemiology & Quality of Care; UDSL, Lille-2 Nord-de-France University; Lille France
| | - F Dubos
- Pediatric Emergency Unit & Infectious Diseases; R. Salengro Hospital; CHRU Lille; UDSL, Lille-2 Nord-de-France University; Lille France
- EA2694, Public Health: Epidemiology & Quality of Care; UDSL, Lille-2 Nord-de-France University; Lille France
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46
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Yu D, Buchvald F, Brandt B, Nielsen KG. Seventeen-year study shows rise in parapneumonic effusion and empyema with higher treatment failure after chest tube drainage. Acta Paediatr 2014; 103:93-9. [PMID: 24117621 DOI: 10.1111/apa.12426] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 08/20/2013] [Accepted: 09/19/2013] [Indexed: 12/19/2022]
Abstract
AIM To evaluate epidemiology, pre-admission characteristics and management of paediatric parapneumonic effusions (PPEs) and empyema in a tertiary paediatric pulmonary centre between 1993 and 2010. METHODS Retrospective chart review study using paediatric and thoracic database searches, with particular emphasis on pre-admission characteristics, disease stage (simple or complex effusion or empyema), general management and surgical procedures. RESULTS One hundred children were eligible, exhibiting a significant increase in incidence from 0.5 to 2.6 per 100 000 across the study period. Baseline characteristics were similar across disease stages. Streptococcus pneumoniae was the most common pathogen. Surgical intervention beyond chest tube drainage (CTD) was required in 50%; this rate showed a particular increase in children aged 0-5 years (OR, 3.1), but was otherwise not influenced by baseline characteristics, disease stage or use of intrapleural fibrinolytics. Length of hospitalisation did not differ across disease stages or primary interventional procedures. CONCLUSION This study confirmed an increasing incidence of PPEs and empyema in a Scandinavian tertiary paediatric pulmonary centre. Young children exhibited higher treatment failure after CTD. Length of hospitalisation was similar across disease stages and was comparable to previous reports according to primary interventional procedure.
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Affiliation(s)
- Danny Yu
- Paediatric Pulmonary Service; Department of Paediatrics and Adolescent Medicine; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - Frederik Buchvald
- Paediatric Pulmonary Service; Department of Paediatrics and Adolescent Medicine; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - Bodil Brandt
- Department of Thoracic Surgery; The Heart and Lung Surgical Clinic; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - Kim G Nielsen
- Paediatric Pulmonary Service; Department of Paediatrics and Adolescent Medicine; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
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Lee SH, Lee EJ, Min KH, Hur GY, Lee SY, Kim JH, Shin C, Shim JJ, In KH, Kang KH, Lee SY. Procalcitonin as a diagnostic marker in differentiating parapneumonic effusion from tuberculous pleurisy or malignant effusion. Clin Biochem 2013; 46:1484-8. [PMID: 23570862 DOI: 10.1016/j.clinbiochem.2013.03.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/28/2013] [Accepted: 03/28/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Differential diagnosis of exudative pleural effusions can be difficult, despite the use of several biomarkers. Serum procalcitonin (s-PCT) is a well-known biomarker for systemic bacterial infections. However, the usefulness of pleural fluid procalcitonin (pf-PCT) in clinical practice has not been established. This study evaluated the usefulness of PCT measurements in differentiating parapneumonic effusion (PPE) from tuberculous (TB) pleurisy or malignant effusion. DESIGN AND METHODS Ninety eight adult patients diagnosed with exudative pleural effusion were enrolled and allocated into the PPE group (n=32), TB pleurisy group (n=40), or malignant effusion group (n=26). Both s-PCT and pf-PCT concentrations were measured at admission using an immunoluminometric assay. RESULTS Both s-PCT and pf-PCT were significantly increased in the PPE group compared with the TB pleurisy or malignant effusion groups (p<0.001). The optimal cut-off value for s-PCT in the diagnosis of PPE was 0.18 ng/mL (sensitivity 83.3%, specificity 81.0%). The pf-PCT cut-off value was 0.16 ng/mL (sensitivity 81.5%, specificity 72.1%). Serum PCT exhibited better diagnostic accuracy than pf-PCT, with areas under the receiver operating characteristic curves of 0.842 for s-PCT and 0.784 for pf-PCT (p=0.015). In addition, s-PCT and pf-PCT showed better diagnostic accuracy than serum C-reactive protein (p=0.005 and p=0.023, respectively). CONCLUSIONS Measurement of s-PCT and pf-PCT is useful in differentiating PPE from TB pleurisy and malignant effusion. Both s-PCT and pf-PCT may be useful biomarkers in the differential diagnosis of exudative pleural effusions.
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Affiliation(s)
- Seung Hyeun Lee
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
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