Pyothorax caused by Nocardia otitidiscaviarum in a patient with rheumatoid vasculitis.
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We report a case of pyothorax caused by Nocardia (N.) otitidiscaviarum infection in a 69-year-old man with rheumatoid vasculitis, who was regularly treated with prednisolone in our hospital. Initially, the patient responded poorly to intravenous imipenem/cilastatin (IPM/CS), minocyclin (MINO), and oral trimethoprim-sulfamethoxazole (TMP-SMX), but later improved after treatment with levofloxacin (LVFX) and gentamicin sulfate (GM) according to in vitro susceptibility tests. To our knowledge, this is the first description of pyothorax caused by N. otitidiscaviarum infection. It is a rare disease, but recognition of the disease in immunocompromised patients and the prompt initiation of appropriate treatments based on isolation of the pathogen and susceptibility testing can lead to a successful outcome. (+info)
Change in pulmonary function following empyemectomy and decortication in tuberculous and non-tuberculous chronic empyema thoracis.
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Chronic empyema thoracis results from various etiologies. Improvement in pulmonary function after empyemectomy and decortication has proved difficult to predict when the etiology of chronic empyema thoracis is tuberculosis. The purpose of this study was to confirm the changes in pulmonary function according to the etiology after an operation. Sixty-five patients were classified into two groups according to their etiology: Group A (tuberculous) and Group B (non-tuberculous), and they were retrospectively evaluated with regard to their forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), percentage of predicted normal value of FEV1 (% FEV1) and FVC (%FVC). Empyemectomy and decortication was performed for all the patients and the two groups were similar in age, gender and preoperative spirometric parameters. In Group A (n=41), the pre- and postoperative mean values were 2.31 L and 2.8 L in FEV1, 65.8% and 80.5% in %FEV1, 2.62 L and 2.55 L in VC, 61.9% and 71.8% in %VC, respectively. In Group B (n=24), the pre- and postoperative mean values were 2.13 L and 2.49 L in FEV1, 66.4% and 73.8% in %FEV1, 2.55 L and 2.95 L in FVC, 64.9% and 71.8% in %FVC, respectively. All the spirometric parameters improved significantly in both groups compared to their preoperative values. However, no significance was shown in the rate of increase of the spirometric parameters between the two groups. In conclusion, improvement of lung function is expected after empyemectomy and decortication, regardless of the etiology of the chronic empyema thoracis. (+info)
Penetration of newer quinolones in the empyema fluid.
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The degree of penetration of newer quinolones into the pleural fluid has not been studied. The objective of the present study was to determine the degree to which moxifloxacin and levofloxacin penetrate into empyemic pleural fluid using a new rabbit model of empyema. An empyema was created via the intrapleural injection of turpentine (1 mL), followed 24 h later by instillation of 2 mL (1 x 10(10)) Escherichia coli bacteria (ATCC 35218) into the pleural space of New Zealand white rabbits. After an empyema was verified by thoracentesis and pleural fluid analysis, moxifloxacin and levofloxacin (25 mg.kg(-1) for both, i.v.) were administered. Antibiotic levels were determined in samples of pleural fluid and in blood collected serially over 12 h. Antibiotic levels were measured using HPLC. Each of the antibiotics penetrated well into the empyemic pleural fluid. Antibiotic penetration was the greatest for moxifloxacin (area under the curve (AUC) for pleural fluid/blood (AUCPF/AUCblood) ratio=1.37) followed by levofloxacin (ratio=1.13). The time to equilibration between the pleural fluid and blood antibiotic levels was more rapid for moxifloxacin (3.9 h) than for levofloxacin (4.4 h). With moxifloxacin, the peak pleural fluid concentration (Cmax,PF) was 2.77 microg.mL(-1) and occurred at a time to maximum pleural fluid concentration (Tmax,PF) of 6 h after infusion and decreased thereafter. The peak blood concentration (Cmax,blood) was 4.81 microg.mL(-1) at 1 h after administration. With levofloxacin, the peak pleural fluid level (Cmax,PF=1.39 microg.mL(-1)) occurred at 6 h (Tmax,PF=6 h) after infusion. The Cmax,blood was 1.88 microg.mL(-1) at 1 h after administration. In conclusion, differences were found in the degree of penetration of the two quinolones into infected pleural fluid in rabbits. The clinical significance of these differences is unknown. More studies are needed to evaluate the pharmacokinetic parameters in the pleural space in humans. (+info)
Pyogenic liver abscesses in a child spreading to pulmonary and subcutaneous tissues: case report.
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Pyogenic liver abscess is a rare and life-threatening disease in children. Our case is noteworthy because of the rapid advancement of liver abscesses without any other systemic disorder. A 16-year-old girl was admitted to the hospital with fatigue, pallor, weight loss and high fever. In physical examination a fluctuating mass was observed under the scapular area and hepatosplenomegaly was found. In computed tomography, three septated cystic lesions which looked like abscesses were demonstrated in the liver. The abscess was drained through percutaneous route. Right pleural empyema with clinical features of adult respiratory distress syndrome appeared after the first day of treatment. Bacteroides sp. was isolated from pus. On the twentieth day of the therapy, control abdominal computed tomography revealed two new abscesses in the liver. They were drained and the antibiotic therapy was continued with ticarcillin-clavulanate, fluconazole and levofloxacin. By the end of the first week of the therapy, the fever of the patient had abated. This therapy was continued for four weeks; 15 days after the end of the therapy there was prominent healing of the liver lesions with only one necrotic remnant 2 cm in diameter on abdominal computed tomography. (+info)
Primary malignant lymphoma arising in the pleura without preceding long-standing pyothorax.
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We report a very rare case of primary malignant lymphoma arising in the pleura with no history of persistent pyothorax. A 72-year-old male was hospitalized with dyspnea on effort and chest CT demonstrated a mass along the right chest wall. Right thoracotomy with complete en bloc resection of the pleural tumor was performed. Immunohistochemical examination of the pleural tumor showed that the histology was marginal zone B-cell malignant lymphoma. We considered that this tumor had originated from the soft tissue in the chest wall based on radiographical and surgical findings. As diagnosis and treatment of pleural malignant lymphoma seems to have been difficult in most cases reported in the literature, it is thought that early active and accurate biopsy with large-bore needles, or, if possible, surgical incision for early diagnosis and aggressive surgery to achieve complete resection combined with radiation therapy and/or chemotherapy would be very important for a good prognosis. (+info)
Empyema: the use of broad range 16S rDNA PCR for pathogen detection.
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BACKGROUND: An increase in the incidence of thoracic empyema in children has been reported. The causative pathogen is often unknown as pleural fluid is frequently sterile at the time of culture. The role of unusual organisms is unclear. AIMS: (1) To compare the detection of organisms in pleural fluid from children with empyema using a molecular technique (16S rDNA polymerase chain reaction (PCR)) and bacterial culture. (2) To compare the concordance of organisms identified using the two techniques and the influence of prior antibiotic treatment on positive detection rate. METHODS: Pleural fluid from children admitted with empyema between January 2000 and February 2002 was cultured and additionally analysed using broad range 16S rDNA PCR. RESULTS: Pleural fluid was cultured from 32 patients, aged 1 month-16 years. Median duration of previous antibiotic therapy was 8 days (range 1-42 days). Six samples were culture positive and 22 were PCR positive. A causal organism was detected by PCR alone, after considering results from the local hospital, in 14 patients. There was complete concordance in organisms cultured and detected by PCR. Additional organisms detected by PCR were predominantly S pneumoniae, S pyogenes, and anaerobes. CONCLUSIONS: Analysis of pleural fluid by broad range 16S rDNA PCR in addition to culture, increases organism identification in empyema. (+info)
Metalloproteinases and tissue inhibitors of metalloproteinases in exudative pleural effusions.
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The aim of this study was to assess the expression of several metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in exudative pleural effusions, and their relationship with inflammatory and fibrinolytic mediators in parapneumonic effusions. The study included 51 parapneumonic effusions (30 empyema or complicated parapneumonic, 21 noncomplicated parapneumonic), 28 tuberculous, 30 malignant and 30 transudates. Inflammatory markers (tumour necrosis factor-alpha, interleukin-8, polymorphonuclear elastase), fibrinolytic system variables (tissue plasminogen activator (PA), urokinase PA (u-PA), plasminogen activation inhibitor (PAI)-1, PAI-2), and several MMPs (MMP-1, MMP-2, MMP-8, MMP-9) and TIMPs (TIMP-1, TIMP-2) were determined by ELISA in plasma and pleural fluid. Elevated MMP-2 and TIMP-1 concentrations were observed in all the pleural fluid samples studied. The group of empyema or complicated parapneumonic effusions showed higher MMP-1, MMP-8 and MMP-9 concentrations than the remaining exudates. There was no correlation between MMP and TIMP levels in plasma and pleural fluid in this group of effusions. In parapneumonic effusions, MMP-1, MMP-8 and MMP-9 showed a positive correlation with the inflammatory markers and with u-PA and PAI-1. Moreover, there was a relationship between MMP-8 concentration in pleural fluid and pleural thickening at the end of treatment. In conclusion, elevated metalloproteinase-1, -8 and -9 expression was found in parapneumonic pleural effusions. These metalloproteinases could be implicated in the local inflammatory response existing in this group of effusions. (+info)
The etiology of extensive pleural effusions with troublesome clinical course among children.
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CONTEXT: In Sao Paulo, pneumonia is the main infectious cause of death among children. Parapneumonic pleural effusion is a possible complication and has to be treated surgically when the patient does not respond to antibiotics. OBJECTIVE: Assessment of the etiology of complicated parapneumonic pleural effusions that needed surgical intervention. TYPE OF STUDY: Retrospective study. SETTING: University hospital of the University of Sao Paulo. METHOD: Analysis of 4,000 files on children hospitalized with pneumonia from November 1986 to November 1996 had shown that 115 of these children presented a total of 117 cases of pleural empyema that required surgical procedures. The children's clinical condition was assessed in relation to radiological findings and to their nutrition and immunization status. Previous antimicrobial therapy and pleural effusion bacterioscopy were also evaluated. RESULTS: Streptococcus pneumoniae was the agent found most commonly, as frequently in blood cultures as in pleural effusions. DISCUSSION: Data on vaccination coverage, birth weight and nutritional status are analyzed and compared to other publications. We observed that pleural effusion has a high potential for discomfort, and in most cases it is not a complication of the first pulmonary disease episode. Previous use of antibiotics interfered with culture positivity. The agent most frequently found was Streptococcus pneumoniae, which is in accordance with the findings from other authors. Nonetheless, the antibiotics used to treat the patients after the procedure were the same used in non-complicated pneumonias, which has led us to conclude that the worse outcome in this cases was not due to drug resistance. CONCLUSION: The bacteriological profile in our series of complicated pneumonia cases was similar to what has been described for non-complicated pneumonia cases. Future studies will be necessary to determine why these children presented a worse outcome. (+info)