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Thoracic empyema is a collection of infectious material (pus) in the pleural cavity. Salmonella enterica species rarely cause pleuropulmonary infections. This condition poses a significant challenge in diagnosis and management due to its atypical presentation and potential for severe complications. This is a case of an immunocompromised host with glioblastoma who presented with a large loculated fluid collection in the left pleural space. The patient received broad-spectrum antibiotics and underwent urgent chest tube placement and drainage of pus, which grew Salmonella enterica subspecies enterica. He was also found to be bacteremic with the same organism. Subsequently, he underwent video-assisted thoracoscopic surgery (VATS) with decortication and evacuation of the empyema. Even though the prognosis for empyema is generally unfavorable, with increased morbidity and mortality, due to timely intervention, a successful outcome was achieved in this patient with an atypical presentation of salmonella infection.

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BACKGROUND: Thoracic empyema and malignant pleural mesothelioma (MPM) are distinct medical conditions with similar symptoms, including cough, chest pain, and breathing difficulty. We present a rare MPM case mimicking thoracic empyema. Physicians must consider MPM risks for patients exposed to building material who exhibit lobulated pleural effusions, indicating thoracic empyema. CASE SUMMARY: A 68-year-old retired male construction worker suffered from shortness of breath and chest tightness over 10 d, particularly during physical activity. A poor appetite and 4 kg weight loss over the past 3 wk were also reported. Chest images and laboratory data concluded a tentative impression of empyema thoracis (right). Video-assisted thoracic surgery with decortication and delobulation (right) was conducted. The pathological report yielded an MPM diagnosis. Refractory pleural bilateral effusions and respiratory failure developed postoperatively, and the patient died three weeks after the operation. CONCLUSION: Thoracic empyema and MPM are distinct medical conditions that can present similar symptoms, and video-assisted thoracic surgery facilitates an accurate diagnosis. Empyema-mimicking presentations and postoperative refractory pleural effusion may indicate a poor MPM outcome.

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The most common bacterial isolates in dogs with pyothorax include mixed anaerobes, Enterobacteriaceae (especially Escherichia coli), Pasteurella spp., Streptococcus spp., and Staphylococcus spp. A fluoroquinolone with amoxicillin (±clavulanate) or a fluoroquinolone with clindamycin are the most commonly recommended empirical antimicrobials whilst pending bacterial culture of the pleural effusion. The aim of this study is to review and compare the pleural effusion culture and antimicrobial susceptibility results to the PROTECT ME poster and other published antimicrobial use guidelines. The medical records of 53 dogs diagnosed with pyothorax between 2014 and 2020 at two veterinary referral centres were reviewed. Information, including culture and susceptibility results, was assessed. Antimicrobial susceptibility panels varied; susceptibility to a particular antibiotic was calculated as a percentage of isolates tested against the same antibiotic. A total of 30 of 53 dogs (57.7%) had a positive pleural fluid culture. The most common isolates were Pasteurella species (23.3%), Escherichia coli (23.3%), and mixed anaerobes (20%). From the aerobic isolates, 73-83% were susceptible to a fluoroquinolone, 14/19 (74%) to amoxicillin, and 20/22 (91%) to potentiated amoxicillin. Resistance to clindamycin was documented in 9/13 (69%) aerobic isolates, with all Gram-negative bacteria (9/9) being resistant. The combination of potentiated amoxicillin with marbofloxacin would have been appropriate in most of the dogs (75-92.9%). This study shows a high rate of resistance to clindamycin, which is not a suitable option for monotherapy and may be less effective in combination therapy compared to potentiated amoxicillin.

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Empyema necessitatis (EN) is an exceedingly rare complication of empyema. EN refers to the expansion and progression of an empyema beyond the thoracic cavity toward the skin wall. Herein, we present the case of a man with EN and detail his clinical course. A 42-year-old male with a prior history of substance use presented to the emergency department with three weeks of fever, cough, and progressively worsening pain overlying the left anterior chest wall. An empiric antibiotic regimen of cefepime, metronidazole, and vancomycin was initiated. Chest X-ray, ultrasound, and chest CT demonstrated a large region of loculation suspicious for a loculated empyema. On day 4 of admission, he underwent a video-assisted thoracoscopy followed by a left minithoracotomy, which confirmed the diagnosis of EN. The patient was discharged on hospital day 16 with marked clinical improvement and monitored for a year via an outpatient clinic. Symptoms did not recur, and there was complete resolution of EN. More predominant in the pre-antibiotic era with the progression of uncontrolled infections, EN is less commonly seen today. As such, EN requires a high degree of clinical suspicion for timely detection and management. Our case illustrates the importance of early intervention with antibiotics and surgical drainage.

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We present the case of a 53-year-old male with complicated left-sided parapneumonic effusion due to Streptococcus intermedius and Prevotella buccae. Management required video-assisted thoracoscopic surgery and partial decortication of the left lung. Complications during the hospital stay were extensive, including sepsis, acute hypoxic respiratory failure, alcohol withdrawal, and transient ischemic attack.

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BACKGROUND: Few cases of traumatic pneumothorax complicated by thoracic empyema have been reported. The indication of antibiotic prophylaxis administration for traumatic pneumothorax during tube thoracostomy remains controversial, and thoracic injury complicated by empyema can be life-threatening and intractable. CASE PRESENTATION: A 42-year-old male patient was injured during a collision with a passenger car while driving a motorcycle. The patient (body mass index, 37 kg/m2) was diagnosed with right first-to-sixth-rib fractures without a flail segment, right clavicle fracture, and slight hemopneumothorax. Tube thoracostomy was performed for traumatic pneumothorax on day 3 without antibiotic prophylaxis. The patient demonstrated a progressive displaced rib fracture complicated by empyema on day 11. Radical surgery was performed for the empyema with rib fixation on day 15. The postoperative course was uneventful, and the patient was discharged from the hospital on day 31. CONCLUSIONS: A traumatic pneumothorax can be complicated by empyema. Thoracic injuries complicated by empyema can be life-threatening and intractable. Antibiotic prophylaxis for traumatic pneumothorax with tube thoracotomy should therefore be considered in select cases. The strategy for thoracic injury requires the assumption of an occult thoracic infection and chest wall instability.

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Necrotizing infections of deep neck spaces are a group of life-threatening infectious diseases acquired through trauma or as a descending infection from an odontogenic source. The isolation of pathogens is unusual because of the anaerobic nature of the infection; however, one way to achieve this is through the use of automated microbiological methods like matrix-assisted laser desorption/ionization and time-of-flight (MALDI-TOF) following standard microbiology protocols for analyzing samples from potential anaerobic infections. We present a case of a patient without risk factors for descending necrotizing mediastinitis with isolation of Streptococcus anginosus and Prevotella​​​​​​​ buccae managed at the intensive care unit with a multidisciplinary team. We present our approach and how we successfully treat this complicated infection.

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A 55-year-old female with hypertension presented to our facility with complicated pneumonia. She complained of progressively worsening shortness of breath and pleuritic chest pain. She was in her usual state of health except for an upper respiratory infection treated with oral antibiotics a month prior. At the presentation, she was febrile, tachycardic, and hypoxic on room air. A chest computed tomography (CT) showed near-complete opacification of the right lung, a cavitation with the fluid level in the right middle lobe, and moderate-to-large effusion. Broad-spectrum antibiotics were started. Sputum culture was later positive for methicillin-resistant Staphylococcus aureus, which prompted antibiotic de-escalation to vancomycin. A chest tube was placed into the right pleural space draining 700 mL of exudative fluid, which cultures grew Streptococcus anginosus group (SAG) bacteria. Due to persistent respiratory distress and residual effusion, right thoracotomy and decortication were performed. A right upper lobe abscess ruptured into the pleural space was noted during the procedure. Pathology revealed necrotic tissue, and the microbiological workup was negative. The patient clinically improved postoperatively and was discharged home with oral Linezolid.

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Background Pleural infection is a common clinical problem resulting in prolonged hospitalization and increased mortality. In patients with active malignancy, management decisions are based on the need for further immunosuppressive therapies, the ability to tolerate surgery, and consideration of the limited life expectancy. Identifying patients at risk for death or poor outcomes is very important as it will guide care. Study design and methods This is a retrospective cohort study of all patients with active malignancy and empyema. The primary outcome was time to death from empyema at three months. The secondary outcome was surgery at 30 days. Standard Cox regression model and cause-specific hazard regression model were used to analyze the data. Results A total of 202 patients with active malignancy and empyema were included. The overall mortality rate at three months was 32.7%. On multivariable analysis, female gender and higher urea were associated with an increased risk of death from empyema at three months. The area under the curve (AUC) of the model was 0.70. The risk factors for surgery at 30 days included the presence of frank pus and postsurgical empyema. The AUC of the model was 0.76. Interpretation Patients with active malignancy and empyema have a high probability of death. In our model, the risk factors for death from empyema included female gender and higher urea.

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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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A 1-year-old female mixed-breed cat was admitted to a veterinary hospital in Southern Brazil with tachypnea, low thoracic amplitude, restrictive breathing pattern, and cyanotic mucous membranes 2 days after elective castration surgery. Radiography revealed pleural effusion, and approximately 100-200 mL of fluid was collected by thoracocentesis. The reddish purulent exudate contained large numbers of yellowish-white granules with branched filamentous structures on cytological examination. The fluid was plated on blood agar and incubated under aerobiosis at 37 °C. On the third day of incubation, circular, dry, and opaque colonies, measuring < 0.5 mm in diameter, were observed. Their phenotypic and molecular characteristics were compatible with Buchananella hordeovulneris (basonym: Actinomyces hordeovulneris), a pathogenic actinomycete rarely detected in cats. Our findings indicate that B. hordeovulneris should be included in the differential diagnosis of pyothorax in cats together with Actinomyces spp. and Nocardia spp. Taxonomic confirmation of disease-causing microorganisms in animals is important to understand the course of infection and its association with disease epidemiology.

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Background: Descending necrotizing mediastinitis (DNM) is a rare but serious complication of odontogenic or pharyngeal infection spreading into the mediastinum. Very few childhood cases of DNM have been described. Case Description: We report a case of DNM complicated with severe thoracic empyema in a previously healthy 6-year-old girl who was successfully treated using minimally invasive video-assisted thoracoscopic surgery (VATS). The patient presented with odynophagia and dental pain, followed by rapid clinical deterioration including high fever, tachypnea, and left chest pain. As chest computed tomography (CT) revealed features of DNM, she was transferred from the local hospital to our hospital for intensive care. Empirical treatment was started with meropenem and linezolid. However, her tachypnea and dyspnea progressed rapidly. An ultrasound-guided left-sided thoracentesis drained 80 mL of brown sticky pus and the pus culture yielded Streptococcus constellatus. A contrast-enhanced CT scan demonstrated large mediastinal abscess and severe thoracic empyema. We performed debridement and drainage of the mediastinum and pleura using VATS. She recovered and was discharged on hospital day 18. Conclusions: Early diagnosis by cervicothoracic CT and multidisciplinary approaches including intensive care, broad-spectrum antibiotics, and aggressive surgical intervention are crucial to reducing morbidity and mortality. VATS is a minimally invasive and appropriate treatment strategy for children with DNM, especially complicated with thoracic empyema.

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Most cases of empyema thoracis are sequelae of severe pneumonia, but chest trauma and complications of chest tube insertion as cause are not uncommon in low-resource settings. Diagnosis is usually delayed due to delayed presentation to health care facilities, low index of suspicion among health care professionals, and inability to properly stage the disease with the available diagnostic tools. Early use of antibiotics and appropriate-sized and well-placed chest tube drainage is associated with good outcomes at a decreased cost. Surgical management of empyema thoracis is indicated when chest tube drainage and antibiotic treatment fail to achieve complete resolution.

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A 62-year-old man was admitted to our emergency department with the complaint of worsening dyspnea after initiating anti-tuberculous therapy (isoniazid [300 mg/day], rifampicin [600 mg/day], ethambutol [750 mg/day], and pyrazinamide [1,500 mg/day]) for tuberculous pleuritis. His oral hygiene status was poor. The patient had no significant past medical history. However, he had a history of smoking (10 cigarettes per day for 45 years) and was a social drinker. Chest radiography revealed increased right pleural effusion and pneumothorax. The pleural fluid was purulent, and the culture grew Alloscardovia omnicolens, Bifidobacterium dentium, and Prevotella loescheii. He was treated with antibiotics (3 g of intravenous ampicillin/sulbactam every 6 h, which was changed to oral amoxicillin/clavulanate potassium on day 34) in addition to anti-tuberculous therapy, he underwent chest tube insertion, and subsequently improved. Bifidobacteriaceae are commensal flora of the mouth and pulmonary infections caused by these organisms are extremely rare. Nevertheless, clinicians should consider these organisms as a possible cause of pulmonary infections, and consider that respiratory infections caused by commensal flora of the mouth may occur during the treatment of other diseases in patients with poor oral hygiene.

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A 45-year-old male presented to the emergency department after being found unresponsive. Vitals, laboratory findings, and chest X-ray revealed concern for tension empyema. Thoracostomy was performed, and hemodynamics subsequently improved. Later, Prevotella denticola was cultured. This is the first known reported case of tension Prevotella denticola empyema.

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INTRODUCTION: Early thoracic empyema is usually treated through video-assisted thoracoscopic (VATS) decortication. Patient selection is important for decortication if an effective surgical outcome is required. Lung isolation techniques are required to provide anesthesia for these patients to facilitate the surgeon while operating on the affected lung. The ultimate target is to protect the non-diseased contra-lateral lung from contamination. PRESENTATION OF CASE: We are presenting a unique case of 20-year-old female, resident of Karachi, who was brought to the emergency room (ER) with signs of sepsis, hypotension, and multi-organ failure. She was brought to the operating room to undergo video-assisted thoracoscopy (VATS) for lung abscess decortication when her medical therapy had failed. On table decision of right upper lobe resection was made and ventilation strategy had to be modified accordingly. DISCUSSION: The main anaesthetic aim was to protect the healthy parts of the lung from the abscess. Regular suctioning of secretions during surgery via the double lumen tube (DLT) lumen on the diseased side is recommended. While performing VATS, the lung abscess got ruptured and immediate measures to isolate the lung was taken to assist with surgical resection of the affected lobe. Lobectomy can only be done once the lung was completely isolated and maintaining perfusion and ventilation of the relatively healthy lung help in managing hypoxia. CONCLUSION: Peri-operative management of ruptured lung abscesses required thorough pre-op evaluation, intraoperative lung isolation and ventilation, and postoperative analgesia with combined team effort both surgical and anaesthetic, are vital fundamentals to consider in guaranteeing the best outcome.

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Thoracic empyema, defined as the accumulation of pus in the pleural space, is a rare cause of respiratory distress in neonates. Its occurrence in neonate patients has been only described in few literatures, as opposed to cases in older children. Even though the diagnosis of thoracic empyema is confirmed by histopathological examination of pleural fluid, radiographic examinations have important roles in helping clinicians narrowing down the differential diagnoses. This case report describes a neonatal patient who exhibited symptoms of respiratory distress and imaging modalities revealed multiloculated thoracic empyema.

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We report here the case of a 49-year-old man admitted for a diagnostic work-up of bilateral lung nodules. Empyema rapidly developed after a chest computed-tomodensitometry guided lung puncture. Despite the lack of obvious aetiology after two biopsies, the diagnosis was reached by performing 16S ribosomal DNA (rDNA) sequence analysis, which identified Prevotella spp in the pleural liquid. The empyema and lung nodules resolved after appropriate antibiotic therapy.

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Campylobacter rectus is a campylobacterium considered to be a primary periodontal pathogen. Thus, C. rectus has rarely been isolated from extraoral specimens, especially in the thoracic region. We herein report a case of thoracic empyema in which Campylobacter infection was suspected after Gram staining of the pleural effusion, and C. rectus was isolated using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Fusobacterium nucleatum was also detected. Molecular identification was performed using polymerase chain reaction amplification and a sequencing analysis of the 16S rRNA gene. Estimation of the causative bacteria using Gram staining led to the proper culture and identification of the causative bacteria.

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A 69-year-old man with occupational exposure to asbestos was referred to our hospital with right diffuse malignant pleural mesothelioma. He underwent extrapleural pneumonectomy with reconstruction of the pericardium and diaphragm using elongated polytetrafluoroethylene patches, followed by postoperative chemotherapy and chest wall irradiation. One year later, he was hospitalized because of a right empyema caused by Escherichia coli infection. As chest drainage and systemic antibiotics did not eliminate the abscess around the artificial patches, a Clagett window was created. To avoid mediastinal and liver overshift into the right thoracic cavity, we only performed partial resection of the diaphragm patch and incision of the artificial pericardium. After 19 days of irrigation and dressing change, the artificial patches were completely removed. Two months later, the patient provided a culture-negative sample and had an improved nutritional status; we therefore performed closure of the Clagett window with thoracoplasty. He did not experience recurrence of empyema.

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