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Pyopneumothorax

Pyopneumothorax is a potentially life-threatening condition marked by the presence of pus and air within the pleural cavity.


Presentation

Pyopneumothorax could arise as a progression of either underlying hydropneumothorax or empyema. Therefore, etiological agents that cause these conditions could also play a role in the evolution of pyopneumothorax [1].

Symptoms of pyopneumothorax overlap with the symptoms seen in any severe lung infection and correlate with the degree of lung collapse on the ipsilateral side. Patients may present with pleuritic chest pain, severe cough and dyspnea, whilst also manifesting certain nonspecific symptoms such as fever, loss of appetite, loss of weight, and night sweats.

A recent history of pneumonia, pleural drainage, or penetrating injury may also be suggestive of the diagnosis [2] [3].

A variety of risk factors predisposing to pleural effusion or empyema that may progress to pyopneumothorax have been identified. Some of these predisposing factors are chronic lung disease, gastrointestinal reflux, and immunosuppression. Laboratory findings such as platelets >400 X 10*9, albumin < 30 g/L, sodium < 130 mmol/L and C-reactive protein >100 mg/L, and a history of either alcohol or drug abuse, suggests an increased risk of purulent pleural complications in patients admitted for community-acquired pneumonia [4].

Physical examination may reveal tachypnea, egophony, a dull note on percussion, decreased or absent breath sounds, rales, and rhonchi [5].

Fever
  • The presence of fever may mandate a blood culture. Chest radiography is of prime importance for the differential diagnosis of pneumonia, pulmonary abscess, and empyema.[symptoma.com]
  • We report an unusual complication of chronic foreign body aspiration--pyopneumothorax--in a 52-year-old patient presenting with productive cough and intermittent fever for more than 3 months.[ncbi.nlm.nih.gov]
  • Presentation Fever, chest pain and cough. Patient Data Age: 45 years Gender: Male Thick lined, loculated radio-opacity in right hemithorax, with an air-fluid level, loss of silhouette with the right dome of diaphragm.[radiopaedia.org]
  • The patient usually presents with chest pain and fever. Cough and breathing difficulty may be present.[radiopaedia.org]
  • He denied fever and chills but reported not being able to lie down because of right pleuritic pain and shortness of breath. His medical history was otherwise unremarkable. Vital signs taken The American Journal of Emergency Medicine Elsevier[deepdyve.com]
Fishing
  • A case of massive pyopneumothorax as a rare sequelae of retropharyngeal abscess following fish bone ingestion is reported.[ncbi.nlm.nih.gov]
  • Flexible fiberoptic bronchoscopy demonstrated a fish bone in the bronchial tree. The bone was successfully removed by forceps. Thoracotomy was done later to ensue adequate drainage of the pyopneumothorax.[ncbi.nlm.nih.gov]
Weight Loss
  • There was loss of appetite and weight loss in the 3 months before examination.[annsaudimed.net]
  • He reported no fever, sweats, anorexia, weight loss, or hemoptysis.[thefreelibrary.com]
Splenectomy
  • A 68-year-old man who had undergone total gastrectomy with splenectomy for gastric cancer and was receiving chemotherapy for esophageal cancer was presented to our hospital with dyspnea.[ncbi.nlm.nih.gov]
Night Sweats
  • Patients may present with pleuritic chest pain, severe cough and dyspnea, whilst also manifesting certain nonspecific symptoms such as fever, loss of appetite, loss of weight, and night sweats.[symptoma.com]
Irritability
  • Kerosene vapours may be mildly irritating to the respiratory system and spray applications of kerosene may provoke signs of pulmonary irritation such as coughing and dyspnoea. Kerosene aspiration leads to inflammation and loss of surfactant.[ncbi.nlm.nih.gov]
  • Agents that irritate the respiratory tract, such as isoflurane or desflurane, should be avoided during the induction of anaesthesia.[ijaweb.org]

Workup

Laboratory and imaging techniques can be used to confirm the diagnosis. Leucocytosis is seen on a complete blood count, with the differential count suggestive of a left shift. Sputum should be collected in order to identify the etiological agent and to exclude tuberculosis. Antibiotic sensitivity testing should further be done on these samples. The presence of fever may mandate a blood culture.

Chest radiography is of prime importance for the differential diagnosis of pneumonia, pulmonary abscess, and empyema. An accurate diagnosis decides the course of future therapy, with pneumonia and lung abscess being treated with antibiotics, while empyema requires surgical evacuation of the pleural cavity [6] [7]. On a chest X-ray, lung abscess usually appears as a single round density with an air-fluid level. The empyema is characterized by the presence of an air-fluid level that extends to the chest wall. This is accompanied by the blunting of the costophrenic angle. Radiography in the lateral decubitus position may help determine whether the pleural collection is mobile or localized.

Chest CT should be performed when the clinical signs are characteristic for lung/pleural infection but the chest radiography is negative. Such a situation may be encountered in patients with immunosuppression. However, a CT-scan should be avoided in children due to the potential risks associated with excessive radiation exposure at a young age [8].

A Doppler ultrasonography may help distinguish a peripheral abscess from empyema by the presence of blood vessels in the tissue surrounding the abscess [9]. An ultrasonography control is needed during needle aspiration and drainage of the pleural cavity to avoid potential complications [10].

Pleural fluid obtained through diagnostic thoracentesis may reveal findings suggestive of an empyema. These pleural fluid characteristics include a purulent character of the fluid, elevated neutrophils, pleural fluid glucose levels < 60 mg/dl, lactate dehydrogenase >1000 IU/ml and the presence of microorganisms on pleural culture.

Pseudomonas
  • The patient was also positive for Pseudomonas, so the color was unexpected. Although rare, malignant melanoma can present as a black pleural effusion due to the presence of melanocytes in the pleural fluid.[ncbi.nlm.nih.gov]
  • Culture and sensitivity of the liver abscess and pleural fluid showed growth of Pseudomonas that was susceptible to amikacin and linezolid.[annsaudimed.net]
  • The fever persisted, and therefore treatment was rotated to colistin and imipenem for 14 days due to the isolation of Klebsiella pneumoniae and Pseudomonas aeruginosa in the bronchoalveolar lavage.[elsevier.es]
  • Dextran exhibits antiadhesive properties in airway epithelial cells and acts as an antimicrobial agent in preventing the Pseudomonas infection.[ijaweb.org]
Clostridium Perfringens
  • Five patients developed pleural empyema due to Clostridium perfringens in the absence of penetration of the thorax; two of the patients presented with pyopneumothorax. Thirteen additional cases from the literature are reviewed.[ncbi.nlm.nih.gov]

Treatment

  • This complication occurred despite treatment with corticosteroids and cyclophosphamide. Active vasculitis and impaired tissue repair are possible explanations for the occurrence of this complication and the fatal outcome in our patient.[ncbi.nlm.nih.gov]
  • Successful treatment consisted of pleural drainage and parenteral antibiotics. The presence of an air-fluid level accompanying tension pneumothorax on chest radiograph should alert the physician to the possibility of this emergency condition.[ncbi.nlm.nih.gov]
  • Here we present two consecutive cases of spontaneous pyopneumothorax that occurred early after initiation of mTOR inhibitors for the treatment of renal cell carcinoma with subpleural pulmonary metastasis.[ncbi.nlm.nih.gov]
  • Treatment consists of drainage and antimicrobial chemotherapy.[ncbi.nlm.nih.gov]
  • Tuberculosis pyopneumothorax is a clinical event, which leads to severe complications and a set of treatment challenges.[erj.ersjournals.com]

Prognosis

  • Treatment and prognosis Large collections require intercostal drainage with antibiotics.[radiopaedia.org]
  • Tuberculous pneumothorax is a severe pathology which requires other anti tuberculor drugs eventually surgical treatment for drainage and lung decortications to improve their prognosis. Tuberculosis - management Pleura Public health 2013 ERS[erj.ersjournals.com]
  • Ferrara N (2004) Vascular endothelial growth factor: basic science and clinical prognosis. Endocr Rev 25:581–611 CrossRef PubMed 10.[springermedizin.de]
  • The prognosis is poor in such cases of distant metastases due to malignant melanoma and in malignant effusion, pleurodesis is performed as part of palliative care.[annsaudimed.net]
  • Mortality in children is generally reported to be less than 3%. [4] No reliable clinical, radiological or pleural fluid characteristics accurately determine patients’ prognosis at initial presentation. [19] Epidemiology [ edit ] The incidence of pleural[en.wikipedia.org]

Etiology

  • Therefore, etiological agents that cause these conditions could also play a role in the evolution of pyopneumothorax.[symptoma.com]
  • The mycobacterium tuberculosis was the most common etiological factor. The best modality of treatment was intercostal drainage by tube with antibiotic coverage. Conclusion: Tuberculosis is main etiology in country like India.[scopemed.org]
  • European Respiratory Journal 2013 42: P306; DOI: Abstract AIMS AND OBJECTIVES The present study is undertaken to study the age-sex profile, symptomatology, microbiologic findings, etiology, management and treatment-outcome in new patients of pyopneumothorax[erj.ersjournals.com]
  • Due to this infrequency and given that the symptoms can lead to erroneous or delayed diagnoses, the purpose of this article is to review the etiologies and the most common clinical presentation of the two entities, as well as to evaluate the treatment[actapediatrica.com]
  • Suspicion of fungal etiology should be made on the basis of no response despite broad-spectrum antibiotic coverage, and evidence of pre-existing immunosuppression.[omjournal.org]

Epidemiology

  • Varieties of coccidioidal infection in relation to the epidemiology and control of the disease. Am J Public Health 1946;36:1394-1402. 8. Batra P. Pulmonary coccidioidomycosis. J Thorac Imaging 1992;7:29-38. 9. Scully RE, Mark EJ, McNeely WF, et al.[thefreelibrary.com]
  • "An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations". Clinical Infectious Diseases . 34 (4): 434–40. doi : 10.1086/338460 . PMID 11797168 .[en.wikipedia.org]
  • Much of the data concerning the epidemiology of LAM and associated pneumothorax is derived from case series. The incidence of pneumothorax in LAM is very high, with reported rates between 39-76%.[jtd.amegroups.com]
Sex distribution
Age distribution

Pathophysiology

  • LAM is related in pathophysiology and clinical presentation to the Tuberous Sclerosis Complex (TSC) syndrome.[jtd.amegroups.com]

Prevention

  • Knowing that a tension pneumothorax can occur with esophageal rupture can help prevent misdiagnosis.[ncbi.nlm.nih.gov]
  • Once tension pyopneumothorax has developed from lung abscess, emergent lobectomy may be a useful option to prevent lethal aspiration pneumonia.[ncbi.nlm.nih.gov]
  • Prevention of mucus plug formation and removing secretions by the above measures probably prevented in having another episode of pneumothorax in our child.[ijaweb.org]
  • Pagina 223 - American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med 2003;167:603-662. ‎[books.google.ro]
  • The situation calls attention to the possibility of multidrug-resistance being underestimated when given as empirical therapy and institution of appropriate and timely antibiotic policy measures to prevent mortality.[sciencedomain.org]

References

Article

  1. Chen P, Lin X. Images in clinical medicine. Hydropneumothorax. N. Engl. J. Med. 2010;362(3):e9.
  2. Barmparas G, DuBose J, Teixeira PG, Recinos G, Inaba K, Plurad D. Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. J Trauma. 2009;66(6):1672-1676.
  3. Burgos J, Falco V, Pahissa A. The increasing incidence of empyema. Curr Opin Pulm Med. 2013;19(4):350-356.
  4. Chalmers JD, Singanayagam A, Murray MP, Scally C, Fawzi A, Hill AT. Risk factors for complicated parapneumonic effusion and empyema on presentation to hospital with community-acquired pneumonia.Thorax. 2009;64(7):592-597.
  5. Maskell NA, Batt S, Hedley EL, Davies CW, Gillespie SH, Davies RJ. The bacteriology of pleural infection by genetic and standard methods and its mortality significance. Am J Respir Crit Care Med. 2006;174(7):817-823.
  6. Khwaja S, Rosenbaum DH, Paul MC et al. Surgical treatment of thoracic empyema in HIV-infected patients: severity and treatment modality is associated with CD4 count status. Chest. 2005;128 (1): 246-249.
  7. Desai H, Agrawal A. Pulmonary emergencies: pneumonia, acute respiratory distress syndrome, lung abscess, and empyema. Med Clin North Am. 2012;96(6):1127-1148.
  8. Gadkowski LB, Stout JE. Cavitary pulmonary disease. Clin Microbiol Rev. 2008;21(2):305-333.
  9. Balfour-Lynn IM, Abrahamson E, Cohen G, Hartley J, King S, Parikh D. BTS guidelines for the management of pleural infection in children. Thorax. 2005;60(Suppl 1):1-21.
  10. Chen HJ, Yu YH, Tu CY, Chen CH, Hsia TC, Tsai KD. Ultrasound in peripheral pulmonary air-fluid lesions. Color Doppler imaging as an aid in differentiating empyema and abscess. Chest. 2009;135(6):1426-1432.

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Last updated: 2018-06-22 08:57