We report a case of tubular adenoma of the colon presenting as empyema necessitatis of the left chest wall.
A 44 year old male presented with left sided anterior chest pain of one month duration. Associated symptoms included nocturnal dry cough and tenderness to touch. Symptoms were relieved with ibuprofen. He denied fever, chills, dyspnea, weight loss, abdominal pain, nausea, vomiting, change in bowel habits, constipation or history of trauma. Past medical history was unremarkable, but he abused alcohol and smoked 2 cigarettes/day. He denied illicit drug use. Medications included ibuprofen as needed for pain relief. On examination, he was afebrile, blood pressure 97/73 mmHg, heart rate 89 beats/minute and respiratory rate 18 breaths/minute. He appeared well without discomfort. His oropharynx was remarkable for poor dentition. Chest examination revealed an area of tenderness in the left midaxillary lower chest wall, 10 centimeter (cm) in diameter and raised 1-2 cm at the highest point. There was possible fluctuance but no crepitus. Lung examination was unremarkable. He had a non-distented soft abdomen with normal bowel sounds and no tenderness. The remainder of his exam was unremarkable. Laboratory data indicated a normal leukocyte count and differential but revealed a microcytic anemia with hematocrit 26% and mean corpuscular volume of 64 fl. Chest radiograph revealed left pleural effusion and consolidation of the lingula. Selected images from a follow up contrast-enhanced computerized tomography are shown below. He was diagnosed with pneumonia and empyema necessitatis and started on antibiotic regimen to cover for actinomyces, nocardia, streptococcus and anaerobic infections. Sputum did not reveal acid fast bacilli on 3 occasions. He underwent thoracentesis that drained air but no fluid. Surgical drainage removed 2 liters of pus and revealed tracking down to the abdomen with large abscess cavity adjacent to the transverse colon. The abdomen was felt to be the source of the infection. Cultures grew Escherichia coli and Staphylococcus aureus. A gastrografin enema was obtained and revealed a small fistula in the transverse colon extending to the chest wall abscess cavity. Flexible sigmoidoscopy showed a non-obstructing 2 cm sized mass in the left transverse colon at 60 cm. Clinical impression was of a locally advanced colonic adenocarcinoma, and he underwent surgical resection. The pathological diagnosis of the mass indicated a tubular adenoma and no evidence of inflammatory bowel disease. The patient is doing well 6 months after discharge.
Empyema necessitatis is a rare entity in the antibiotic era and is usually caused by actinomycoses, mycobacterial tuberculosis or streptococcus. It has rarely been reported to extend to the retroperitoneal space or cause mastitis. Our case involves the reverse pathway: from the abdominal cavity to the pleural space, lingula and chest wall. To our knowledge, this is the first case report involving an intraperitoneal infection which migrated into the pleural space then into the lung and chest wall. The scout film of the CT scan (not illustrated) demonstrates a collection of air in the abdominal wall and examination of select mediastinal views indicate the infection communicating between the pleural space and intraperitoneal cavity.
We report a infectious process initiated in the abdominal cavity and secondarily crossing into the pleural space and chest wall.
T.E. Duggan, None.