INTRODUCTION: In patients with Achalasia Cardia regurgitation of retained esophageal contents results in pneumonia; airway injury in the form of bronchitis, bronchiolitis and bronchiectasis and diffuse and localized alveolar injury leading to chemical pneumonitis, ARDS and lipoid pneumonia. Respiratory infections are caused by the pathogenic oral flora. We describe a patient at risk for aspiration due to Achalasia Cardia who developed an empyema due to infection by streptococcus morbillorum usually a gastric saprophyte possibly made virulent by the fatty nature of aspirate matter.
CASE PRESENTATION: 49-year-old Asian woman complained of productive cough, and fever of 2 weeks duration, and dysphagia to solids and liquids, regurgitation of food and weight loss of few months duration. She was ill looking and febrile with normal physical findings except for absent breath sounds over the right hemithorax. Blood white cell count was 17,000 per cubic millimeter with 90% neutrophils. PPD skin test was negative. Thoracentesis revealed exudative effusion with pleural fluid ph 7.1. Pleural fluid gram stain was negative and culture grew Streptococcus morbillorum sensitive to penicillin. Her sputum and pleural fluid mycobacterial cultures were negative. Chest CT scan revealed a multi-loculated pleural effusion, thickened parietal pleura, thickened extra pleural sub costal tissues and increased attenuation of the extra pleural fat, all features of empyema (Fig 1). Also seen was a dilated esophagus with an air-fluid level indicative of achalasia cardia, confirmed by esophagogram (Fig 2). She was treated for empyema with antibiotics and closed chest tube drainage followed by thoracotomy and open drainage. Achalasia was corrected by elective laparoscopic Heller myotomy and partial fundoplication.
DISCUSSIONS: Achalasia cardia is frequently associated with aspiration related lung disorders both infectious and non infectious. Aspiration pneumonia secondary to infection by oral flora such as anaerobes, streptococi and H. influenza is well known. However, empyema due to streptococcus morbillorum has not been described before in this setting. Streptococus morbillorum also known as gemella morbillorum is a gram positive bacteria a known saprophyte in the gastro intestinal system. The cause of transformation of this bacteria from a harmless saprophyte to a virulent pathogen causing a large empyema can only be speculated upon. Fatty material in aspirate contents have been demonstrated in the lung in the form of lipoid pneumonia. Animal studies have demonstrated that saprophytic mycobacteria injected into fatty medium show increased virulence and become pathogenic. Mycobacterial lung disease with the fortuitum-chellonie complex have been described in patients at risk for aspiration. It is possible that retained food with fatty contents when aspirated may serve to increase the virulence of saprophytic bacteria and mycobacteria and thereby explain the virulence of streptococcus moribillorum in our patient. Chest CT features of empyema include loculated pleural effusion, thickening and enhancement of parietal pleura, thickening of extrapleural subcostal tissues and high attenuation of extrapleural fat. Chest CT in our patient, not only led to recognition of empyema but also identified the predisposing disorder in the form of achalasia cardia, which allowed for the curative surgical treatment of both disorders.
CONCLUSION: It must be recognized that in a setting of aspiration non virulent saprophytic bacteria such as streptococcus morbillorumcan lead to severe infections such as empyema. The value of Chest CT in the identification of empyema and its ability to detect an underlying treatable cause like achalasic cannot be overemphasized.
DISCLOSURE: Karthikeyan Kanagarajan, None.