SESSION TITLE: Infectious Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Empyema necessitatis is a rare complication of empyema, in which purulent pleural fluid spontaneously drains through the dissected chest wall. We present possibly the first case of empyema necessitatis caused by Fusobacterium necrophorum.
CASE PRESENTATION: A 76-year old male presented with a 4-week history of productive cough and a 2-week history of chest pain. He complained of an enlarging chest wall mass of 1-week duration. There was no history of tuberculosis or any illness compromising his immune system. On physical examination, his body temperature was 38.2 °C. A 10×10 cm, slightly erythematous, smooth, soft, and tender left anterior chest mass was observed. His white blood cell count was 18490/mm3 with 85% neutrophils. Chest computed tomography (CT) revealed a left upper lobe lung abscess that penetrated the chest wall and formed an abscess under the pectoralis major muscle. We confirmed a tract between the lung abscess and the submuscular abscess. There was no pleural fluid or pleural thickening in any other lung region. Retrospectively we reviewed the CT image, taken 3 weeks previously, which revealed consolidation with a low density area at the same position in the lung. We concluded that the untreated lung abscess had invaded the pleura and penetrated the chest wall. Sputum culture showed normal flora. We performed an ultrasound guided percutaneous fine needle aspiration of the abscess under the pectralis major muscle and aspirated 1mL of fluid. The fluid culture revealed Fusobacterium necrophorum. Ziehl-Neelsen staining and polymerase chain reaction (PCR) of the sputum and aspirated fluid tested negative for Mycobacteria. No malignant cells were observed on histopathology. We prescribed oral sultamicillin tosilate hydrate as the patient refused intravenous antibiotic therapy. His fever subsided 5 days after initiating treatment, and cough, sputum, and thoracic tenderness gradually alleviated. After 4-weeks of oral antibiotic treatment, a chest CT scan showed resolution of the lung and chest wall abscesses with no recurrence.
DISCUSSION: Empyema necessitatis is a rare complication of empyema, in which purulent pleural fluid spontaneously drains through the dissected chest wall. Pathogenesis of empyema necessitatis is determined by several factors, including increased positive pressure in the affected cavity, inflammation, necrosis, and cavity wall erosion. When the cavity wall ruptures, the purulent material drains into the surrounding soft tissue through the weakest part. In this case, the abscess contents leaked from the lung into the visceral pleura. Adhesion may prevent the pus from spreading into the pleural free space, directly involving the parietal pleura and dissecting the chest wall. Following the advent of antibiotics, empyema necessitatis occurs rarely in the modern era. A review of empyema necessitatis from 1994 to 2004 revealed that 50% of the infections were caused by M. tuberculosis while 24% were due to Actinomyces1). Empyema necessitatis was rarely caused by Fusobacterium, with only one case of Fusobacterium nucleatum reported2). Our case is the first of empyema necessitatis caused by Fusobacterium necrophorum . Empyema necessitatis is treated by drainage and administration of antibiotics. Most cases require tube thoracostomy or radical resection. In this case, the patient was treated successfully without tube thoracostomy, because there was no apparent pleural cavity involvement.
CONCLUSIONS: Empyema necessitatis is a rare condition. To our knowledge, this is the first report of empyema necessitatis caused by F. necrophorum. Correct diagnosis with a culture and imaging technologies like CT is warranted.
Reference #1: Freeman AF, Ben-Ami T, Shulman ST. Streptococcus pneumoniae empyema necessitatis. Pediatr Infect Dis J. 2004; 23: 177-9.
Reference #2: Hockensmith ML, Mellman DL, Aronsen EL. Fusobacterium nucleatum empyema necessitans. Clin Infect Dis. 1999; 29:1596-8.
DISCLOSURE: The following authors have nothing to disclose: Yoko Takahashi, Masatomo Kiyota, Noriyuki Ebi
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