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Point and Counterpoint |

Rebuttal From Dr Lai et alRebuttal From Dr Lai et al FREE TO VIEW

Yu Kuang Lai, MD; Glenn Eiger, MD, FCCP; Robert A. Fischer, MD
Author and Funding Information

From the Department of Internal Medicine (Drs Lai and Eiger), and the Department of Infectious Disease (Dr Fischer), Einstein Medical Center.

CORRESPONDENCE TO: Yu Kuang Lai, MD, Department of Internal Medicine, Einstein Medical Center, 5501 Old York Rd, Klein 363, Philadelphia, PA 19141; e-mail: laijulie@einstein.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1210-1211. doi:10.1378/chest.15-0093
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The well-constructed argument of Dr Nguyen and colleagues1 that spontaneous bacterial empyema (SBEM) is essentially a complication of spontaneous bacterial peritonitis (SBP) consists of six points: (1) Both hepatic hydrothorax and SBEM occur mostly in the right lung, (2) ascitic fluid and pleural fluid in patients with cirrhosis have reduced opsonic activity, (3) SBEM is often caused by enteric organisms, (4) SBP may have been missed in some reports because of failure to culture in broth, (5) pneumonia may have been missed in some reports because of failure to obtain CT scan or ultrasonography, and (6) SBEM is a bad term because the infected fluid may be transudative.

Our rebuttal addresses these points in sequence.

  1. The predominance of the right side for both hydrothorax and SBEM is entirely compatible with the proposed pathogenesis of SBEM occurring as a result of transient bacteremic seeding of preexisting hepatic hydrothorax.

  2. Similarly, the reduced opsonic activity in both ascites and pleural fluid is compatible with an increased risk for both SBP and SBEM in patients with cirrhosis but does not imply that the latter always represents a complication of the former. Furthermore, there are cases of SBEM in patients without ascites.2-4

  3. The frequent occurrence of enteric organisms as etiologic agents of SBEM does not imply that infection spreads by direct extension from the abdomen to the thorax; an equally plausible explanation is that patients with cirrhosis are prone to transient bacteremias with enteric organisms as a result of bacterial overgrowth and translocation, altered gut permeability, and depression of the hepatic reticuloendothelial system.5

  4. It is unclear whether broth cultures were used in the studies cited; the study by Xiol et al6 used broth cultures for pleural fluid and may well have used broth cultures for ascites also.

  5. It is unlikely that undiagnosed pneumonia accounts for a significant number of SBEM cases since enteric organisms cause most cases of SBEM but are rarely the agents of bacterial pneumonia.5 Moreover, there are cases of SBEM with negative CT scans of the thorax.7,8

  6. We agree that the use of the word “empyema” is problematic when referring to an infected transudate, but for the sake of historical continuity we are willing to accept this example of dubious nomenclature.

In conclusion, note that we concur with Dr Nguyen and colleagues1 that SBEM requires a high index of suspicion, since symptoms may be vague; that the threshold for performing thoracentesis should be very low in patients with cirrhosis with pleural effusions; and that the management of SBEM is primarily medical, as opposed to typical empyema where it is primarily surgical. Thus, we reiterate that clinicians should be aware of SBEM and recognize it as a unique clinical entity.

References

Nguyen TA, Liendo C, Owens MW. Counterpoint: does spontaneous bacterial empyema occur? No. Chest. 2015;147(5):1208-1210.
 
Abba AA, Laajam MA, Zargar SA. Spontaneous neutrocytic hepatic hydrothorax without ascites. Respir Med. 1996;90(10):631-634. [CrossRef] [PubMed]
 
Garcia-Tsao G. Spontaneous bacterial peritonitis. Gastroenterol Clin North Am. 1992;21(1):257-275. [PubMed]
 
Lam ST, Johnson ML, Kwok RM, Bassett JT. Spontaneous bacterial empyema: not your average empyema. Am J Med. 2014;127(7):e9-e10. [CrossRef] [PubMed]
 
Căruntu FA, Benea L. Spontaneous bacterial peritonitis: pathogenesis, diagnosis, treatment. J Gastrointestin Liver Dis. 2006;15(1):51-56. [PubMed]
 
Xiol X, Castellví JM, Guardiola J, et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology. 1996;23(4):719-723. [CrossRef] [PubMed]
 
Nguyen H, Gupta S, Eiger G. Spontaneous bacterial empyema in a noncirrhotic patient: an unusual scenario. Am J Med Sci. 2011;342(6):521-523. [CrossRef] [PubMed]
 
Mofredj A, Guérin JM, Leibinger F, Masmoudi R. Spontaneous pleural empyema due toYersinia enterocoliticaSouth Med J. 2003;96(5):525-527. [CrossRef] [PubMed]
 

Figures

Tables

References

Nguyen TA, Liendo C, Owens MW. Counterpoint: does spontaneous bacterial empyema occur? No. Chest. 2015;147(5):1208-1210.
 
Abba AA, Laajam MA, Zargar SA. Spontaneous neutrocytic hepatic hydrothorax without ascites. Respir Med. 1996;90(10):631-634. [CrossRef] [PubMed]
 
Garcia-Tsao G. Spontaneous bacterial peritonitis. Gastroenterol Clin North Am. 1992;21(1):257-275. [PubMed]
 
Lam ST, Johnson ML, Kwok RM, Bassett JT. Spontaneous bacterial empyema: not your average empyema. Am J Med. 2014;127(7):e9-e10. [CrossRef] [PubMed]
 
Căruntu FA, Benea L. Spontaneous bacterial peritonitis: pathogenesis, diagnosis, treatment. J Gastrointestin Liver Dis. 2006;15(1):51-56. [PubMed]
 
Xiol X, Castellví JM, Guardiola J, et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology. 1996;23(4):719-723. [CrossRef] [PubMed]
 
Nguyen H, Gupta S, Eiger G. Spontaneous bacterial empyema in a noncirrhotic patient: an unusual scenario. Am J Med Sci. 2011;342(6):521-523. [CrossRef] [PubMed]
 
Mofredj A, Guérin JM, Leibinger F, Masmoudi R. Spontaneous pleural empyema due toYersinia enterocoliticaSouth Med J. 2003;96(5):525-527. [CrossRef] [PubMed]
 
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