Chronic empyema: importance of preventing complications in the management of pleural effusions

Our plain-English summary of Chronic empyema: importance of preventing complications in the management of pleural effusions, by V. Molander, M. Diakopoulou, L. Orre, et al (BMJ Case Reports, 2013).

The study

• Authors: V. Molander, M. Diakopoulou, L. Orre, G. Ferrara
• Journal: BMJ Case Reports
• Published: 2013;2013
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

We report a case of chronic empyema in a 63-year-old man with a history of asbestos exposure and alcohol overconsumption. In 2009, he presented with dyspnoea, exudative pleurisy on the right side with no symptoms of infection or malignancy. In 2013, the patient presented with increased dyspnoea and a massive chronic empyema had evolved. Culture of the pleural fluid was positive for Escherichia coli and anaerobic bacteria, and he was treated with antibiotics, chest drainage as well as surgical evacuation. After surgery, as the lung failed to expand, growth of opportunistic bacteria and rising C reactive protein obliged long-time treatment with broad-spectrum antibiotics as well as chest drainage with daily saline flushes. The patient still suffers from fatigue, poor nutritional status and anaemia, and further treatment with chest drainage and antibiotics is planned. Advanced chronic empyema is a difficult condition with poor response to treatment, and diagnostic delay is the main cause of complications.

In plain English

This was a case report from Karolinska University Hospital in Stockholm, Sweden, about one 63-year-old man. He was a previous smoker with a history of asbestos exposure and alcohol overconsumption. The article did not describe the source, fiber type or amount of his asbestos exposure. In January 2009 he had a rapidly growing fluid build-up around his right lung, and 15 L of fluid were drained in a few days. No cancer or infection was found, and he was diagnosed with exudative pleurisy, likely secondary to asbestos. Over the next years the fluid returned, his lung could not re-expand, and mesothelioma was suspected but never confirmed. He declined surgery. In January 2013, drained pleural fluid grew Escherichia coli and anaerobic bacteria, and a massive chronic empyema (pus in the pleural space) was found. Despite antibiotics, drainage and surgery, his recovery was complicated by bleeding, a bronchopleural fistula and intensive care. His right lung did not re-expand, and in early June 2013 he was still in hospital. The authors concluded that diagnostic and interventional delay is extremely detrimental in managing pleural infections.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (one patient)
• Who was studied: One 63-year-old man, a previous smoker, first seen at a peripheral hospital in January 2009 and later managed at Karolinska University Hospital, Stockholm, Sweden, followed until early June 2013
• Exposure: A history of asbestos exposure (fiber type, job and dose not described), along with previous smoking and alcohol overconsumption
• Main results:
  • In 2009, 15 L of exudative pleural fluid were drained from the right side over a few days. No signs of malignancy or infection were found, and he was diagnosed with exudative pleurisy, likely secondary to asbestos.
  • After drainage of a recurrent effusion in late 2009, the lung could not expand ('trapped lung'). Thoracoscopic biopsies and cytology were negative for malignancy or infectious diseases.
  • In April 2012, a CT scan showed thickened pleura and raised suspicion of mesothelioma. A PET CT did not confirm mesothelioma, and later tissue samples also showed no malignancy.
  • In January 2013, cultures of dark, smelling pleural fluid were positive for Escherichia coli and anaerobic bacteria. Opportunistic bacteria (Enterococcus faecium, Stenotrophomonas maltophilia) were found later.
  • After surgical evacuation of the empyema, the postoperative period included massive bleeding, two re-operations, a bronchopleural fistula, a tracheostomy and intensive care. C reactive protein reached 428.
  • After surgery the right lung still failed to re-expand. The patient stayed in hospital more than 5 months, needed continuous chest drainage, and in early June 2013 had fatigue, dyspnoea and weight loss.
• The authors' conclusion: The authors concluded that diagnostic and interventional delay is extremely detrimental in the management of pleural infections, which need early diagnosis and treatment to avoid severe complications.
• Limitations the authors state:
  • The authors stated that microbiology was of limited value: no isolated organism could be identified as the cause of the empyema, and healthcare-related infections could not be excluded.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Empyema, Pleural Effusion, Asbestos Exposure, Pleurisy.

Related studies

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• Awake video-assisted pleural decortication for empyema thoracis — F. Tacconi, E. Pompeo, et al. (2010)
• Malignant pleural mesothelioma presenting as acute empyema with severe leukocytosis — K. Matsuoka (2014)
• Sonography of the pleura — J. Reuss (2010)
• The relative importance of clinical, radiological and pulmonary function variables in evaluating asbestosis and chronic obstructive airway disease in asbestos workers — G.M. Regan, B. Tagg, et al. (1971)
• Pleural effusion in an asymptomatic patient. Spectrum and frequency of causes and management considerations — N.A. Smyrnios, P.J. Jederlinic, et al. (1990)

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