Thoracic empyema – A review based on three cases reports

 

Antonio Murinello* 1

A Manuel Figeiredo* 2

Júlio Semedo** 3

Helena Damásio* 4

N Carrilho Ribeiro*** 5

Helena Peres**** 6

 

 

Abstract

Complicated parapneumonic effusion is one in which an invasive procedure is necessary for its resolution and empyema means pus in the pleural space. An early diagnosis and therapy of these conditions results in less morbidity and mortality. CT of the chest is important to study complex pleural effusions. Loculated effusions, those occupying more than 50% of the thorax, or which show positive Gram stain or bacterial culture, or a purulent effusion with a pH below 7.20, with a glucose level below 60 mg/dl or a LDH level more than three times the upper limit of normal for serum, are indications for an invasive procedure. These characteristics result from the evolution of a not well treated parapneumonic effusion, through the three stages: (1) exsudative; (2) fibrinopurulent; (3) fibrotic. Depending on the stage therapeutic methods vary from therapeutic thoracentesis, insertion of a chest tube with or without instillation of fibrinolytics, video-assisted thoracoscopic surgery, and lung decortication. A review of all these aspects are done based on a series of three cases reports with very different clinical presentation: one patient with empyema by Streptococcus pyogenes and that died rapidly due to massive hemoptysis; a patient with empyema due to acute pneumonia developing during an airflight; a patient with empyema and bacteraemia by Streptococcus pneumonia leading to the diagnosis of an unknown HIV infection.

Key-words: Empyema, parapneumonic effusion, Streptococcus pyogenes, pneumococcus, HIV.

 

 

Empiema torácico – Revisão baseada em três casos clínicos

Resumo

O derrame parapneumónico caracteriza-se pela necessidade de um processo invasivo para a sua resolução e o empiema pela presença de pus na cavidade pleural. Em ambos os casos, o diagnóstico por TAC e o tratamento precoces resultando em menores morbilidade e mortalidade. São indicação para um tratamento invasivo os derrames loculados, os que ocupam mais de 50% do tórax, os que revelam coloração por Gram e exame cultural positivos, ou derrames com pH inferior a 7,20, glucose inferior a 60 mg/dl, e nível de DHL superior a três vezes o limite normal no soro. Estas características resultam da evolução através de três estádios dos derrames incorrectamente tratados: 1) exsudativo; 2) fibrino-purulento; 3) fibrótico. Dependendo do estádio evolutivo, a abordagem terapêutica varia entra toracentese terapêutica, colocação de drenagem torácica com ou sem instilação de fibrinolíticos, cirurgia toracoscópica vídeo-assistida e decorticação pulmonar. Os autores fazem uma revisão do estudo destas situações baseados em três casos clínicos com apresentações muito dispares: uma doente com empiema por Streptococcus pyogenes que faleceu rapidamente por hemoptise maciça; um doente com empiema resultante de pneumonia aguda ocorrida durante um voo de avião; uma doente com empiema e bacteriemia por Streptococcus pneumoniae conduzindo a diagnóstico até então desconhecido de infecção por VIH.

Palavras-chave: Empiema, derrame parapneumónico, Streptococcus pyogenes, pneumococos, VIH, avião.

 

 

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1 Chefe de Serviço Graduado de Medicina Interna/Unit Head, Internal Medicine graduate

2 Interno de Especialidade de Medicina Interna/Intern, Internal Medicine

3 Assistente Hospitalar Graduado de Pneumologia/Consultant, Pulmonology graduate

4 Assistente Hospitalar Graduada de Medicina Interna/Consultant, Internal Medicine graduate

5 Director de Serviço de Radiologia/Director, Radiology Unit

6 Assistente Hospitalar Graduada de Patologia Clínica/Unit Consultant, Clinical Pathology graduate

 

Institutions and units:

* Hospital Curry Cabral – Internal Medicine

** Hospital Pulido Valente – Pneumology

*** Hospital Curry Cabral – Radiology

**** Hospital Curry Cabral – Pathology

 

Recebido para publicação/received for publication: 08.10.27

Aceite para publicação/accepted for publication: 08.12.16