313
Alerts, Notices, and Case Reports Failure to Recognize Late Postpneumonectomy Empyema Role of Diagnostic Thoracentesis MAXINE A. PAPADAKIS, MD SUSAN D. WALL, MD San Francisco
POSTPNEUMONECTOMY EMPYEMA, an unusual occurrence, generally occurs soon after pneumonectomy.1 We describe a case of late empyema necessitatis-extension of an empyema to the chest wall-which presented eight months after the patient had a lung resection for squamous cell carcinoma.
Report of a Case The patient, a 60-year-old man with chronic obstructive pulmonary disease, underwent a left pneumonectomy for squamous cell carcinoma of the lung in 1986. There were no untoward infectious complications postoperatively. Five months later, he was admitted to the medicine service with exacerbations of his underlying pulmonary insufficiency. New findings included a temperature of 37.7°C, a pericardial friction rub, splenomegaly, and anemia of chronic disease with leukocytosis. A chest x-ray film showed persistent but unchanged left pleural opacification, compatible with a left pneumonectomy. An extensive investigation failed to elicit a cause for his deterioration. In the absence of localizing symptoms to the left chest, a thoracentesis or chest computed tomographic (CT) scan was not done. The diagnosis was a presumed viral syndrome and the patient was discharged on a regimen of prednisone, 20 mg a day, for his obstructive respiratory disease. Six weeks later the patient was readmitted for respiratory insufficiency and hemoptysis. His temperature was 38.4°C. There was no pericardial or pleural friction rub, and the splenomegaly had diminished. Laboratory data included a hemoglobin of 100 grams per liter and a leukocyte count of 19 x 109 per liter, with a polymorphocytic predominance. A chest roentgenogram was unchanged from previous postoperative films. One week later, a bulging left axillary mass developed abruptly. A contrast-enhanced chest CT scan was done (Figure 1). The patient underwent surgical drainage of a 3-liter empyema necessitatis. No recurrence of carcinoma or bronchopleural fistula was found. Cultures of the purulent fluid grew Streptococcus viridans and anaerobic peptococci. The patient is alive two years later.
postpneumonectomy empyema occur late, or more than 1 month to 25 years after the operation.3 A delay in diagnosis of several months is the rule.2 After a pneumonectomy, fluid that has accumulated in the pleural space clots and becomes a fibrotic mass, but the cavity is not completely obliterated. Isolated areas of fluid may persist for years and be a nidus for bacterial seeding, either by direct extension from a fistula or by hematogenous spread.24 Risk factors for the development of postoperative empyema include the size of resection; pneumonectomy confers the highest risk. This case shows the difficulty in the diagnosis of late postpneumonectomy empyema. The postoperative course is unremarkable for most patients.2 Symptoms of the empyema are mainly infectious and constitutional and may resemble an influenzalike syndrome. Often there are no localizing signs to the chest.2 In retrospect, the presence of a pericardial friction rub was suggestive of a contiguous infection. The absence of gas on a chest x-ray film does not rule out a postpneumonectomy empyema. If the cause of the empyema is a fistula, either bronchopulmonary or esophagopulmonary, gas is generally seen on a chest film that had previously shown postoperative opacification. In patients with late-onset postpneumonectomy empyema in whom empyema necessitatis develops, a fistula tends not to be the cause of the infection and, therefore, these patients do not have gas on the chest radiograph.2 In our patient, extension of the empyema to the chest wall probably occurred because there was no means of decompression through fistulization to either a bronchus or the esophagus. When a patient with a previous pneumonectomy, no matter how long ago, is undergoing an evaluation for a source of infection, the pneumonectomy space must be considered as a possible site. Comnputed tomographic evaluation of the pneumonectomy space may be of some help.5 Fluid-filled spaces, as well as re-expansion of the postoperative hemithorax with mediastinal shift to the midline due to pleural expansion, may be shown. Diagnostic thoracentesis, with ultrasonographic or CT guidance, if necessary, should be strongly encouraged even if lung imaging studies fail to identify the pleural space as a source of infection.2
Comments Empyema necessitatis was mainly seen in the prechemotherapy era with tuberculosis and, now, after resection for pulmonary carcinoma.2 As many as 25% of cases of (Papadakis MA, Wall SD: Failure to recognize late postpneumonectomy empyema-Role of diagnostic thoracentesis. West J Med 1990
Sep; 153:313-314) From the Departments of Medicine (Dr Papadakis) and Radiology (Dr Wall), Veterans Administration Medical Center, and the University of California, San Francisco, School of Medicine. Reprint requests to Maxine A. Papadakis, MD, Veterans Administration Medical Center, 4150 Clement St 111A1, San Francisco, CA 94121.
Figure 1.-A computed tomographic scan taken at the level of the main pulmonary artery shows a large left pleural fluid collection that has re-expanded the left hemithorax, shifted the mediastinum back to the midline, and extended into the left chest wall at the site of a previous rib resection.
314
ALERTS, NOTICES, AND CASE REPORTS REFERENCES
1. Zumbro GL, Treasure R, Geiger JP, et al: Empyema after pneumonectomy. Ann Thorac Surg 1973; 15:615-621 2. Kerr WF: Late-onset post-pneumonectomy empyema. Thorax 1977; 32: 149-154 3. Kirsh MM, Rotman H, Behrendt DM, et al: Complications of pulmonary resection. Ann Thorac Surg 1975; 20:215-236 4. Holden MP, Wooler GH: 'Pus somewhere, pus nowhere else, pus over the dia2hragm'-Post-pneumonectomy emphyema necessitatis. Am J Surg 1972;
5. Heater K, Revzani L, Rubin JM: CT evaluation of empyema in the postpneumonectomy space. AJR 1985; 145:39-40
11
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Alerts, Notices, and Case Reports Failure to Recognize Late Postpneumonectomy Empyema Role of Diagnostic Thoracentesis MAXINE A. PAPADAKIS, MD SUSAN D. WALL, MD San Francisco
POSTPNEUMONECTOMY EMPYEMA, an unusual occurrence, generally occurs soon after pneumonectomy.1 We describe a case of late empyema necessitatis-extension of an empyema to the chest wall-which presented eight months after the patient had a lung resection for squamous cell carcinoma.
Report of a Case The patient, a 60-year-old man with chronic obstructive pulmonary disease, underwent a left pneumonectomy for squamous cell carcinoma of the lung in 1986. There were no untoward infectious complications postoperatively. Five months later, he was admitted to the medicine service with exacerbations of his underlying pulmonary insufficiency. New findings included a temperature of 37.7°C, a pericardial friction rub, splenomegaly, and anemia of chronic disease with leukocytosis. A chest x-ray film showed persistent but unchanged left pleural opacification, compatible with a left pneumonectomy. An extensive investigation failed to elicit a cause for his deterioration. In the absence of localizing symptoms to the left chest, a thoracentesis or chest computed tomographic (CT) scan was not done. The diagnosis was a presumed viral syndrome and the patient was discharged on a regimen of prednisone, 20 mg a day, for his obstructive respiratory disease. Six weeks later the patient was readmitted for respiratory insufficiency and hemoptysis. His temperature was 38.4°C. There was no pericardial or pleural friction rub, and the splenomegaly had diminished. Laboratory data included a hemoglobin of 100 grams per liter and a leukocyte count of 19 x 109 per liter, with a polymorphocytic predominance. A chest roentgenogram was unchanged from previous postoperative films. One week later, a bulging left axillary mass developed abruptly. A contrast-enhanced chest CT scan was done (Figure 1). The patient underwent surgical drainage of a 3-liter empyema necessitatis. No recurrence of carcinoma or bronchopleural fistula was found. Cultures of the purulent fluid grew Streptococcus viridans and anaerobic peptococci. The patient is alive two years later.
postpneumonectomy empyema occur late, or more than 1 month to 25 years after the operation.3 A delay in diagnosis of several months is the rule.2 After a pneumonectomy, fluid that has accumulated in the pleural space clots and becomes a fibrotic mass, but the cavity is not completely obliterated. Isolated areas of fluid may persist for years and be a nidus for bacterial seeding, either by direct extension from a fistula or by hematogenous spread.24 Risk factors for the development of postoperative empyema include the size of resection; pneumonectomy confers the highest risk. This case shows the difficulty in the diagnosis of late postpneumonectomy empyema. The postoperative course is unremarkable for most patients.2 Symptoms of the empyema are mainly infectious and constitutional and may resemble an influenzalike syndrome. Often there are no localizing signs to the chest.2 In retrospect, the presence of a pericardial friction rub was suggestive of a contiguous infection. The absence of gas on a chest x-ray film does not rule out a postpneumonectomy empyema. If the cause of the empyema is a fistula, either bronchopulmonary or esophagopulmonary, gas is generally seen on a chest film that had previously shown postoperative opacification. In patients with late-onset postpneumonectomy empyema in whom empyema necessitatis develops, a fistula tends not to be the cause of the infection and, therefore, these patients do not have gas on the chest radiograph.2 In our patient, extension of the empyema to the chest wall probably occurred because there was no means of decompression through fistulization to either a bronchus or the esophagus. When a patient with a previous pneumonectomy, no matter how long ago, is undergoing an evaluation for a source of infection, the pneumonectomy space must be considered as a possible site. Comnputed tomographic evaluation of the pneumonectomy space may be of some help.5 Fluid-filled spaces, as well as re-expansion of the postoperative hemithorax with mediastinal shift to the midline due to pleural expansion, may be shown. Diagnostic thoracentesis, with ultrasonographic or CT guidance, if necessary, should be strongly encouraged even if lung imaging studies fail to identify the pleural space as a source of infection.2
Comments Empyema necessitatis was mainly seen in the prechemotherapy era with tuberculosis and, now, after resection for pulmonary carcinoma.2 As many as 25% of cases of (Papadakis MA, Wall SD: Failure to recognize late postpneumonectomy empyema-Role of diagnostic thoracentesis. West J Med 1990
Sep; 153:313-314) From the Departments of Medicine (Dr Papadakis) and Radiology (Dr Wall), Veterans Administration Medical Center, and the University of California, San Francisco, School of Medicine. Reprint requests to Maxine A. Papadakis, MD, Veterans Administration Medical Center, 4150 Clement St 111A1, San Francisco, CA 94121.
Figure 1.-A computed tomographic scan taken at the level of the main pulmonary artery shows a large left pleural fluid collection that has re-expanded the left hemithorax, shifted the mediastinum back to the midline, and extended into the left chest wall at the site of a previous rib resection.
314
ALERTS, NOTICES, AND CASE REPORTS REFERENCES
1. Zumbro GL, Treasure R, Geiger JP, et al: Empyema after pneumonectomy. Ann Thorac Surg 1973; 15:615-621 2. Kerr WF: Late-onset post-pneumonectomy empyema. Thorax 1977; 32: 149-154 3. Kirsh MM, Rotman H, Behrendt DM, et al: Complications of pulmonary resection. Ann Thorac Surg 1975; 20:215-236 4. Holden MP, Wooler GH: 'Pus somewhere, pus nowhere else, pus over the dia2hragm'-Post-pneumonectomy emphyema necessitatis. Am J Surg 1972;
5. Heater K, Revzani L, Rubin JM: CT evaluation of empyema in the postpneumonectomy space. AJR 1985; 145:39-40
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