Dr Varsha V S, Dr Jayakumar.C, Dr Vinitha Prasad, Dr Praveena N Bhaskaran, Dr Navya
George.AIMS, Kochi
Seven year old female child, who is developmentally normal with no significant past history presented to the ER with complaints of, on and off fever since 2 weeks
associated with wet cough. Child was treated with macrolides for 2 days,
followed beta lactam for 2 days.
Labs showed raised blood counts and high ESR.
At this time child complained of right sided chest pain and fever and she had
tachypnoea also
Vitals were ,temperature of 100.3F, PR of 121 / min, RR of 38 / min and
Sp02 of 99% in RA. Chest examination reduced air entry in the right
side with stony dull note+ over the rt infra scapular and infra-axillary area. Other
systems within normal limits.
Initial X ray showed Right basal consolidation with pleural effusion.
At this time Child came to our hospital
D/D considered
Synpneumonic effusion,
Empyema,
Lung abscess with bronchopleural
fistula.
Asthma with collapse of right lower lobe
USG chest at admission showed right basal
consolidatory changes with minimal pleural effusion.
Labs showed neutrophilic leucocytosis and high CRP
After taking Blood cultures she was started on Piptaz and vancomycin.
Since fever spikes persisted,
vancomycin was changed to linezolid and repeated the chest X-ray which revealed extensive consolidation and pleural effusion. Repeat USG showed multiple loculation . Hence USG guided diagnostic pleural tap was done, which showed multiple loculated and thick pleural effusion, pleural fluid analysis was suggestive of exudate/? early empyema.
Pleural fluid cytology was neutrophil predominant with TC 1250 cells/mm3 , ADA – 75.70 , LDH – 3666 and pleural fluid protein – 5 which suggestive of exudate/? early empyema
Pleural fluid culture smear AFB /TB, GeneXpert MTB – RIF test were negative.
CECT chest showed features of necrotising pneumonia with empyema on right side
and enlarged mediastinal lymph nodes.
Child underwent video assisted thoracoscopy (VATS )and
debridement. Excision biopsy sections of Pleural peel showed hyalinised tissue with
large areas of necrosis, nuclear debris, ghost outlines and suppuration.
PAS and Grams did not highlight any organism.
AFB culture and tissue culture negative.
Hence diagnosis of Rt Lobar pneumonia with Rt sided empyema was made.
Child improved and discharged after a week
Empyema is defined the presence of intrapleural pus and, it is a type of advanced
parapneumonic effusion.
Complicated parapneumonic effusions (CPE) refer to those fluid collections that require thoracentesis, tube thoracostomy, or surgery for their resolution. The bacteriology of the pleural space varies with patient age. In the pediatric population, the most common implicated organisms are
S pneumoniae, 27%
Saureus, 70 %
Group A streptococci
Klebsiellae 3%
Anaerobic organism
Mixed infections
Tuberculosis
Pseudomonas
Nocardia
Fungal
Light’s Criteria are used to determine whether a pleural effusion is exudative or transudative.
Satisfying any ONE criterium means it is exudative:
• Pleural Total Protein/Serum Total Protein ratio > 0.5
• Pleural lactate dehydrogenase/Serum lactate dehydrogenase ratio > 0.6
• Pleural lactate dehydrogenase level > 2/3 upper limit of the laboratory’s reference range of serum lactate dehydrogenase.
Because of the use of oral antibiotics before the recognition of the parapneumonic effusion, most specimens cultured are sterile;thus, the relative incidences of the aforementioned organisms are not known.
Video-assisted thoracoscopic surgery (VATS) has proven to be an effective and less-invasive replacement for the limited decortication procedure. Thoracoscopic
debridement closely imitates open thoracotomy and drainage. Mechanical removal of purulent material and the breakdown of adhesions can be easily accomplished via this route. VATS results in more rapid relief of symptoms, earlier hospital discharge,
and significantly less discomfort and morbidity. The prognosis for most patients with parapneumonic effusions is quite good.
Intra pleural fibrinolytic therapy (IPFT) has been part of the therapeutic armamentarium to expedite pleural drainage in patients with multiloculate empyema. It is a treatment approach that involves the administration of fibrinolytic agents directly into the pleural space to help break down fibrin deposits and promote drainage of infected fluid. While this therapy has been studied in adults with empyema, its use in children is more limited. One commonly used agent used for IPFT is tissue plasminogen activator (tPA).
TPA is a naturally occurring enzyme in the body that converts plasminogen to plasmin, which, in turn, helps break down fibrin clots.It is frequently used in conjunction with other treatments such as chest tube drainage. Other agents include urokinase and streptokinase, though their use has become less common over time. The choice of fibrinolytic agent may depend on factors such as availability, local protocols, and the specific characteristics of the patient.
The prognosis for most patients with parapneumonic effusions is quite good. Extended antibiotics and surgical interventions may be needed in some patients with complicated parapneumonic effusions (CPE). Despite the variability in presentation, most patients recover without sequelae.
Extended antibiotics and surgical
interventions may be needed in some patients with complicated parapneumonic
effusions (CPE). Despite the variability in presentation, most patients recover without sequel