Keywords pleural empyema - pyothorax - SARS COVID-19 infection - pneumonectomy - aspergillosis
- bronchial stump insufficiency
Introduction
Pleural empyema, or pyothorax, is the accumulation of purulent exudate between the
parietal and visceral pleura as a result of infection of the pleural cavity.[1 ]
Although pneumonia is considered the most common cause of pleural empyema, complications
following thoracic surgery, such as trauma, iatrogenic infections, and pneumonectomy,
can also lead to pleural empyema.[2 ]
[3 ]
Pneumonectomy can also be associated with other complications. Early complications
are those described as occurring within the first 30 days postoperatively. The second
most common early complications include postoperative pneumonia. Furthermore, postoperative
atelectasis, pulmonary embolism, bronchopleural fistula, wound infection, and postoperative
hemorrhage may occur. In the later course, bronchial fistula is prominent, for example,
as bronchus stump insufficiency after pneumonectomy with accompanying pleural empyema.[4 ]
In the therapy of postpneumonectomy pleural empyema, there are basically two treatment
options, surgical therapeutic procedures with additional antimicrobial therapy if
needed or pure conservative treatment. The conservative treatment method includes
antimicrobial therapy, chest drain placement, and intrapleural fibrinolysis.[5 ]
This article describes the conservative management of a postpneumonectomy empyema
using antimicrobial therapy and placement of a chest drain in combination with daily
lavage of the postpneumonectomy space.
Case Description
A 58-year-old patient with a history of seminoma, lymphoma, hepatitis C infection,
and heavy nicotine abuse underwent a right-sided pneumonectomy due to a destroyed
lung syndrome after invasive pulmonary aspergillosis ([Fig. 1A ]; July 3, 2021). On postoperative day 1, he went for a smoke and developed left-sided
pneumonia, which led to acute respiratory distress syndrome (ARDS). In addition to
left-sided pneumonia, the computed tomography (CT) images ([Fig. 1B ]) showed subcutaneous emphysema and a slight mediastinal shift to the left. Since
these findings were compatible with a bronchopleural fistula, a bronchoscopy was ordered
on the third postoperative day, which ruled out a bronchopleural fistula. A venovenous
extracorporeal membrane oxygenation therapy (VV-ECMO) was started and carried out
for the following 20 days. Shortly before termination of the ECMO therapy, gram-positive
cocci and gram-negative Citrobacter were detected in bronchial secretions. After ECMO therapy and tracheostomy weaning,
the patient was transferred to a pulmonary rehabilitation center. The endotracheal
tube was in place from September 26th to October 5th, 2021, and the tracheostomy tube
was in place from October 5th to 20th, 2021. No air leak was described. The patient
was transferred to the rehabilitation center without a chest tube.
Fig. 1 (A–D ) Diagnostics via axial computed tomography (CT). COVID-19 was diagnosed on December
21, 2021. The next available CT is dated January 7, 2022 and thus does not correspond
to COVID-19 pneumonia. The CT (C ) from January 7, 2022 corresponds to the condition after COVID-19 infection with
the question for possible surgery planning. Except for the known aspergilloma for
7 years, no other previous lung diseases are known. (A ) Preoperative CT. (B ) Postoperative CT. (C ) CT before intrapleural lavage with vancomycin. (D ) CT after removal of the thoracic drainage.
Four weeks later, he presented with partial respiratory insufficiency and fever due
to COVID-19 pneumonia of the left lung. Additionally, a bronchial stump insufficiency
was suspected. Staphylococcus aureus was detected in the pleural punctate. Antibiotic therapy with meropenem was started,
which was extended later with cephazolin in place of flucloxacillin in accordance
with the antibiogram and due to the lower liver toxicity with known hepatitis C infection.
Standard supportive therapy for COVID-19 pneumonia with rosuvastatin, urbason, and
anticoagulation was continued. The patient had a chest tube placed on the right side
at the referring hospital without an air leak after arrival at our center. Bronchoscopy
excluded the suspicion of bronchial stump insufficiency.
Due to COVID-19 pneumonia, reduced performance status, and morphologic changes of
the lung parenchyma, seen in the computed tomography (CT) scans ([Fig. 1C ]), we considered the patient inoperable for a thoracoplasty. Daily intrathoracic
vancomycin (2 g in 2-L “full electrolyte solution”) irrigation was performed for 11
days via the placed chest tube. After germ-free swabs of the chest tube, final irrigation
with vancomycin, caspofungin, and gentamycin was performed, and the chest tube was
subsequently withdrawn ([Fig. 1D ]). The further hospital stay was uneventful. With a germ-free smear, the chest tube
was removed on January 19th, 2022. In the further course, there was a single dyspnea
symptom with a drop in saturation, which was resolved by inhalation therapy with salbutamol.
The patient spent another 12 days in inpatient care without chest drainage. The patient
was transferred to a postoperative rehabilitation clinic. The follow-up was done in
an outpatient clinic near his hometown.
Discussion
Based on this case, we were able to demonstrate that conservative treatment can be
successful in the therapy of postpneumonectomy empyema. There is still disagreement
in the current literature. The Cochrane collaboration has shown that most recommendations
do not take into account comorbidities, underlying lung function, the severity of
concomitant or causative pneumonia, the degree of pleural inflammation, and/or the
virulence of the pathogens detected.[6 ]
In this case, surgical treatment of postpneumonectomy empyema was not possible due
to the presence of COVID-19 infection and reduced performance status. However, pleural
empyema could be successfully treated purely conservatively despite predamaged lung
and past COVID-19 infection.
Conservative treatment in our case included established COVID-19 therapy with a glucocorticoid,
a statin, and an anticoagulant. After S. aureus was detected in the pleural puncture, antibiotic therapy was started with 1 g of
meropenem intravenously, three times daily. In addition, the patient received daily
intrapleural lavages with 2 g of vancomycin dissolved in 2 L of “full electrolyte
solution” for 10 days. This was adapted from our experience with vancomycin irrigation
of the pleura in parapneumonic pleural empyema and in the treatment of mediastinitis.[7 ]
Conclusion
Our case shows the viability of adequate drainage of the empyema in combination with
repeated irrigation of the postpneumonectomy cavity and long-course antibiotic therapy
as an alternative treatment option. We used vancomycin as a local irrigation solution
because of its broad spectrum of activity, covering the most common pathogens of pleural
empyema.
Conservative treatment in these patients is not the standard therapy but should be
considered in patients with reduced operability.
