Empyema Necessitans Due to Klebsiella Bacterial Pneumonia

Abstract

INTRODUCTION: Empyema necessitans (EN) is a rare condition resulting from a communicating track between an intrathoracic infection and the chest wall [1]. The use of antibiotics has made EN rare, with an estimated incidence of 2% in the United States [2]. We present a case of a 54-year-old male, who was found to have EN and sputum culture, suggestive of Klebsiella pneumonia. CASE PRESENTATION:A 54-year-old male, with no past medical history, presented complaining of progressive, constant weakness for four days. It was also associated with a mild non-productive cough, shortness of breath, subjective fever, and intermittent diarrhea.On presentation, the patient was febrile to 102.1 degrees Fahrenheit, but was otherwise vitally stable. On exam, he was in respiratory distress, with rales in bilateral lower lung fields and erythema from the right chest wall extending down to the right flank. He was also found to have leukocytosis and lactic acidosis. Sputum culture returned positive for Klebsiella pneumoniae, confirming intrapulmonary Klebsiella infection. The patient was started on ceftriaxone 2g daily. He underwent video-assisted thoracoscopic surgery (VATS) and decortication, followed by placement of two chest tubes and a wound vacuum. He was then discharged on oral cefuroxime therapy.DISCUSSION: EN involves sinus tract formation from the chest cavity to the chest wall. Bacterial infections associated with EN include M. tuberculosis, A. Israeli, as well as Staphylococcus, Pseudomonas, and Proteus species [1], [3]. Empyemas commonly develop in immunocompromised patients, such as those with malignancy, diabetes mellitus, or tuberculosis [1]. Prior to the availability of antibiotics, EN was a complication in 5% of parapneumonic effusions [2]. Diagnosis of EN relies on imaging and pleural fluid analysis. The American Association for Thoracic Surgery (AATS) guidelines suggest chest x-ray and pleural ultrasound analysis to visualize effusions and empyema. Sizing of the effusion is also essential in order to determine the viability of thoracentesis.Current recommendations for community-acquired infections include the use of 2nd or 3rd generation cephalosporin with metronidazole or penicillin-beta lactamase inhibitor combination therapy. Hospital-acquired infections, however, rely on coverage of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. In addition to antibiotic therapy, it is recommended to perform thoracentesis [2]. VATS is an acceptable surgical solution to EN with advanced stage empyemas requiring decortication due to treatment failure [3].CONCLUSIONS: While EN is a rare clinical manifestation, it warrants a high index of suspicion due to its high mortality rate. EN also increases the risk for sepsis and systemic spread of infection. Therefore early recognition, diagnosis, and treatment of EN can be greatly beneficial for patients.