Empyema Necessitatis

Abstract

A 45-year-old man with a history of incarceration complained of right sided chest pain, nonproductive cough, and an area of painful swelling on his right back. Magnetic resonance imaging (MRI) of the chest showed empyema necessitatis ( Figs. 1 and 2). A purified protein derivative (PPD) test was positive at 13 mm of induration. Three acid-fast bacilli sputum smears were negative and he underwent drainage through chest tube placement. Blood cultures and drained fluid cultures were both negative. He was started on four-drug therapy for suspected tuberculous empyema necessitatis. After discharge, sputum cultures grew out Mycobacterium avium complex and Mycobacterium gordonae. He was continued on isoniazid, pyrazinamide, rifampin and ethambutol, but did not receive a full course of treatment due to poor compliance.Empyema necessitatis is a rare complication of empyema that occurs when pleural infection extends into the chest wall. 1 The most commonly reported pathogen is Mycobacterium tuberculosis, followed by Actinomyces species. Other organisms that have been implicated as causes of empyema necessitatis include Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus milleri, Burkholderia cepacia and Mycobacterium avium-intracellulare. 2 Often no causative organism is identified. The treatment of empyema necessitatis is surgical drainage in combination with antimicrobials, including consideration of antituberculous medications when appropriate. 2

Actinomyces Meyeri Empyema Necessitatis—A Case Report and Review of the Literature

“…1 Surgical intervention is also the treatment of choice for the rare complication of extended local infection through the chest wall known as empyema necessitatis. 2 On one hand the etiology of empyema and, particularly, the causative organism has almost no impact on the initial performed surgical intervention of infected tissue excision. On the other hand, for the further postoperative treatment, especially type and duration of antibiotics, knowledge of the causal agent is crucial.…”

Radiological features and surgical management of lung abscess directly extending into the chest wall: A case report

“…Thoracic empyema, which is defined as the presence of bacteria or pus in the pleural cavity, is a potentially fatal infection with high morbidity and mortality rates. Empyema necessitatis is a rare complication of empyema in which the pleural infection spreads outside the pleural space to involve the soft tissues of the chest wall [ [7] , [8] , [9] , [10] ]. It can present as pleuritic chest pain.…”

“…It can present as pleuritic chest pain. Most commonly, an enlarging soft tissue mass is present on the chest wall [ [7] , [8] , [9] , [10] ]. In the present case, continuous passage of air from the lung abscess to the subcutaneous emphysema under the pectoralis was observed on CT ( Fig.…”

Empyema Necessitatis: A Rare Complication of Empyema

“…However, negative culture results do not necessarily exclude infectious causes of EN as organisms may be difficult to isolate. In fact, it is not uncommon for no causative organism to be identified in EN [ 7 ]. An infectious disease consultation should also be obtained.…”

“…The most common causative organisms of EN today are M. tuberculosis and Actinomyces israelii , while other less common causative agents include methicillin-resistant Staphylococcus aureus (MRSA) and fungi [ 7 ]. In cases of suspected EN, empiric therapy is usually given until final culture results are available [ 7 ]. Our patient received IV vancomycin, cefepime, and metronidazole for 14 days.…”