Figure 2. Spiral chest CT scan showing a left chest wall mass contain
air bubbles and thickened septa infavor of empyema.
The patient underwent a septic workup, which included aerobic and
anaerobic blood cultures, polymerase chain reaction (PCR) testing for
respiratory viruses, and an analysis of sputum samples for gram stain,
acid-fast bacilli (AFB), and pyogenic culture, which were found to be
negative. In addition, a specimen of the purulent discharge from the
patient’s chest wall was collected and sent for Gram staining, AFB
staining, and culture. The pyogenic culture of the patient’s discharge
was positive for Staphylococcus aureus .
After confirming the diagnosis of empyema necessitans, which happened as
a complicated side effect of incompletely treated parapnuemonic effusion
due to the lack of fibrinolytic injection in Zahedan Medical Centre, the
patient was started on a treatment plan involving intravenous (IV)
administration of a broad-spectrum antibiotic regimen, video-assisted
thoracic surgery (VATS), and finally a chest tube insertion. The
antibiotic regimen included vancomycin at a dosage of 200 mg four times
daily, metronidazole at a dosage of 200 mg three times daily, cefepime
at a dosage of 1 g three times daily, and meropenem at a dosage of 400
mg three times daily. As previously mentioned, the most important part
of the treatment was VATS, which was identified as a crucial aspect of
the treatment plan given the prolonged duration of the patient’s EN. In
the surgery performed for the patient, after making an incision along
the midaxillary line, ports were inserted between the 4th and 5th
intercostal spaces. Ports numbered 5 and 10 were implanted for the
patient, and our surgeon entered the thoracic cavity under camera
guidance. There were significant adhesions present in that area. These
adhesions were meticulously dissected and thoroughly irrigated with
ample amounts of saline solution. Additionally, necessary biopsies were
taken from the pleural membrane and lung tissues to confirm the
diagnosis by gram staining and culture. After the surgery, a chest tube
was inserted to facilitate the drainage of purulent secretions. It
allowed for the continuous drainage of fluids from the affected area,
thereby promoting the healing process and helping the patient recover.
The chest tube on the left side was successfully removed after a period
of seven days. In addition, an echocardiogram was conducted to assess
for endocarditis, which yielded negative results. This approach is aimed
at relieving pressure and reducing the risk of further complications
associated with empyema necessitans.
The patient’s recovery was notably smooth and uneventful, with no
reported complications. This positive outcome is a testament to the
effectiveness of the treatment approach employed, which involved a
combination of broad-spectrum antibiotics, VATS, and the insertion of a
chest tube for drainage. Overall, the patient responded well to the
treatment plan and was able to make a full recovery without any
significant issues.