Discussion
Empyema necessitans (EN) is a rare and potentially life-threatening condition that requires timely diagnosis and treatment to prevent significant morbidity and mortality (7, 8). Due to its uncommon nature, EN can be challenging to identify and manage (1, 9). Empyema necessitans occurs when an untreated empyema spreads through the parietal pleura and forms abscesses in the subcutaneous tissue of the anterior chest wall (10, 11). This often arises as a complication of an untreated parapneumonic effusion, which is the most common underlying cause and responsible for approximately 70% of cases (7).
EN is typically caused by the same organism responsible for the pneumonia that preceded it (2, 12). According to a review of 26 cases published after 1966, Mycobacterium tuberculosis andActinomyces species were found to be responsible for 75% (20/26) of cases (13). This highlights the importance of considering these organisms in the differential diagnosis of patients with suspected empyema necessitans, particularly in areas with a high prevalence of tuberculosis. Accurate identification of the underlying organism is critical to guiding appropriate antimicrobial therapy and improving patient outcomes.
One of the less common causes of empyema necessitans isStaphylococcus aureus , with less than 10 case reports of empyema necessitans caused by this bacterium found in a search of the PubMed database.
White-Dzuro CG et al. reported a rare case of a 55-year-old male patient presenting with right shoulder and upper chest pain, diagnosed withmethicillin-sensitive Staphylococcus aureus empyema necessitans. As treatment, intravenous antibiotics were initiated, followed by surgical intervention and thoracic reconstruction to effectively manage the condition (1). In another study, C. Preston Pugh et al. reported a case of empyema necessitans (EN) caused by MRSA in a 5-year-old boy with a ventricular shunt due to hydrocephalus and a history of type A influenza infection one week before the onset of fever and chest pain. The patient underwent treatment that included antibiotic therapy, chest tube insertion, and the infusion of a fibrinolytic agent to manage the condition (14). Moreover, S. Basndaru et al. documented a case of a 29-year-old man with a heroin addiction who presented with empyema necessitans and a complex lesion on the tricuspid valve. The causative bacterial agent underlying these conditions was identified asStaphylococcus aureus upon further evaluation (15).
In managing cases of loculated pleural empyema, the most effective approach is considered to be the injection of fibrinolytic agents into the pleural space, resulting in a complete recovery. If the designated timeframe for administering fibrinolytics for empyema treatment has elapsed, our therapeutic approach will transition to VATS with the option to switch to thoracotomy if required as a result of the chronic nature of the disease (16-19). Conservative treatments such as thoracostomy tubes are often inadequate to manage organized empyemas, and studies have found that patients who undergo VATS have lower mortality rates and significantly reduced 30-day readmission rates compared to those treated with tube thoracostomy (20). These findings highlight the importance of selecting the most appropriate treatment strategy for patients with loculated pleural empyema, as it can significantly impact their outcomes.
Alongside surgical interventions, the administration of appropriate antibiotics based on the microbial coverage determined from the patient’s culture specimens plays a crucial role in the treatment process.
In the case discussed in this article, the patient did not receive treatment with fibrinolytic agents during their hospitalization at Zahedan Medical Center. As a result, the empyema treatment process was incomplete, leading to a disease relapse in EN. Due to the loss of the golden window for fibrinolytic injection in the patient, the patient was treated with VATS and chest tube insertion. This emphasizes the importance of personalized treatment plans and the need to consider all available options for patients with loculated pleural empyema, taking into account their unique circumstances and medical history.