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.