Empyema Following Pneumonectomy

A 64-year-old man underwent a right pneumonectomy forsquamous cell carcinoma of the right lung. He was dischargedfrom the hospital on the fifth day after surgery.Three weeks later, the patient presented with fever,chills, and rigors. He was diaphoretic. Blood pressure was90/40 mm Hg; pulse rate, 126 beats per minute; and respirationrate, 28 breaths per minute. Lung examination revealedno air entry on the right side. The chest films demonstratedan air-fluid level, or hydropneumothorax, in theright pleural space (A and B). Culture of the pleural fluidobtained during a thoracentesis grew Staphylococcus aureus,which confirmed the clinical suspicion of empyema.A chest tube was inserted for drainage, and intravenousvancomycin was given. The patient's condition improvedmarkedly; he was discharged from the hospital 4weeks after admission.Postpneumonectomy empyema occurs in about 2% ofall pneumonectomies and usually causes significant morbidityor death. Empyema generally develops within 4weeks of surgery; symptoms include fever and toxemia,expectoration of a large amount of pleural fluid or drainageof fluid from the surgical site, and the presence of anair-fluid level in the pneumonectomy space. Since nearly40% of cases are associated with bronchopleural fistula oresophagopleural complications, consider a barium swallowand a bronchoscopic examination for all patients withthis condition.¹A CT scan can help distinguish a loculated hydrohydropneumothoraxfrom a lung abscess, which also presentswith an air-fluid level on a chest film. The scan can demonstratewhether the air-fluid level is located in the pleuralspace or in the lung, as seen in another patient (C).S aureus is the most commonly isolated organism;chest tube drainage and antibiotics are the standard therapies.If nonsurgical treatment fails, decortication may berequired.A lung abscess can be treated with antibiotics alone;however, patients with loculated hydropneumothorax requirechest tube drainage as well as antibiotic therapy.

References:

REFERENCE:

1.

Ueda H. Postoperative pyothorax. Surg Today. 1992;22:115-119.(Case and photographs courtesy of Drs Sonia Arunabh and R. K. Jain.)