A 62‐year‐old man was found unresponsive with a stab wound to the posterior chest wall 2 weeks prior to admission and presented to our hospital with a full‐thickness wound on the infrascapular region. His medical history was significant for cirrhosis, ischemic cerebral infarct, and seizure disorder. During the third week of hospital admission, he spiked a fever of 102°F. Labs were significant for white blood cell count (WBC) of 19,000/mm3 with 87% of granulocytes. Chest x‐ray showed a right basal pleural pneumonic process. The patient was started empirically on meropenem. Fever and shortness of breath persisted for a week, and physical examination was remarkable for spontaneous purulent suppuration from the necrotic eschar on the back. Repeat chest x‐ray showed a worsening pleural effusion on the right and WBC of 24,000/mm3 with 95% granulocytes. CT chest with contrast showed a 10 × 8 × 13 cm fluid collection containing gas. The spontaneous purulent suppuration from the back wound persisted. The next day, thoracatomy and decortication of the empyema were performed, with drainage of 800 mL of purulent material and subsequent spontaneous expansion of the lung cavity. Two chest tubes were placed intraoperatively and removed a week later, with drainage of an additional 400 mL of pus. The aerobic pleural fluid culture grew Klebsiella pneumoniae sensitive to ertapenem, and anaerobic cultures grew Peptostreptococcus micros. The patient was started on ampicillin and ertapenem. He showed clinical improvement, and antibiotics were continued for 6 weeks.
Chest x‐ray before (1) and after (2) treatment of empyema necessitans. Wound on back with spontaneous purulent drainage.
CT chest showing 10 × 8 × 13 cm right pleural space fluid collection and adjacent atelectasis of right lower lung with drainage of pus through the posterior chest wall into the superficial wound on back as shown with the arrow.
Empyema necessitans is a rare complication of pleural space infections that occurs when empyema fluid spontaneously dissects into the chest wall from the pleural space. The majority of cases are caused by anaerobic organisms, and most of them occur from inadequate treatment of empyema and usually occur following a necrotizing pneumonia or pulmonary abscess. Anaerobic and facultative gram‐positive bacteria account for 41% of complicated pleural effusions, mostly from S. aureus and S. pneumoniae. The cases of empyema necessitans that have been reported in the literature were caused by the Streptococcus milleri and actinomycosis. Studies have shown that K. pneumoniae infection is associated with a high mortality rate and is an independent risk factor for a fatal outcome. It should be considered possible etiological agent for acute thoracic empyema or complicated para‐pneumonic effusions in patients with diabetes mellitus, cirrhosis, or bronchogenic carcinoma and with an acute presentation.
The lung is more adherent posteriorly at the apex and the base, and hence empyema necessitans often tends to rupture in the upper part of the anterior chest wall, but the full‐thickness wound in the back facilitated the pus drainage through the posterior chest wall. Empyema necessitans is a very rare complication of hospital‐acquired pneumonia. Timely intervention by either closed or open drainage is very important to reduce mortality from empyema.
V. Rajasurya ‐ Staten Island University Hospital, resident; N. Mobarakai ‐Staten Island University Hospital, attending; M. Chalhoub ‐ Staten Island University Hospital, intensivist; B. Koirala ‐ Staten Island University Hospital, resident; N. Parikh ‐ Staten Island University Hospital, attending; Puja Singh ‐Staten Island University Hospital, student.
To cite this abstract:Rajasurya V, Chalhoub M, Mobarakai N, Koirala B, Singh P, Parikh N. Empyema Necessitans Resulting from a Stab Wound. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 377. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/empyema-necessitans-resulting-from-a-stab-wound/. Accessed May 26, 2019.