Empyema necessitans is a rare complication of a pleural effusion that is characterized by a communication between the pleural cavity and soft tissue and skin of the chest wall.1 This collection results from extension of an empyema through pleura into subcutaneous tissue that typically occurs from persistent pleural effusions. Pleural effusions with empyema necessitans have been reported as predominantly caused by Mycobacterium tuberculosis and Actinomyces israelii, although other organisms have been reported in the literature.2 Methicillin-resistant Staphylococcus aureus (MRSA) has been one of those rare organisms described to result in this complication. Because of the limited literature on this complication, exact management and guidelines have not yet been established. Historically, management has relied on surgical intervention and prolonged antibiotics, but the duration of treatment is not well defined. As such, further reports are needed to broaden the understanding of this complication. This case describes a 5-year-old boy who presented with an MRSA empyema necessitans and highlights the approach to management. Further, this report discusses current literature of cited cases and management of MRSA empyema necessitans in the pediatric population.
This patient is a 5-year-old Hispanic boy with a past medical history of obstructive hydrocephalus status postventriculoatrial shunt placement who presented with complaints of fever, chest and right shoulder pain. One week before presentation, the patient was diagnosed with influenza A infection and completed a course of oseltamivir with negative blood, urine and cerebrospinal fluid cultures. The patient returned with complaints of fever, emesis, progressive right-sided chest pain, swelling and tenderness of neck to the point that the patient was refusing to move his right arm. Physical examination included a patient in respiratory distress with limitation of the upper right extremity secondary to pain, diminished lung sounds on the right and extension of subcutaneous emphysema from the upper chest wall extending to the right upper neck. Additionally, overlying erythema without drainage extended laterally from the xiphoid process to the axilla and superiorly to the supraclavicular area of the patient’s neck. Neurosurgery evaluated the patient upon presentation for a shunt involvement. The patient had a complex shunt system which included 2 ventricular catheters with 1 distal system placed into the right atrium. The distal catheter coursed down the side of the neck in the location of subcutaneous emphysema. The overlying shunt site was well healed and intact with no sign of migration of the distal catheter. The ventriculoatrial shunt was placed 5 months before presentation. Initial laboratory values included a white blood count of 17.71 K/µL, hemoglobin 11.2 g/dL, platelet count 226 K/µL with a left shift including 68% bands, 10% neutrophils, 2% eosinophils, 12% monocytes, 8% lymphocytes, C-reactive protein >270 mg/L, procalcitonin 6.76 ng/mL and a venous blood gas with pH 7.44, partial pressure of carbon dioxide 36 mm Hg, partial pressure of oxygen <57 mm Hg and base excess 0 mmol/L. Chest radiograph was positive for complete opacification of right lung. A chest ultrasound revealed a large right pleural effusion with multiple septae in addition to focal infiltration into the upper chest wall concerning for a possible abscess formation. A computed tomography (CT) scan of the chest and neck with contrast (Fig. 1) was performed to further characterize the disease. The CT scan revealed a large right pleural effusion with underlying partial collapse of the lung with pleural fluid that appears to be in continuum with the right lower neck and upper chest wall with a rim-enhancing fluid collection. The distal catheter of the ventriculoatrial shunt was also going through the empyema and entering the right atrium. Additionally, a CT scan of the head showed an interval increase in the size of the ventricles significantly. A diagnosis of empyema necessitans was made on the basis of the clinical presentation and CT scan.
The patient was intubated and admitted to the pediatric intensive critical care unit. The patient was started on vancomycin and cefepime and taken to the operating room. Because of the risks of a shunt infection as well as findings of the shunt malfunction, the shunt system was removed with replacement of bilateral external ventricular drains. The patient also had a chest tube placed with a 12-French Thal-Quick placed under ultrasound guidance. The chest tube was infused with fibrinolytic agent alteplase and secured with tegaderm to suction at 20 cm water. Chest tube placement was confirmed with chest radiograph. Clindamycin was started postoperatively. Blood, urine and cerebrospinal fluid cultures were negative. Pleural fluid grew MRSA. Cefepime and clindamycin were discontinued on day 2 after pleural fluid susceptibilities resulted and the patient was continued on vancomycin. Goal vancomycin trough levels were 15–20 µg/mL. Right chest tube was removed after a total of 7 days. Echocardiogram obtained with no evidence of endocarditis. Magnetic resonance imaging of the brain was obtained to evaluate for focal or intracranial abscesses which was negative. The patient was treated for a total of 21 days with intravenous vancomycin following drainage of the empyema. Following course of antibiotics, the patient had reinternalization of bilateral ventricular shunts with placement of the distal catheter on the same side as previous site with termination in the right atrium.
Empyema necessitans refers to the dissection of a pleural effusion into the subcutaneous tissue of the chest wall and surrounding structures. This complication can be a result of multiple etiologies. It may occur in the setting of a trauma, recent thoracotomy or result from long-standing empyema typically after necrotizing pneumonia.3 The causative organisms have typically been identified from pleural effusions as predominantly caused by Mycobacterium tuberculosis and Actinomyces israelii.2 Other organisms have been identified, but only rare cases of empyema necessitans caused by MRSA have been reported in the medical literature. As of 2018, only 7 total case reports of empyema necessitans secondary to MRSA have been reported in both adults and pediatrics from a PubMed literature search described by Bandaru et al.4 Of these reports, only 4 cases involve pediatric patients ranging in ages 4 weeks to 19 months. To our knowledge, this case would only represent the fifth pediatric case and the first documented case of a pediatric patient older than 2 years of age.
Because of the rarity of this disease, exact treatment guidelines have not been established particularly in the pediatric population. Treatment of empyema necessitans typically includes intraoperative drainage followed by intravenous antibiotics while monitoring the clinical response of the patient. This methodology has been followed in the previous cases of MRSA empyema necessitans. One case Stallworth et al5 reported an 8-month-old with MRSA blood and pleural effusion treated by simple chest tube placement with intravenous vancomycin for a total of 10 days, followed by oral trimethoprim-sulfamethoxazole to complete a 21-day course of antibiotics with resolution of the infection. Moore et al6 describe a 3-month-old with an MRSA infection treated by tube thoracotomy with decortication as well as drainage of a subscapular collection while receiving intravenous vancomycin for a total of 14 days followed by oral linezolid for 7 days. Contreras et al7 describe a 19-month-old with MRSA bacteremia with pleural and chest wall abscess treated with thoracoscopic decortication followed by a prolonged course of antibiotics secondary to a complication of a right femur osteomyelitis. This course of treatment included 2 weeks of vancomycin and gentamicin and was followed by vancomycin with oral clindamycin for a total of 36 days to complete a course for osteomyelitis. The final case described by Rosebush et al8 included a 4-week-old with MRSA chest mass with some osseous involvement of a rib who had a history of exposure to a maternal breast abscess who was treated with pigtail catheter drainage and 4 weeks of intravenous clindamycin followed by 4 weeks of oral clindamycin. The above cases represent our current knowledge of the management of MRSA empyema necessitans in the pediatric population. While a few of the above case reports described decortication followed by a course of antibiotics, our patient was adequately treated by removal of the ventricular shunt system and chest tube drainage with pleural fluid instillation of fibrinolytic agents. Chest thoracostomy tube drainage with the addition of fibrinolytic agents and video-assisted thoracoscopic surgery have both been demonstrated to be effective methods of treatment of parapneumonic effusions, and these methods are associated with decreased morbidity rates compared with chest tube drainage alone.9,10 Primary video-assisted thoracoscopic surgery decortication and fibrinolysis have been compared for the treatment of empyema with no therapeutic or recovery advantages between the 2 management options; however, video-assisted thoracoscopic surgery resulted in significantly greater charges.10 Additionally, fibrinolysis may pose less risk of acute clinical deterioration and should be the first-line therapy for children with empyema.10
In conclusion, empyema necessitans remains a rare complication of a pleural effusion and as such there are limited data in management and treatment particularly in children. This case report describes a rare microbiologic cause of an MRSA empyema necessitans following an influenza A infection. Further, this case report highlights the methodology used for the treatment in this pediatric patient as well as summarizes the management of other cases previously described with MRSA infections in pediatric populations.
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