A CASE OFFUNGAL EMPYEMA Dr. Sugata DasguptaMD, FNB (Critical Care Medicine)
Fungal Empyema• Not largely reported or studied• Mainly isolated case reports• Mostly in patients with severe underlying diseases / immunocompromised / malignancy• Can have a fulminant course with sepsis, organ dysfunction, respiratory failure, persistent pleural collections & high mortality
Largest data• Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC; Fungal empyema thoracis : An emerging clinical entity; Chest 2000;117:1672-8• Commonest : abdominal / thoracic surgery, GI perforation, bronchopulmonary infection• Mostly in pts with severe underlying diseases• Crude mortality rate : 73%
Our patient• 55 year old lady• Admission : 5F( /HDU) : 19/6/10 ICU : 9/7/10• Past History : GERD, Laparoscpoic Nissen’s Fundoplication 8 years ago
Chief Complaints & History of present illness on Hospital admission• Right sided chest pain/SOB/Fever/Dysphagia• 8.6.10 = Redo Laparoscopic Fundoplication• Symptoms started after surgery• 9.6.10 = Gastrograffin : Distal Oesophageal leak (oesophageal perforation)• 16.6.10 = Barium : leak + Right Pleural Effusion• Cefazolin Ig 8/24 + Metronidazole 500mg 8/24• 19.6.10 = Admission to 5F (/HDU)
Clinical Examination & Investigations• Fever, tachypnoea, tachycardia, normotension• Chest : dullness & ↓breath sounds on right• Abdomen : slightly tender epigastrium• Other systems : NAD• Blood : WBC 26.9, CRP 240, ↑ AST/ALT/AP• CXR : Rt. Pleural Effusion, small Lt. effusion, No pneumomediastinum / diffuse mediastinal widening / subcutaneous emphysema• ABG : Hypoxemia in Room Air
Investigations (continued)• CECT : perforation with dye leakage at GE junction + Large Right Hydropneumothorax with underlying collapse / consolidation + Small Left effusion (No mediastinal air / air- fluid levels / diffuse mediastinal widening)• Right Pleural Fluid (12F pigtail) : Empyema : Yeast + viridans streptococci• Blood / Urine / Sputum : Sterile
Clinical Course : first TEN days• 19.6.10-22.6.10 = Metronidazole 500 mg 1V 12/24 + Ampicillin 1g IV 6/24 ; TPN• Remained septic with fever + increasing counts & CRP ; worsening SOB +↑ing O₂ requirements; worsening LFTs• 23.6.10 = Pip-Tazo 4.5g IV 8/24• Blood / Urine / Sputum : Sterile• Echocardiography : Normal study
Clinical Course : first TEN days• 25.6.10 = Endoscopic Oesophageal Stent + Rt. 28F ICD ↓GA• 28.6.10 = Pleural Fluid : Candida albicans (No sensitivity report); Pip-Tazo + Fluconazole 400 mg IV OD; Gastrograffin : No leak , oral + TPN• 30.6.10 = CECT : ↓ Right Pleural Collection + persistent Left pleural effusion ; No leakage• SOB improved, but still septic with fever, persistent leukocytosis,↑CRP; deranged LFTs
Clinical Course : next TEN days• Progressively decreasing ICD output; clinically persistent bilateral pleural effusion + sepsis• Blood / Sputum / Urine : always sterile• Rt Pleural Fluid : persistently C. albicans (with CONS once : Vanco, Doxy); Lt : sterile exudate• 6.7.10 = CECT : Persistent Rt. Hydropneumo (not much change from last CT) + Left effusion• 6.7.10 = USG guided Bilateral 8F Pigtails• Worsening sepsis, SOB with ↑WOB, AHRF
Clinical Course : next TEN days• 8.7.10 : Fluconazole off, Caspofungin started (70 mg IV on D1→ 50mg IV OD) + Pip-tazo on• 9.7.10 = Right Thoracotomy + Pleural debridement (2 28F + 2 15F ICDs) + Feeding Jejunostomy ↓GA (OLV with Lt sided DLT)• ICU (Intubated) : ventilated (4 Rt +1 Lt drains)• 9.7.10 = Caspo 50 mg IV OD + Vancomycin 1g IV 12/24 + Meropenem 1g IV 8/24• Pleural tissue : C.albicans, Lt effusion: sterile
Clinical Course in the ICU• 11.7.10 = Extubated, Jejunostomy feeds• 12.7.10 = Tachypnoea,↑WOB, Hypoxemia : Reintubated; C. albicans grown in 1 drain fluid• 13.7.10 = CECT : Persistent Right pleural collection as thick enhancing rind / loculated fluid in oblique fissure + Left pleural Effusion• Afebrile; leukocytosis + ↑CRP; deranged LFTs• Blood / DTA / Urine / Left Pleural fluid : sterile
Clinical Course in the ICU• ↓Albumin ; Fluid overload : Albumin, Filtered• Difficult weaning ; Tracheostomy on 19.7.10• Still growing C. albicans from 1 drain fluid• 21.7.10 = CECT : Rt hydropneumo reduced , but loculated collections + Lt Effusion reduced• Sequential drain removal, slowly weaned off• 23.7.10 = Rt Intrapleural STK 250000 U 1dose• 24.7.10 = Antibiotics stopped; Caspofungin on
Clinical Course in the ICU : Presently• Clinically getting better; 40 days of hospital stay• Tracheostomy / High flow / Weaned off• Right 28F ICDs (2) still present , Left ICD out• Afebrile, Counts, LFTs normalizing, still ↑CRP• 24.7.10 = Pleural fluid : totally culture sterile• C/O reflux : ? Stent (5cm above leak to 2-3cm in stomach)• Stent removal scheduled on 30.7.10
Empyema following oesophageal perforation• Mainly reported along with other radiological features of acute mediastinitis• Mainly bacterial: anaerobes / aerobes (Staph, β/α haemolytic strep / GNB) / mixed• Fungal : few case reports : mostly malignancy / immunocompromised / fungaemia• Mostly isolated : Candida (albicans>tropicalis)
Nissen’s Fundoplication• Oesophageal / gastric perforation (Open 1%, Lap 2%; Mortality : 26% in Open, Nil in Lap)• Empyema following perforation after Lap Fundoplication : very few reports : bacterial• Fungal Empyema without other radiological features of acute mediastinitis following Oesophageal perforation after Laparoscopic Fundoplication in immunocompetent adult ?
Management issues• Antifungals + Tube Thoracostomy +/- Surgery• Candida Empyema without Candidemia : No definite guideline on choice / route / duration of Antifungals in 2009 1DSA Guidelines• Pleural penetration : Fluconazole , Ampho : good; Echinocandins : not largely studied, good efficacy in invasive candidiasis• ? Reasonable to treat like Candidemia
Management issues• Echinocandin: ?clinical improvement / 1-2wks• Change to Fluconazole / Voriconazole (if susceptible) may be appropriate• ? Total duration of antifungals : Pleural Fluid Culture + Drainage + Clinical improvement• 14 days after culture sterility / drain removal + total resolution of pleural collection with clinical improvement : may be appropriate
Controversies : in retrospect• Interval between oesophageal perforation & definitive treatment : predictor of outcome : Were we late ? (Leak : 9.6.10; Stent : 25.6.10)• Empiric Antifungals (with antibiotics) on detection of distal oesophageal perforation ?• Yeast : 20.6.10; C. albicans + Fluconazole : 28.6.10 ; Could have been started on 20.6.10?
Controversies : in retrospect• Single dose of Intrapleural Streptokinase ?o MIST1 Trial (NEJM 2005;352(9):865-74): No effect on mortality / LOS / need for surgeryo Before surgical drainage ; 3 days (BTS ; ACCP)• Persistently deranged LFT (↑AST/ALT/AP/Bi) : sepsis / azole (off) / ↓Caspo dose ? / LFAmB ?