This document discusses the case of a 51-year-old male patient (G.P.A.) who was admitted to the hospital with a pleural effusion. On October 31st, chest imaging showed a pleural effusion. By November 5th, the effusion became purulent, indicating an empyema, so the patient underwent thoracoscopy to drain the empyema. The patient was discharged on November 23rd after the empyema had resolved with thoracoscopic drainage. The conclusion discusses how thoracoscopy is a useful minimally invasive treatment for empyema but that more large controlled trials are still needed to fully validate its role in parapneumonic effusions and empyema.

1. U.O. di Pneumologia - Endoscopia Toracica

2. P.te Indiano (Singh): 43 anni
Sintomas: dor “abdominal”
no flanco direito, febre (37,8)
Investigação:
•Ecografia abdominal:
negativa
•Rx tórax:
•negativo
28-10-2011
U.O. di Pneumologia - Endoscopia Toracica

3. P.te Indiano (Singh): 43 anni
Sintomas:
• dor toracica
• febre (38°)
• Dispneia
Laboratorio:
GB: 7.81 (N=78%)
VHS: 96
D-Dimero: 3150
Rx Torax:
Pequeno derrame pleural a D.
1-11-2011
U.O. di Pneumologia - Endoscopia Toracica

4. P.te Indiano (Singh): 43 anni
2-11-2011
U.O. di Pneumologia - Endoscopia Toracica

5. P.te Indiano (Singh): 43 anni
Drenagem Toracica (pig tail)
700 ml de liquido pleurico corpuscolado e
amarelado
pH: 6,56!!!
Proteinas: 4,1 (no soro 5,5)
Glicose: 19
LDH: 10955!
4-11-2011
U.O. di Pneumologia - Endoscopia Toracica

6. P.te Indiano (Singh): 43 anni
U.O. di Pneumologia - Endoscopia Toracica

7. P.te Indiano (Singh): 43 anni
U.O. di Pneumologia - Endoscopia Toracica

8. • Pleurite parapneumônica
– pleurite simples
– Derrame parapneumônico complicado e empiema
• Derrame pleurico tubercular.
– pleurite
– empiema (raro)
• Pleurite atípica (Em pacientes imunodeprimidos é frequente a infecção oportunista.)
– fungos
• candida, aspergillo, criptococco, coccidioides, histoplasma, blastomyces,
sporotrichose
– bactérias incomuns
• Actinomicosi, nocardiosi, chlamidia, rickettsiae
– parasitas
• Amebiase, echinococcose, paragonimiase, trichominiase
– virus (não se conhece a real epidemiologia!)
• Adenovirus, hantavirus, cytomegalovirus, herpes virus, hepatite, mononucleose,
dengue
U.O. di Pneumologia - Endoscopia Toracica

9. • Dificil isolar os agentes patogênicos
– Dificuldades com os métodos atuais. Identificação do agente patogênico em
menos de 40% dos casos com os métodos tradicionais.
– Frequentemente não vem procurados!!!
– A pleurite viral, em particular no adulto, é uma realidade, um “mito” ou um
diagnóstico “refúgio”???
• Derrames parapneumônicos: mesma etiologia das pneumonias?
– Poucos estudos, com indicações de seleção, retrospectivo e com poucos casos,
porém, orientam para etiologias diferentes.
• Empiema:
– Toracocentese precoce e tratamento correto (drenagem): muitas vezes
inexplicavelmente retardados
– Mortalidade em 12 meses de 22%; 35% no P.te imunodepresso.
– Diferença entre adquiridas na comunidade e hospitalar? etiologia.. mortalidade.
• Derrame pleural tubercular:
– Acredita-se de se tratar de uma patologia muito rara.
– Se dá muita importancia a procura do BK no liquido pleurico
– Descuida-se da importancia fundamental da biopsia pleurica
U.O. di Pneumologia - Endoscopia Toracica

10. U.O. di Pneumologia - Endoscopia Toracica

11. U.O. di Pneumologia - Endoscopia Toracica

12. U.O. di Pneumologia - Endoscopia Toracica

13. 454 Pts
Bacterial identification: 74%
U.O. di Pneumologia - Endoscopia Toracica

14. Bacteriology of community acquired pleural infection
streptococcus
staphylococcus
enterococcus
Gram negatives
anaerobes
Myc tuberc
actinomyces
others
U.O. di Pneumologia - Endoscopia Toracica

15. • The group Streptococcus milleri (SM) includes several species of
pathogenic streptococci associated with pyogenic infections: at least three
well-differentiated species:
– S. constellatus, S. intermedius and S. anginosus
– The SM group is part of the usual flora of the mouth, it is also found among
normal faecal flora in 16–67% of healthy adults
• The most important clinical feature of these micro-organisms is their
tendency to cause suppurative infections at various sites, ranging from
dental abscesses to deep visceral abscesses
U.O. di Pneumologia - Endoscopia Toracica

16. Conclusions
community-acquired pleural infection is caused by penicillin-sensitive
streptococci in about 50% of cases, with the other 50% being due to
organisms that are usually penicillin resistant, including staphylococci and
Enterobacteriaceae.
About 25% of community-acquired pleural infections include anaerobic
bacteria.
Appropriate empiric antibiotic choices for these patients should therefore
cover streptococci, penicillin-resistant staphylococci, and Enterobacteriaceae
and should usually also include anaerobic bacterial therapy.
U.O. di Pneumologia - Endoscopia Toracica

17. One year Mortality
•53/304 (17%) in community-
acquired infection
•17/36 (47%) in hospital ac inf
Approximately 60% of
hospital-acquired infections
included bacteria frequently
resistant to antibiotics
U.O. di Pneumologia - Endoscopia Toracica

18. •Mortality in different bacterial
subsets:
•23/137 (17%): streptococcal inf.
•10/49 (20%): anaerobic-mixed inf.
•15/34 (44%) S. aureus inf.
•10/22 (45%) gram-negative inf.
•13/28 (46%) mixed aerobic inf.
U.O. di Pneumologia - Endoscopia Toracica

19. U.O. di Pneumologia - Endoscopia Toracica

20. •The mean delay in diagnosis was
44.2 days
•Long delays in diagnosis •On average each patient:
•long hospital stays • underwent CT 10.1 times
•recovery with surgery •had 2.6 percutaneous
drainage procedures
•The mean time from the first
percutaneous chest drainage to
the date of diagnosis was 29.8
days
•the mean delay until thoracic surgery
referral was 47.4 day
•The mean length of hospital stay
postoperatively was 15.2 days
U.O. di Pneumologia - Endoscopia Toracica

21. Ultrasonography and CT scanning, however,
have greater sensitivity for fluid detection and
provide additional information for determining
the extent and nature of pleural infection.
U.O. di Pneumologia - Endoscopia Toracica

22. U.O. di Pneumologia - Endoscopia Toracica

23. empyema
U.O. di Pneumologia - Endoscopia Toracica

24. U.O. di Pneumologia - Endoscopia Toracica

25. Clinical and pathological evolution
• Exudative stage: pleural fluid culture is negative, pH > 7.20,
LDH <1000: 5 to 7 days
• fibrino-purulent stage: pleural fluid becomes purulent, early
loculations, positive microbial culture. pH <7.20, LDH > 1000: 7
days up to 2 weeks
• organizing stage: fibroblasts grow into the pleural space; this
results in a thik pleural peel: generally occurs within 2 to 4
weeks of onset of the pleural effusion.
G.F. Tassi, G.P. Marchetti. Il versamento parapneumonico e l’empiema. In Pneumologia
Interventistica. A.G. Casalini. Springer Italia. 2007 U.O. di Pneumologia - Endoscopia Toracica

26. stage Pleural fluid Biochemical treatment
aspects
Simple parapneumonic yellow •pH>7.20 antibiotics
pleural effusion •LDH<1000
•GRAM neg
Complicated Yellow/ •pH<7.20 Chest tube
parapneumonic effusion turbid •LDH>1000 drainage
•GRAM pos
empyema Purulent Chest tube
drainage
U.O. di Pneumologia - Endoscopia Toracica

27. U.O. di Pneumologia - Endoscopia Toracica

28. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD002312.
The primary outcome of the review was treatment failure resulting in death and surgery.
U.O. di Pneumologia - Endoscopia Toracica

29. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD002312.
The primary outcome of the review was treatment failure resulting in death and surgery.
U.O. di Pneumologia - Endoscopia Toracica

30. U.O. di Pneumologia - Endoscopia Toracica

31. Conclusions: In patients with loculated, complex fibrinopurulent parapneumonic
empyema thoracis, a primary treatment strategy of VATS is associated with a higher
efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes
catheter-directed fibrinolytic therapy.

32. Case Report
G.P.A. 51 years old
october 30th
U.O. di Pneumologia - Endoscopia Toracica

33. Case Report
G.P.A. 51 years old
october 31st
U.O. di Pneumologia - Endoscopia Toracica

34. Case Report
G.P.A. 51 years old
november 5th: Thoracoscopy
U.O. di Pneumologia - Endoscopia Toracica

35. Case Report
G.P.A. 51 years old
november 23th
U.O. di Pneumologia - Endoscopia Toracica

36. Conclusion
Although thoracoscopy has proved useful in the treatment of
infected pleural space, in particular in multiloculated empyema where it allows
recovery avoiding thoracotomy, even today its employment has not been
justified by large controlled trials. Moreover there are no prospective,
controlled studies on the role of medical thoracoscopy in
parapneumonic effusions and empyema.
Medical thoracoscopy, as a drainage procedure intermedate between tube
thoracostomy and VATS, is significantly lower in cost and can avoid surgical
thoracoscopy under general anaesthesia. It is essential that it is performed
early on in the course of empyema and it is particularly advisable for frail
patients at high surgical risk.
U.O. di Pneumologia - Endoscopia Toracica