DOI: https://doi.org/10.21203/rs.3.rs-2296530/v1
Tension pyopneumothorax is a rare and life-threatening complication of pneumonia, lung abscess and empyema, and immediate thoracic drainage or surgery is required in most cases.
A 70-year-old man presented to another hospital 2 weeks after exacerbation of dyspnea and inability to eat. Supine chest x-ray imaging revealed leftward deviation of the mediastinum, pleural effusion and collapse of the right lung. The patient was then referred to our hospital for surgical treatment. He underwent chest drainage immediately after the transfer. The patient’s blood pressure was elevated after drainage. Chest x-ray imaging showed improvement in the mediastinal deviation, but expansion failure of the lung occurred. Debridement and parietal and visceral decortications were performed. The thoracic cavity was irrigated using a pulse lavage irrigation system with 12,000 ml of saline. The patient underwent fibrinolytic therapy with intrathoracic urokinase postoperatively. Parvimonas mica was detected in the preoperative pleural fluid culture. The patient was discharged on postoperative day 22 and followed up as an outpatient afterwards. Two years have passed since the surgery, and there has been no recurrence of empyema.
We successfully treated a rare case of tension pyopneumothorax caused by P. micra. The patient developed tension pyopneumothorax due to gas production from an anaerobic bacterial infection. Decortication of the parietal and visceral pleura and irrigation using a pulse lavage irrigation system were effective in treating the condition.
Tension pyopneumothorax (TPPTx) is a rare and life-threatening complication of pneumonia, lung abscesses and empyema [1]. Although gas the accumulation is the most common cause of an expanding interpleural space, the presence of other substances (hydrothorax, hemothorax, chylothorax, and pyothorax) under pressure may be sufficient to cause hemodynamic and respiratory compromise. TPPTx occurs when a large volume of purulent fluid evokes an inflammatory and fibrotic response that entraps the lung and shifts the mediastinal organs, such as the heart, lungs, and trachea. Increased intrathoracic pressure can reduce venous return with secondarily decreased cardiac output, and mediastinal deviation can compress the contralateral lung, leading to an emergent situation [2, 3]. Therefore, immediate thoracic drainage or surgery is often required. Herein, we report a successful surgical treatment of TPPTx caused by Parvimonas micra.
A 70-year-old man presented to the hospital 2 weeks after experiencing exacerbation of dyspnea and inability to eat. His medical history included comorbidities, such as hypertension, atrial fibrillation, untreated dental caries, and periodontitis. He had a body temperature of 37.6 degrees, blood pressure of 92/58 mmHg, and heart rate of 105 bpm. A supine chest x-ray imaging revealed right lung collapse, decreased radiolucency of the right thoracic cavity with leftward deviation of the mediastinum (Fig. 1a). Chest computed tomography revealed pleural effusion with niveau and collapse of the right lung (Fig. 1b). No mediastinal air was seen. White blood cell count and C-reactive protein levels increased markedly to 21900 /MCL and 24.03 mg/dL, respectively. Procalcitonin level was elevated to 1.90 ng/mL. Thoracentesis was performed and 860 mL of the pleural fluid was aspirated. The pH of the pleural effusion decreased markedly down to 7.1. After initiating meropenem (MPEM) administration, the patient was referred to our hospital for surgical treatment. He underwent chest drainage immediately after the transfer. From the tube, 2000mL of foul-smelling pus drained without air leakage. The patient’s blood pressure increased to 124/74 mmHg. Chest x-ray imaging showed improvement in the mediastinal deviation; however, an expansion failure of the lung was noted, and surgery was planned. We first attempted thoracoscopic debridement. However, the parietal and visceral pleura were markedly thickened. Therefore, we converted to thoracotomy and performed parietal and visceral decortication. The thoracic cavity was irrigated using a pulse lavage irrigation system with 12,000 mL of saline. A drain was placed over lung apex and diaphragm. The operation time was 161 min, and the volume of blood loss was 600mL. The drain placed lung apex was removed on postoperative day (POD) 3. The patient underwent fibrinolytic therapy using intrathoracic urokinase administration to promote lung expansion on POD 5 and POD 13. P. micra was detected in the preoperative pleural fluid culture. Based on the pleural effusion culture provided by previous doctor, it was determined to be the causative bacterium, and antibiotics were de-escalated from MPEM to metronidazole on POD 8. The rest of the drain was removed on POD 20, because no bacteria were detected in either of the two pleural fluid cultures. The patient was discharged on POD 22. The patient is under careful follow-up as an outpatient; two years have passed since the operation, and there has been no recurrence of empyema.
TPPTx is a rare and life-threatening condition that was previously reported only in 20 cases, including our case [1, 3–20] (Table 1). Pyothorax has a high mortality rate of 15%, and 30% of cases require early and appropriate treatment such as surgical drainage of the pleural space [21]. Of the 20 previously reported cases of TPPTx, nine (45%) had a serious course, including cardiopulmonary arrest, shock, respiratory failure, and sepsis, and two of them had a fatal outcome. Of the 17 patients with a confirmed prognosis, three (17.6%) died. Five patients were woman, and 15 were men. The average age is 52.1 years (standard deviation: 17.6 years). Four cases involved the gastrointestinal tract (gastropleural fistula, esophageal rupture), four cases involved lung infection (lung gangrene, echinococcal cyst, pulmonary nocardiosis, and aspiration pneumonia), four cases were undergoing treatment for malignancies, and three cases had a history of immunocompromising conditions (human immunodeficiency viral infection, steroid addict). Facultative or obligatory anaerobes were identified from pleural effusion cultures in 10 of 15 cases which described in previous reports. To the best of our knowledge, this is the first reported case of TPPTx caused by P. micra.
Empyema surgery is based on debridement and lavage of the pleural cavity. In recent years, the effectiveness of using pulse lavage irrigation system in the treatment of empyema has been reported [22–24]. Pulse irrigation uses high water pressure and can wash the area of its application without damaging the surrounding soft tissues, such as nerves and blood vessels. In addition, the fibrin and necrotic tissues can be easily removed and washed. It has been reported that 90% of patients with acute empyema in the fibrinopurulent phase were cured completely without recurrence after pulse irrigation [22]. This case was considered to be in the late fibrinopurulent phase to the chronic organizing phase. For this case, it was observed that decortication and pulse irrigation were effective in cleaning the thoracic cavity.
P. micra is a bacterial flora in the oral cavity and gastrointestinal tract, and can be a pathogenic bacterium for chronic periodontal disease, alveolar pyorrhea, peritonsillar abscess, chronic sinusitis, chronic otitis media, and pulmonary suppuration [25, 26]. Cobo et al. reported pleurisy in 3 (9.6%) out of 31 cases of P. micra infection, and intrathoracic infection was relatively rare [27]. P. micra is part of the oral flora, and 16 out of the 31 cases described above had comorbidities, such as periodontitis and dental caries, dental procedures, or tooth extraction [27]. This patient had untreated dental caries and periodontitis, that were suspected to be related to the occurrence of TPPTx.
In conclusion, we successfully treated a rare case of TPPTx caused by P. micra infection. The patient developed TPPTx owing to gas production from an anaerobic bacterial infection. Decortication of the parietal and visceral pleura and irrigation using a pulse lavage irrigation system proved to be efficient in the treatment of the condition.
TPPTx tension pyopneumothorax
MEPM meropenem
POD postoperative day
P. micra Parvimonas micra
Ethics approval and consent to participate
Not applicable
Consent for publication
Written informed consent was obtained from the patient for the publication of this report and its accompanying images.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
Competing interests
All authors declare that they have no competing interests.
Funding
None.
Authors’ contributions
YI participated in the surgery, conceived and conducted the study, and performed the literature search. HU participated in the surgery. SI, NM and HU supervised manuscript preparation and critically revised the manuscript. All the authors have read and approved the final manuscript.
Acknowledgements
We would like to thank Dr. Mitsugu Omasa, Department of Thoracic Surgery, Nishi-Kobe Medical Center, for kindly providing us with a reprint of the article (reference number 18).
We would like to thank Editage (www.editage.jp) for the English language editing.
Table 1 is available in the Supplementary Files section.