Kaohsiung J Med Sci January 2010 Vol 26 No 1 45 2010 Elsevier. All rights reserved.

Posttraumatic empyema commonly results from bluntor penetrating chest injuries, and its severity is relatedto morbidity and mortality because of post-pneumoniaempyema [1]. Potential causes of posttraumatic empy-ema thoracis include iatrogenic infection during chesttube insertion, direct infection resulting from pene-trating wounds and secondary infection resultingfrom associated intra-abdominal organ injuries [2].Although the incidence of posttraumatic empyemathoracis has been reported to range from 1.6% to 2.4%in adult patients suffering from blunt thoracic trauma[2], it is relatively rare in children, particularly in asso-ciation with lung abscess, compared with adult pa-tients [2]. Here, we report our experience of treating

a 15-year-old boy who suffered from posttraumaticempyema thoracis, accompanied with lung abscessafter blunt chest trauma. The patient was not initiallygiven any prophylactic antibiotic under the impressionof chest contusion. Two weeks later, he was trans-ferred to our hospital because of the development ofsevere empyema. Chest ultrasound and computedtomography (CT) revealed empyema and abscess. Inthis report, we describe the case history and treat-ments, including CT-guided drainage and antibioticsadministered, and review the appropriate treatmentsfor complicated empyema thoracis in children afterlung contusion.

CASE PRESENTATION

A 15-year-old boy was involved in a traffic accidentand experienced blunt trauma to the right chest. Hewas initially sent to a local hospital. At the time, hedenied fever, cough or hemoptysis. A chest radiograph

Received: Mar 5, 2009 Accepted: May 19, 2009Address correspondence and reprint requests to:Dr Zen-Kong Dai, Department of Pediatrics,Kaohsiung Medical University Hospital, 100Tzyou 1st Road, Kaohsiung 807, Taiwan.E-mail: zenkong@kmu.edu.tw

CO-EXISTENCE OF POSTTRAUMATIC EMPYEMATHORACIS AND LUNG ABSCESS IN A CHILD AFTER

BLUNT CHEST TRAUMA: A CASE REPORTChang-Hung Kuo,1 I-Chen Chen,1 Shih-Shiung Lin,1 Ming-Chen Paul Shih,2

Jiunn-Ren Wu,1,3,4 Zen-Kong Dai,1,3,4 and Mei-Chyn Chao1,3,41Departments of Pediatrics and 2Medical Imaging, Kaohsiung Medical University Hospital; 3Faculty of

Medicine and 4Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

Posttraumatic empyema is a rare complication of trauma with an incidence of 1.62.4% in traumapatients. However, it is rarely reported in children. We report the case of a 15-year-old boy whowas involved in a traffic accident and diagnosed with a pulmonary contusion at a local hospital.Fourteen days after the accident, posttraumatic empyema thoracis and lung abscess developedwith clinical presentations of fever, productive cough and right chest pain. He was successfullytreated with computed tomography-guided catheter drainage and intravenous cefotaxime. Weemphasize that posttraumatic empyema thoracis and lung abscess are very rare in children, andcareful follow-up for posttraumatic lung contusion is essential. Image-guided catheter drainagecan be an adjunctive tool for treating selected patients, although most complicated cases of post-traumatic empyema thoracis require decortication therapy.

Key Words: CT-guided catheter drainage, lung abscess, posttraumatic empyema thoracis(Kaohsiung J Med Sci 2010;26:459)

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performed at the time showed opacity over the rightlower lobe of the lung, compatible with the diagnosisof pulmonary contusion (Figure 1). He was dischargedfrom the local hospital and treated with acetamino-phen only. Seven days later, cough with sputum andfever developed, and he was admitted to a local hos-pital. He was then diagnosed with pneumonia and in-travenous cefazolin was given. However, after 7 daysof cefazolin treatment, his fever and cough were stillpersistent. He began to complain of right chest painon deep respiration. A chest radiograph showed anair-fluid level containing cavity mass-like lesion overthe right lower lung field (Figure 2A). Therefore, hewas transferred to our hospital because of his wors-ening condition.

On physical examination, the boy weighed 57 kgand was 167 cm tall. He looked ill and uncomfortable.Chest auscultation revealed decreased breath soundsover the right side. Laboratory studies showed thatthe white blood cell count was 11,310/mm3 and seg-mented neutrophils were 72%. Serum C-reactive pro-tein was 30.28 mg/dL (normal range: < 5 mg/dL).Chest CT revealed a lung abscess and empyema overthe right lower lobe (Figure 2B). Chest ultrasonogra-phy revealed a hypoechoic cavity with a thickenedwall (Figure 2C). Under CT guidance, an 8-Fr Pigtailcatheter (SkaterTM Drainage Catheter; Angiotech,Denmark) was unevenly inserted to the abscess cav-ity through the posterior aspect from the back, and alarge amount of pus was drained out. Gram stainingof the pus revealed numerous Gram-positive cocci.Aerobic and anaerobic cultures of the drained pus,

blood and sputum revealed negative results. After 8 days of cefotaxime administration, the catheter was removed because the drainage became nonpro-ductive and chest radiographs showed that the em-pyema and lung abscess had markedly regressed(Figure 2D). After 2 weeks of continuous administra-tion of cefotaxime, the patient was discharged withan improved condition. At a follow-up 1 month afterdischarge, the boy was asymptomatic with normalchest radiography.

DISCUSSION

Thoracic infection after trauma is an important issuebecause it is a common cause of morbidity and latemortality [1]. The incidence of posttraumatic empyemathoracis was reported to range from 1.6% to 2.4% inpatients with blunt chest trauma [2]. However, thereare few reports of pediatric patients with posttraumaticempyema thoracis and lung abscess. Risk factors forposttraumatic empyema thoracis include retainedhemothorax, pulmonary contusion, and multiple chesttube placements [3]. Our patient had suffered frompulmonary contusion and empyema thoracis devel-oped 2 weeks later.

The treatment of children with pulmonary contu-sion involves the general principles of injury manage-ment, together with pulmonary care and supplementaloxygen [4]. In addition, avoiding fluid overload, paincontrol and appropriate nutritional support are rec-ommended [5]. Corticosteroids do not provide anybenefits [6]. The use of prophylactic antibiotics toprevent the development of posttraumatic empyemathoracis remains a controversial issue. The EasternAssociation for the Surgery of Trauma practice Man-agement Guidelines Work Group concluded that theevidence is insufficient to recommend the routine useof prophylactic antibiotics for the management of chesttrauma [7]. Eren et al suggested using prophylacticantibiotics only in patients with risk factors, such asprolonged duration of tube thoracostomy, prolongedintensive care stay, presence of contusion, retainedhemothorax, and exploratory laparotomy [8]. For bluntchest trauma, secondary deterioration within a fewdays of the injury may indicate complications andshould be investigated [4].

The pathophysiology of posttraumatic empyemathoracis is quite different from that of parapneumonic

Figure 1. Chest radiograph showed opacity over the right lowerlobe, compatible with the diagnosis of pulmonary contusion.

empyema thoracis. Hoth et al reported that there waslittle correlation between preoperative bronchoalveo-lar lavage and sputum cultures and intraoperativecultures in patients with posttraumatic empyema [9].Staphylococcus aureus was the most common organ-ism identified in cases with posttraumatic empyema,followed by pure or mixed anaerobic bacteria [2,8,9].The pathophysiology is most likely related to the inoc-ulation of the pleural space by the injury itself [9].However, in children with parapneumonic empyemathoracis, the most common pathogen isolated fromblood and pleural fluid is Streptococcus pneumonia [10].In our patient, there were numerous Gram-positivecocci based on Gram staining of the pleural fluid,while cultures of sputum, pleural fluid and blood wereall negative. Although S. aureus is the most likely

pathogen, mixed infection or other pathogens shouldalso be considered.

Accordingly, conventional radiographic techniquesand clinical histories are not sufficient to delineatebetween an abscess or empyema and a cavity lesion.A CT scan can help to make the distinction betweenboth lesions [11]. Empyema is diagnosed by the pres-ence of loculated pleural fluid with or without airbubbles or air-fluid levels. In contrast, lung abscess is diagnosed by a relatively thick-walled pulmonaryparenchymal cavity with air-fluid levels. A pleuro-parenchymal abscess is also diagnosed if there areinflammatory changes adjacent to the pleural fluid[1113]. In the present case, the CT revealed loculatedpleural fluid with air-fluid levels. Meanwhile, a pul-monary parenchymal cavity with a thickened wall

Posttraumatic empyema thoracis and lung abscess

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A B

DC

Figure 2. (A) Chest radiograph in the standing position showed a cavity mass lesion with air-fluid level. (B) Chest computed tomogra-phy confirmed the loculated fluid-containing lung abscess with a surrounding irregular thick-walled border. (C) Lung sonographyshowed a hypoechoic cavity with thickened wall. (D) Chest X-ray performed 8 days later revealed dramatic regression of infiltrationand fluid collection after insertion of an 8-Fr drainage catheter.

and consolidation was noted, suggesting coexistenceof empyema thoracis and lung abscess.

In general, the treatment for posttraumatic empy-ema thoracis includes continued tube thoracostomy,decortication and image-guided catheter drainage.Except for some cases with complicated empyemarequiring decortication, image-guided drainage canprovide a safer and more effective therapeutic mo-dality and was recently suggested as first-line treat-ment in most patients with empyema thoracis [14], or lung abscess [15]. Furthermore, it was reportedthat image-guided percutaneous drainage improvedthe success rate when the anechoic or complex non-septated lesions are detectable, rather than a complexseptated area, suggesting an empyema on chest ul-trasonography [14]. Similarly, in the present case,hypoechoic empyema and a single loculated cavitywith fluid accumulation was noted on chest ultra-sonography. Therefore, CT-guided percutaneous cath-eter drainage could provide a satisfactory outcome insuch cases.

In conclusion, thoracic infection after trauma is aconcern for prevention and treatment. In pediatric pa-tients, the combination of empyema thoracis and lungabscess resulting from a blunt chest trauma has beenrarely reported in medical literature. Careful follow-upof posttraumatic lung contusion is essential, althoughtreatment with antibiotics is controversial. Using care-ful assessment with chest ultrasound, image-guidedpercutaneous drainage can provide a safer, less inva-sive, and more effective method for treating posttrau-matic patients with both empyema thoracis and lungabscess, instead of direct decortication.

REFERENCES

1. Richardson JD, Carrillo E. Thoracic infection aftertrauma. Chest Surg Clin N Am 1997;7:40127.

2. Mandal AK, Thadepalli H, Mandal AK, et al.Posttraumatic empyema thoracis: a 24-year experienceat a major trauma center. J Trauma 1997;43:76471.

3. Aguilar MM, Battistella FD, Owings JT, et al. Post-traumatic empyema. Risk factor analysis. Arch Surg1997;132:64751.

4. Ruddy RM. Trauma and the paediatric lung. PaediatrRespir Rev 2005;6:617.

5. Cullen ML. Pulmonary and respiratory complicationsof pediatric trauma. Respir Care Clin N Am 2001;7:5977.

6. Allen GS, Cox CS, Jr. Pulmonary contusion in children:diagnosis and management. South Med J 1998;91:1099106.

7. Luchette FA, Barrie PS, Oswanski MF, et al. Practicemanagement guidelines for prophylactic antibiotic usein tube thoracostomy for traumatic hemopneumotho-rax: the EAST practice management guidelines workgroup. Eastern association for trauma. J Trauma 2000;48:7537.

8. Eren S, Esme H, Sehitogullari A, et al. The risk factorsand management of posttraumatic empyema in traumapatients. Injury 2008;39:449.

9. Hoth JJ, Burch PT, Bullock TK, et al. Pathogenesis ofposttraumatic empyema: the impact of pneumonia onpleural space infections. Surg Infect 2003;4:2935.

10. Lahti E, Peltola V, Virkki R, et al. Development of para-pneumonic empyema in children. Acta Paediatr 2007;96:168692.

11. Baber CE, Hedlund LW, Oddson TA, et al. Differentiat-ing empyemas and peripheral pulmonary abscesses:the value of computed tomography. Radiology 1980;135:7558.

12. Stark DD, Federle MP, Goodman PC, et al. Differenti-ating lung abscess and empyema: radiography andcomputed tomography. AJR Am J Roentgenol 1983;141:1637.

13. Mirvis SE, Rodriguez A, Whitley NO, et al. CT evalua-tion of thoracic infections after major trauma. AJR Am JRoentgenol 1985;144:11837.

14. Shankar S, Gulati M, Kang M, et al. Image-guided per-cutaneous drainage of thoracic empyema: can sonog-raphy predict the outcome? Eur Radiol 2000;10:4959.

15. Wali SO, Shugaeri A, Samman YS, et al. Percutaneousdrainage of pyogenic lung abscess. Scand J Infect Dis2002;34:6739.

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