Empyema Thoracis 45 Years After Pneumonectomy for Tuberculosis: Reactivation of a Dormant Mycobacteria?

Abstract

Introduction: The presentation of a post pneumonectomy space (PPS) infection may be very subtle. Late empyema is rare and usually occurs more than three months post-surgery; however, it has been reported several decades following surgery. CASE PRESENTATION: A 66 year-old man with hypertension, COPD, coronary artery disease and pneumonectomy for pulmonary tuberculosis in 1968 presented with pleuritic chest pain, fever, chills and night sweats for two weeks. He had tachycardia and absent breath sounds in the left hemithorax. Chest images revealed air-fluid level in the left cavity. Acid fast bacilli were present on AFB stain of two sputum samples and fluid aspirated from the left cavity. The fluid cultures only grew MRSA. A bronchoscopy evaluation did not reveal a bronchopleural fistula. He received broad spectrum antibiotics and anti-tuberculous for suspected mycobacteria tuberculosis infection and empyema of the PPS. He underwent VATS with debridement, rib resection and chest tubes placement. A closed Clagget procedure with continuous irrigation of the cavity with antibiotics (DAB solution) and saline for 10 days rendered cultures negative. Later a polymicrobial infection ensued with persistent purulence drainage from the site of the removed chest tubes. An Eloesser flap was created and fluid continues to drain to an ostomy bag. Dakin's soaked Kerlix is used to pack the chest cavity. DISCUSSION: We report a rare case of reactivation tuberculosis presenting as PPS empyema 45 years after pneumonectomy. The presence of a new air-fluid level in the space raised the suspicion of this serious complication. His initial treatment with ciprofloxacin rendered cultures negative for MTB. In very ill patients with PPS empyema open chest wall thoracostomy (OWT) allow time for rehabilitation in preparation for a definitive therapy. Conclusions: Drainage remains the main step of therapy for this condition with high morbidity and mortality. Although closed irrigation was initially successful, the creation of an OWT controlled the recurrent infection. The obliteration of the cavity by thoracoplasty or muscle flap transposition is the standard treatment, but a good open drainage can give long lasting control.