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\begin{document}

\title{Empyema necessitans as a rare manifestation of Staphylococcus aureus}



\author[1]{nzaznin zeinali nezhad}%
\author[1]{Aazam Gholami Shahrebabak}%
\author[1]{Amirhossein Shahpar}%
\affil[1]{Kerman University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 30, 2024}


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\textbf{Empyema necessitans as a rare manifestation
of\emph{Staphylococcus aureus}}

\textbf{Nazanin Zeinali Nezhad\textsuperscript{1},Aazam Gholami
Shahrebabak\textsuperscript{2*}, Amirhossein Shahpar\textsuperscript{3}}

\textsuperscript{1} Faculty of Medicine, Kerman University of Medical
Sciences, Haft Bagh Alavi Blvd, Kerman, Iran Postal Code: 7616913555

\textsuperscript{2} Department of Medical Education, Medical Education
Research Center, Kerman University of Medical Sciences, Haft Bagh Alavi
Blvd, Kerman, Iran Postal Code: 7616913555

\textsuperscript{3} Faculty of Medicine, Kerman University of Medical
Sciences, Haft Bagh Alavi Blvd, Kerman, Iran Postal Code: 7616913555

*\textbf{Corresponding author} : Aazam Gholami Shahrebabak, Assistant
Professor of Pediatrics, Department of Medical Education, Medical
Education Research Center, Kerman University of Medical Sciences, Haft
Bagh Alavi Blvd, Kerman, Iran

Email: a.gholami@kmu.ac.ir

\textbf{Abstract}

Empyema necessitans is a rare complication of empyema in which pus
accumulates within the pleural space and spreads through the chest wall,
leading to the formation of a subcutaneous abscess. This condition
presents significant diagnostic and therapeutic challenges due to its
rarity and potential for serious complications. Here we present the case
of an eight-year-old boy with a history of parapneumonic effusion that
was incompletely treated due to a lack of fibrinolytic agent injection.
He presented with fever, chills, a productive cough, and left-sided
chest pain with yellowish purulent secretions from the left chest wall.
The patient was diagnosed with empyema necessitans caused
by\emph{Staphylococcus aureus} , which has occurred due to inadequate
treatment and the lack of administration of a fibrinolytic agent
injection for the patient. He was treated with broad-spectrum
antibiotics, video-assisted thoracic surgery (VATS), and a chest tube
for complete drainage. The patient showed a smooth and uneventful
recovery, highlighting the importance of early diagnosis and prompt
treatment of empyema necessitans to avoid further complications. This
case report aims to increase awareness among clinicians about the
importance of early recognition and appropriate management of empyema
necessitans to improve patient outcomes.

\textbf{Key words:} empyema necessitans, pediatric, Staphylococcus

\textbf{Consent statement}

A written informed consent was obtained from the patient to publish this
report in any medical journals. Also, a written consent was obtained
from both parents because the patient was under the age of 16.

\textbf{Introduction}

Empyema necessitans (EN), also known as empyema necessitates, is an
infrequent pathological process that may arise when an empyema
penetrates and breaches the pleural membrane, subsequently extending
beyond the pleural space and following the path of least resistance
through the adjacent soft tissues (1). It typically arises as a
secondary complication of an underlying pneumonia or parapneumonic
effusion, although it may also occur as a consequence of an infection at
alternative sites (2). Other potential etiologies of EN comprise chest
trauma or surgical procedures, albeit rare, as well as foreign body
aspiration (3). EN may also occur in immunocompromised individuals, such
as those receiving immunosuppressive therapy or with underlying HIV or
cancer (4). Empyema necessitans may manifest with various clinical
symptoms, including but not limited to local pain, cough, dyspnea,
fever, and weight loss (5). The symptoms of Empyema necessitans can be
managed with a range of treatment options, including the administration
of antibiotics, tube drainage, and decortication, which can effectively
eliminate the cavity and restore optimal pulmonary function (6). In this
report, we present a case of pediatric Staphylococcus-associated Empyema
necessitans, which was characterized by the presence of purulent
drainage from the chest wall. The patient received treatment through
open drainage by video-assisted thoracic surgery (VATS), a tube
thoracotomy, and a course of antibiotics.

\textbf{Case report}

An eight-year-old boy patient, who had previously been admitted to
Zahedan hospital due to parapneumonic effusion and received incomplete
treatment involving a chest tube and lacked the administration of a
fibrinolytic agent injection one month prior, presented with symptoms of
fever, chills, and a productive cough, as well as pain in the left arm
and left-sided chest. He also complained of yellowish, purulent
secretions from the left chest wall within the two weeks before
admission (Figure 1).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1. The yellowish secretions from the patient's left chest wall.

On examination, he was ill, tachypneic (30 breaths per minute), and
febrile, with a corrected axillary temperature of 38.9. His oxygen
saturation in room air was 90\%, and his blood pressure was within
normal limits. There were multiple enlarged, tender supraclavicular and
axillary lymph nodes observed on the left side. The lymph nodes measured
approximately 0.5 cm and were found to be mobile with a firm
consistency.

On the chest examination, a visible scar from the previous chest tube
was observed on the left side of the chest. In proximity to the chest
tube scar, a fistula measuring 2 cm was detected. The tract was found to
be actively discharging yellowish, purulent drainage. In chest
auscultation, breath sounds were reduced in the left lower zone of the
lung with few crepitations. Other systemic examinations were found to be
normal.

The patient visited a physician with the mentioned complaints and was
prescribed oral therapy consisting of clindamycin capsules 150 mg four
times daily and cephalexin capsules 250 mg four times daily.
Nonetheless, due to the lack of improvement, the patient was referred to
Kerman Afzalipour Hospital for further assessment and management.

Laboratory testing revealed leukocytosis with a white blood cell count
of 17\(\times\)\(10^{3}\)per mm? \selectlanguage{english}with a neutrophil
predominance of 80\%, normocytic anemia with hemoglobin of 9.7 g/dl, a
mean corposcular volume of 79  fl and a platelet count of
435\(\times\) \(10^{3}\)per mm?. \selectlanguage{english}The initial blood
sample analysis indicated a C-reactive protein level of 112 mg/dl and an
erythrocyte sedimentation rate (ESR) of 44 mm/h.

Based on the patient's history and physical examination, a chest
radiograph was performed to evaluate the patient's clinical status. A
radiological investigation revealed the existence of a mass-like lesion
in the left lower lobe. A chest CT scan was remarkable for left lower
lobe cosolidation and loculated effusion, which contain air bubbles in
favor of empyema (Figure 2).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure 2. Spiral chest CT scan showing a left chest wall mass contain
air bubbles and thickened septa infavor of empyema.

The patient underwent a septic workup, which included aerobic and
anaerobic blood cultures, polymerase chain reaction (PCR) testing for
respiratory viruses, and an analysis of sputum samples for gram stain,
acid-fast bacilli (AFB), and pyogenic culture, which were found to be
negative. In addition, a specimen of the purulent discharge from the
patient's chest wall was collected and sent for Gram staining, AFB
staining, and culture. The pyogenic culture of the patient's discharge
was positive for \emph{Staphylococcus aureus} .

After confirming the diagnosis of empyema necessitans, which happened as
a complicated side effect of incompletely treated parapnuemonic effusion
due to the lack of fibrinolytic injection in Zahedan Medical Centre, the
patient was started on a treatment plan involving intravenous (IV)
administration of a broad-spectrum antibiotic regimen, video-assisted
thoracic surgery (VATS), and finally a chest tube insertion. The
antibiotic regimen included vancomycin at a dosage of 200 mg four times
daily, metronidazole at a dosage of 200 mg three times daily, cefepime
at a dosage of 1 g three times daily, and meropenem at a dosage of 400
mg three times daily. As previously mentioned, the most important part
of the treatment was VATS, which was identified as a crucial aspect of
the treatment plan given the prolonged duration of the patient's EN. In
the surgery performed for the patient, after making an incision along
the midaxillary line, ports were inserted between the 4th and 5th
intercostal spaces. Ports numbered 5 and 10 were implanted for the
patient, and our surgeon entered the thoracic cavity under camera
guidance. There were significant adhesions present in that area. These
adhesions were meticulously dissected and thoroughly irrigated with
ample amounts of saline solution. Additionally, necessary biopsies were
taken from the pleural membrane and lung tissues to confirm the
diagnosis by gram staining and culture. After the surgery, a chest tube
was inserted to facilitate the drainage of purulent secretions. It
allowed for the continuous drainage of fluids from the affected area,
thereby promoting the healing process and helping the patient recover.
The chest tube on the left side was successfully removed after a period
of seven days. In addition, an echocardiogram was conducted to assess
for endocarditis, which yielded negative results. This approach is aimed
at relieving pressure and reducing the risk of further complications
associated with empyema necessitans.

The patient's recovery was notably smooth and uneventful, with no
reported complications. This positive outcome is a testament to the
effectiveness of the treatment approach employed, which involved a
combination of broad-spectrum antibiotics, VATS, and the insertion of a
chest tube for drainage. Overall, the patient responded well to the
treatment plan and was able to make a full recovery without any
significant issues.

\textbf{Discussion}

Empyema necessitans (EN) is a rare and potentially life-threatening
condition that requires timely diagnosis and treatment to prevent
significant morbidity and mortality (7, 8). Due to its uncommon nature,
EN can be challenging to identify and manage (1, 9). Empyema necessitans
occurs when an untreated empyema spreads through the parietal pleura and
forms abscesses in the subcutaneous tissue of the anterior chest wall
(10, 11). This often arises as a complication of an untreated
parapneumonic effusion, which is the most common underlying cause and
responsible for approximately 70\% of cases (7).

EN is typically caused by the same organism responsible for the
pneumonia that preceded it (2, 12). According to a review of 26 cases
published after 1966, \emph{Mycobacterium tuberculosis}
and\emph{Actinomyces} species were found to be responsible for 75\%
(20/26) of cases (13). This highlights the importance of considering
these organisms in the differential diagnosis of patients with suspected
empyema necessitans, particularly in areas with a high prevalence of
tuberculosis. Accurate identification of the underlying organism is
critical to guiding appropriate antimicrobial therapy and improving
patient outcomes.

One of the less common causes of empyema necessitans
is\emph{Staphylococcus aureus} , with less than 10 case reports of
empyema necessitans caused by this bacterium found in a search of the
PubMed database.

White-Dzuro CG et al. reported a rare case of a 55-year-old male patient
presenting with right shoulder and upper chest pain, diagnosed
with\emph{methicillin-sensitive Staphylococcus aureus} empyema
necessitans. As treatment, intravenous antibiotics were initiated,
followed by surgical intervention and thoracic reconstruction to
effectively manage the condition (1). In another study, C. Preston Pugh
et al. reported a case of empyema necessitans (EN) caused by MRSA in a
5-year-old boy with a ventricular shunt due to hydrocephalus and a
history of type A influenza infection one week before the onset of fever
and chest pain. The patient underwent treatment that included antibiotic
therapy, chest tube insertion, and the infusion of a fibrinolytic agent
to manage the condition (14). Moreover, S. Basndaru et al. documented a
case of a 29-year-old man with a heroin addiction who presented with
empyema necessitans and a complex lesion on the tricuspid valve. The
causative bacterial agent underlying these conditions was identified
as\emph{Staphylococcus aureus} upon further evaluation (15).

In managing cases of loculated pleural empyema, the most effective
approach is considered to be the injection of fibrinolytic agents into
the pleural space, resulting in a complete recovery. If the designated
timeframe for administering fibrinolytics for empyema treatment has
elapsed, our therapeutic approach will transition to VATS with the
option to switch to thoracotomy if required as a result of the chronic
nature of the disease (16-19). Conservative treatments such as
thoracostomy tubes are often inadequate to manage organized empyemas,
and studies have found that patients who undergo VATS have lower
mortality rates and significantly reduced 30-day readmission rates
compared to those treated with tube thoracostomy (20). These findings
highlight the importance of selecting the most appropriate treatment
strategy for patients with loculated pleural empyema, as it can
significantly impact their outcomes.

Alongside surgical interventions, the administration of appropriate
antibiotics based on the microbial coverage determined from the
patient's culture specimens plays a crucial role in the treatment
process.

In the case discussed in this article, the patient did not receive
treatment with fibrinolytic agents during their hospitalization at
Zahedan Medical Center. As a result, the empyema treatment process was
incomplete, leading to a disease relapse in EN. Due to the loss of the
golden window for fibrinolytic injection in the patient, the patient was
treated with VATS and chest tube insertion. This emphasizes the
importance of personalized treatment plans and the need to consider all
available options for patients with loculated pleural empyema, taking
into account their unique circumstances and medical history.

\textbf{Conclusion}

In conclusion, empyema necessitans is a rare but serious complication
that can arise as a result of an underlying pneumonia or parapneumonic
effusion. This case report highlights the importance of prompt
recognition, diagnosis, and management of empyema necessitans,
particularly in pediatric patients. The case underscores the importance
of a multidisciplinary approach to patient management, including close
monitoring and follow-up to prevent further complications. Increased
awareness among healthcare professionals of the clinical features,
diagnosis, and treatment options for empyema necessitans would lead to
early diagnosis and prompt intervention, ultimately improving patient
outcomes.

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of empyema necessitans: case report and review of the literature.
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2. Elyashiv D, Alpert EA, Granat N. Empyema necessitans diagnosed by
point-of-care ultrasound. The Journal of Emergency Medicine.
2020;59(6):e221-e3.

3. ASHRAF S, MASOOD S, MEER T, Iqbal S, Rashid J. Empyema Necessitans
Caused By Methicillin Resistant Staphylococcus Aureus--Two Rare
Presentations. Pak Pediatr J. 2022;46(2):224-28.

4. Kumar A, Azmi MAFM, Jasmani AH, Mokhter WMW, Mokhzani W. Empyema
Necessitans Secondary to Tuberculosis: A Case Report. Malaysian Journal
of Medicine \& Health Sciences. 2022;18.

5. Gomes MM, Alves M, Correia JB, Santos L. Empyema necessitans: very
late complication of pulmonary tuberculosis. Case Reports.
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6. Abdi AM, Mambet E, Ali AY. A case of empyema necessitans in an
adolescent with mycobacterium tuberculosis. Annals of Medicine and
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7. Sahn SA. Diagnosis and management of parapneumonic effusions and
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8. Atay S, Banki F, Floyd C. Empyema necessitans caused by
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9. Kono SA, Nauser TD. Contemporary empyema necessitatis. The American
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10. Tripathi S, Meena DS, Rohila AK, TR N, Jain V, Kumar D, et al.
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16. Hajjar WM, Ahmed I, Al-Nassar SA, Alsultan RK, Alwgait WA, Alkhalaf
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