Empyema necessitans is a rare long-term complication of poorly or uncontrolled empyema thoracis characterized by the dissection of pus. Images in Clinical Medicine from The New England Journal of Medicine — Tuberculosis Empyema Necessitatis. Images in Clinical Medicine from The New England Journal of Medicine — Empyema Necessitatis.

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Cough was insidious in onset and productive of purulent and nonbloody sputum. A year-old male with no significant medical history came to the emergency department with worsening right-sided chest swelling associated with fever, chills, night sweats, and weight loss, following sudden-onset rib pain 7—8 months prior.

Furthermore, malnutrition in children may suppress the tuberculin sensitivity leading to a negative Mantoux test which explains the difficulty in diagnosing tuberculosis in this case.

Studies [ 89 ] also revealed that the em;yema of empyema thoracis studied was based on a chest radiograph and not on a CT scan as was the case in our report.

Empyema Necessitans

It is characterised by pus collection in the thorax which bursts and communicates with the exterior, forming a fistula between the pleural cavity and the skin [ 1 ]. Computed tomography chest, without contrast. Empyems systemic examination was normal.

However, there were challenges in differentiating between Mycobacterium tuberculosis empyeka nontuberculous empyema in a resource poor setting like ours. Financial support and sponsorship Nil. Articles Cases Courses Quiz. Empyema necessitatis is a rare condition that can be caused by Gram negative bacterial pathogens like Proteus species.

Empyema necessitans EN is a rare clinical entity in which a suppurative infection in the soft tissue forms due to a sinus tract between an empyema and the thoracic wall, usually in the setting of smoldering pneumonia or osteomyelitis.


Management of this case was challenging in terms of diagnosis and treatment. Pleural effusion with empyema necessitans is usually caused by Mycobacterium tuberculosis and Actinomyces israelii [ 2 ]. Our case had antimicrobials therapy, tube drainage, and nutritional rehabilitation and was referred to the cardiothoracic surgeons for other management.

He was also dyspnoeic with reduced chest expansion on the right hemithorax. You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. If pleural effusion is left for several months without intervention, this can lead to developing this complication, empyema necessitans [ 67 ].

It was only the chest X-ray that suggested TB. N Engl J Med. Case report and review of the literature.

There was a stony dull percussion note on the right hemithorax but dull percussion notes on the left hemithorax. On presentation, he was febrile with erythema, tenderness, and induration over the right lateral chest and decreased air entry in the right lung base.

There were no other systemic symptoms and he was not a known sickle cell anaemia subject. Case 2 Case 2. Case 5 Case 5. Both pus from the pleural aspirate and wound swab culture grew Proteus spp.

Impaired synthesis of polyclonal non-paraprotein immunoglobulins by circulating lymphocytes from patients with multiple myeloma role of suppressor cells.

Synonyms or Alternate Spellings: Full Blood Count revealed haemoglobin of 5. The isolation of Proteus species from the pleural fluid aspirate and wound swab suggests Proteus as the etiologic agent of the parapneumonic effusion. It is also reported to be rare by other workers elsewhere [ 24 ]. This was the first case seen in our hospital for the past 12 years confirming the rarity of the condition.

He has not had any vaccination due to sociocultural factors. Findings on chest radiographs are often nonspecific and at times can even be normal.

Empyema Necessitans: An Unexpected Infectious Presentation of Multiple Myeloma

It may either occur due the virulence of the organism or may be facilitated by previous thoracic surgery e. Author information Copyright and License information Disclaimer.


Open in a separate window. Fifteen days before presentation, he developed a swelling on the right side of the chest wall which became fluctuant and later ruptured and started discharging foul smelling pus.

Empyema necessitans complicating pleural effusion is rare in our environment. Contrast enhanced computed tomographic CECT scan which is the diagnostic study of choice that will show lung and mediastinal windows and reveal the extent and nature of the disease was not available.

J Glob Infect Dis. The patient underwent induction therapy with bortezomib, thalidomide, and dexamethasone for multiple myeloma and was lost to subsequent follow-up.

Empyema necessitans in the setting of pneumonia and parapneumonic effusion.

Subscribe to Table of Contents Alerts. However, a chest radiograph will only show opacity occupying a certain area of the hemithorax, which may be secondary to consolidated parenchyma, pleural peel, or a lung abscess.

There was associated difficulty in breathing but no discoloration of the mucous membrane. The abscess resolved following 4 weeks of outpatient intravenous antibiotics through the peripherally inserted vascular catheter. Bone marrow biopsy confirmed the diagnosis of multiple myeloma.

The management consists of antimicrobials, tube drainage, and decortication for obliterating the cavity to prevent fibrosis and facilitate lung expansion [ 11 ]. He was febrile We report a child with pleural effusion dmpyema empyema necessitans secondary to Proteus spp. Log in Sign up.

Pleural fluids are usually diagnostic and help in the choice of appropriate antibiotics.