Evr Respir J 1988, 1, 868···869 CASE REPORT

Pseudomonas thoracic secondary to nosocomial rhinosinusitis

Ph. Meyer*, J.M. Guerin•, Y. Habib*, C. Levy*

PseudonwTUJs thoracic empyef1Ul secorulary to nosocomial rhinosinusitis. Ph. Medical Intensive Care Unit• and Depar1ment of Meyer, J.M. Guerin, Y. Habib, C. Levy. Otolaryngology••. Lariboisiere's Hospital, Univ­ ABSTRACT: Three cases of Pseudomonas thoracic empyema occurring ersite Paris VII, 2 rue Ambroise Pare, 75010 Paris. ln nasotTacbeally intubated patients are reported. Paranasal rhino­ Keywords: Nasotrachcal intubation; sinusitis, a well documented complication of prolonged nasotTacheaJ pyopneumothorax. intubation, could be the primary infectious location. Massive colonization leads to extensive necrotizing pulmonary lesions. Received July 1, 1987; accepted after revision Failure of diagnosis and treatment of sinus involvement could be March 28, 1988. responsible for persistent or recurrent pleural empyema. Treatment includes continuous pleural drainage, sinusitis treatment and . This complication should be considered In the choice between early tracheostomy and prolonged nasotracheal Intubation In Intensive Care Unit (ICU) patients. Eur Respir J., 1988, 1, 868--869.

Pseudomonas thoracic empyema is a rare disease. Case2 Pseudomonas species are isolated in 2.5% of out-patient and 10% of nosocomial empyema cultures [1]. In A 73 yr old woman had massive pulmonary haemor­ Intensive Care Units (ICU), prior use of antibiotics rhage due to acute systemic lupus erythematosus. An and associated rhinosinusitis related to nasotracheal acute was treated with corticos­ intubation place patients particularly at risk of teroid therapy and continuous positive pressure ven­ acquiring such a life-threatening infection. We report tilation after left nasotracheal intubation. Sputum three cases. specimens and blood samples grew pneumoniae. High dose sodium was added to the treatment and the patient became afebrile. Case 1 On the eighth day a CT-scan demonstrated bilateral ethmoid and maxillary sinus involvement. A transnasal A 33 yr old man was admitted to the medical ICU needle aspiration and a tracheostomy were performed. with severe pleuropneumonia and Streptococcus pneu­ On the ninth day a new septic course developed. Under moniae septicaemia. He needed nasotracheal intubation a high level of positive end-expiratory pressure (PEEP), and intermittent positive pressure ventilation (IPPV) a compressive pyopneumothorax developed requiring associated with high dose penicillin sodium therapy. Six emergency drainage. The patient died a few hours later. days later he remained febrile in spite of sterile Sinus aspirate, and sputum cultures grew cultures from blood samples, pleural aspirate and Pseudomonas aeruginosa. sputum. No clinical evidence for a septic process could be found. On the eighth day a computerized tomography (CT) scan demonstrated air-fluid levels in Case 3 the sphenoid, ethmoid and left maxillary sinuses. A transnasal needle puncture of the left maxillary sinus A 45 yr old man was admitted with Streptococcus and a tracheostomy were performed. On the tenth pneumoniae septicaemia and pleuropneumonia. An day a pyopneumothorax developed requiring continu­ acute respiratory failure developed, and IPPV was ous suction drainage. Culture specimens from blood, instituted after nasotracheal intubation. Cultures from sputum, sinus aspirate and pleural effusion all grew blood, sputum and pleural effusion grew Streptococcus Pseudomonas aeruginosa. The septic course progres­ pneumoniae. After six days of treatment by pleural sively improved with ceftazidim and amikacin therapy. suction drainage and high dose penicillin sodium, all Six weeks of thoracic drainage was needed. Two cultures were negative_ Eight days after admission, months after admission the patient made a full recovery. in spite of respiratory status improvement, a new septic PSEUDOMONAS THORACIC EMPYEMA 869

course developed. A Cf-scan demonstrated maxillary and antibiotics. Ceftazidim could bechosen for its low and ethmoid sinusitis on the side of the nasotracheal minimal inhibitory concentration (MIC) [7), alone or tube. A needle transnasal sinus aspiration was per­ associated with an [8]. formed. Respiratory stabilization allowed nasotracheal The prognosis of pseudomonas empyema depends tube removal. Sinus aspirate, pleural effusion and on the underlying pulmonary lesions and primary blood samples grew Pseudomonas aeruginosa, and disease. Mortality rate varies from 41% [I] to 80% penicillin was changed to ceftazidim and amikacin. when massive necrotizing lesions or septicaemia are In spite of adequate drainage of the pyopneumot­ associated [9). horax, and antimicrobial chemotherapy, the septic course did not improve. Cultures remained positive for Pseudomonas and a new CT-scan showed no References change in rhinosinusitis. A surgical drainage of the left maxillary sinus was performed. The situation then 1. Finland M, Bames MW. - Changing ecology of acute bacterial empyema occurrence and mort.ality at Boston city slowly improved: a CT-scan on the fiftieth day Hospital during 12 selected years from 1935 to 1972. J lnf showing normal sinuses. Continuous suction drainage Dis, 1978, 137, 274-290. in front of a massive bronchopleural was 2. Caplan ES, Hoyt NJ.- Nosocomial sinusitis.] AmMed maintained for twelve weeks in association with anti­ Assoc, 1982,247,639-641. biotics. Four months after admission the patient was 3. 0' Reilly MJ. Reddick EJ, Black W, Carter PL, Erhardt abe to be discharged. I, Fill W, Maughn D, Sado A. - from sinusitis in nasotrachcally intubated patients. Am J Surg, 1984, 147, 601-604. Comments 4. Deutschman CS, Wilton P, Sinow J, Dibbell D, Konstanti­ nides FN, Cerra F. - Paranasal sinusitis associated with Pseudomonas empyema is a life-threatening situation. nasotracheal intubation: a frequently unrecognized treatable source of sepsis. Crit Care Med, 1986, 14, 111-114. In patients with prolonged nasotracheal intubation, 5. Knodel AR, Beekman JF. - Unexplained fevers in patients paranasal sinusitis should be considered as a possible wilh nasotracheal intubation. JAmMed Assoc, 1982, 248, source of bronchopleural infection. 868-870. Paranasal nosocomial sinusitis is a well-documented 6. Guerin JM, Meyer P, Habib Y. - Nosocomial pneumo­ complication of prolonged nasotracheal intubation [2-4]. nia in intubated patients: role of nosocomial rhinosinusitis. Am Pseudomonas is responsible for 35% [4] to 48% [2] Rev Respir Dis, 1987, 136, 1310. of the cases, especially among patients treated with prior 7. Trenholme GM, Pottage JC, Karanusis PH. - Use of regimens and oorticosteroids. The diagnosis Ceftazidime in the treatment of nosocomial lower respiratory must be considered in the event of unexplained fever infections. Am] Med,l985, 79 (Suppl. 2A), 32-36. and/or purulent nasal discharge [2, 5]. The extent of 8. Kamad A, Alvarez S, Berk SL. - caused by gram negative bacilli. Am J Med, 1985. 79 (Suppl. lA), 61~7. disease is best seen in CT-scans. Ethmoid and sphenoid 9. Tannini PB, Claffey T, Quintiliani R.- Bacteriemic pseudo­ involvement associated with maxillary sinusitis are fre­ monas pneumonia. 1 Am Med Assoc. 1974, 230, 558-561. quent [2, 4]. Active Pseudomonas multiplication in an obstructed sinus leads to massive pharyngeal colonization. Pleu­ RESUME: Trois cas d'empyeme thoracique A Pseudomonas, ropneumonia related to the same pathogen is noted developpes chez des patients sous intubation naso-trachcale. in 50% of the patients presenting with nosocomial sin­ font l'objel de ceue publication. La rhino-si nusite para-nasale, usitis [4, 6]. Delay in diagnosis and treatment of the complication acruellement bien document&! des inrubations sinusitis leads to persistent pneumonia even with ade­ na~o - trach eales prolongces, pourrait etre la localisation infec­ quate antimicrobial agents. Mechanical ventilation, tieuse primairc. La colonisation massive de l'arbre respiratoire especially with high levels of PEEP, leads to ruptures entraine des lesions pulmonaires n&:rosarlles cxtcnsives. C'est sans doute en raison du manque de diagnostic et de traitcment of necrotic cavities. de l'atteinte sinusale, que l'empyeme pleural persistant ou Recovery from sinusitis can be obtained by sinus recidivant s'est deve!oppe. Le traitement a combine un drainage drainage. Removal of the nasotracheal tube, releasing pleural continu, le craitcment de la sinusite et !'administration obstruction, will permit adequate drainage and resolu­ d' antibiotiques. Ceue complication do it etrc prise en comptcdans tion of the problem within 48 h [4]. Persistent sinus le choi.x entre tracheostomic prccoce et intubation naso-trachCale obstruction should be treated by surgical drainage [3], prolongee chez les patients dans !es services de so ins intensifs.