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Tension Empyema Thoracis ORIGINAL PAPER CASE REPORT The ANNALS of AFRICAN SURGERY | www.annalsofafricansurgery.com Tension Empyema Thoracis Ooko PB, Ongondi M, White RE Tenwek Hospital Correspondence to: Dr. Philip Blasto Ooko, P.O Box 39 Bomet 20400, Kenya. Email: [email protected] Summary Tension empyema is a rare and life threatening considereddecortication as for a trapped differential lung and in had young an uneventful patients postoperative stay. Tension empyema should be complication of pleural space infection requiring procedures or thoracic surgery, who present with oldemergent male drainagepatient withto restorepulmonary cardio-respiratory tuberculosis, without a history of trauma, thoraco-abdominal function. The authors report a case of a 27-year- cough, fever and chest pain, with clinical findings of who presented with severe dyspnea, right sided Keywordscardiovascular: Tension collapse. Empyema, Tuberculosis, chest pain, and persistent cough. He subsequently developed cardiovascular collapse requiring an emergent right chest tube which drained over 2 Cardiac Arrest, Thoracostomy. liters of pus under pressure. The cardiovascular Ann Afr Surg. 2015; 12(2): 109-10. Introductionsystem stabilized and he subsequently underwent Empyema thoracis is the accumulation of pus were initiated, and the airway secured with an in the pleural space. “Tension” is a term used endotrachealrespiratory arrest. tube. Basic Resumption and advanced of spontaneous life support atropine and epinephrine. The patient’s blood when fluid or air accumulated in the pleural pressurecardiac activity was still was unrecordable, noted after but three the roundspulse rate of shiftspace andis underhemodynamic sufficient compromise positive pressure (1). While to cause severe respiratory distress, mediastinal and saturation had improved to 120 beats/min and tension pneumothorax is a relatively common right90% respectively.hemithorax with absent breath sounds and event, scattered cases of tension hemothorax, Assessment of the chest revealed a hypoinflated aurohemothorax, rare complication hydrothorax of pleural and space chylothorax infection, havewith sided tension hemothorax, a needle thoracocentesis been previously reported (2-6). Tension empyema is atsignificant the 2nd left intercostaltracheal deviation. space Suspectingwas performed, a right andonly acute a few management case reports existingof this rare in the condition. literature (7- 9). Our objective was to describe the presentation revealing thick yellow fluid. An emergent portable Case effusionchest X-Ray with (CXR) left mediastinal was obtained shift to corroborate(Figure 1). with Athe diagnosis aspirate of findings, tension whichempyema showed was made,a large and right an emergent right tube thoracostomy was performed. (TB),We report who a presented case of a 27-year-old to our facility male with patient, a 2 withweek a history ofof sputum-positiveworsening dyspnea, pulmonary right tuberculosissided chest withoutImmediately a concomitant upon entry drainage in to theof air pleural (Figure cavity, 2). A drainage of purulent fluid under pressure was noted topain, onset fever of symptoms.and persistent cough. He reported that – 20 minutes (Figure 3). The blood pressure rapidly he completed his anti-TB medication 2 months prior total of 2900 ml of pus was drained over a period of 10 tachypnea, diaphosesis, hypotension with unrecordableOn examination, low bloodhe was pressure, noted andto hypoxichave severe with improved to 91/69mmHg and pulse rate reduced to started95beats/min. on broad He spectrumwas transferred antibiotics. to the The intensive patient care unit, placed on a ventilator and immediately saturations of 60% on room air. Before adequate continued to improve, and was extubated 4 hours 108 The ANNALS of AFRICAN SURGERY. July 2015 Volume 12 Issue 2 evaluation, he deteriorated and had cardio-The ANNALS of AFRICAN SURGERY. July 2015 Volume 12 Issue 2 109 The ANNALS of AFRICAN SURGERY | www.annalsofafricansurgery.com later with no resumption of respiratory distress, but soundsEvaluation and of pus the on chest thoracocentesis. during resuscitation Immediate revealed return required supplemental oxygen. ofa hypoinflatedspontaneous circulationleft hemothorax and blood with pressure absent ensuedbreath plateletThe blood count work of showed204, 000 a hemoglobinper mm3, sodium of 14.9 of gm/142 dl , white blood cell (WBC) count of 10 600 per µL, thoracostomy after cardiac arrest with a similar result (8). Thoracocentesis,with removal of pus. used Ahern in this and case Miller and also reported used tube in mmol/L, potassium of 5.5 mmol/L, and creatinine of 64 µmol/L. An HIV test was positive with a subsequent tension empyema from other differential diagnosis. A CD4 count of 369cells/µl. Microscopy of the aspirated higherthe studies index above of suspicion, was important as noted inin the differentiating case by Ahern a fluid revealed no cells. Gram and Acid Fast Bacilli(AFB) stains of the pus were negative, and a bacteriologic Retreatmentculture showed TB noregimen growth was at initiatedtwo days. after Sputum baseline was and Miller, should have prevented the unnecessary negative for acid and alcohol fast bacteria (AAFB). Conclusiondelay in obtaining an X-ray for our patient (8). highly likely to be due to TB. The patient continued Tension empyema should be considered as a liver function tests, as the empyema was thought differential in young patients without a history of trauma or thoracic surgery, who present with Heto demonstrateunderwent decortication lung re-expansion, on hospital reduced day oxygen18 for requirements, and reduced chest tube drainage. hypotension, mediastinal shift and lung collapse due a pleural biopsy was not sent for histology. The patient cough, fever and chest pain, with clinical findings of fibrinous adhesions with a trapped lung. Unfortunately, two weeks later to complete his TB medication. to significant amount of fluid on one side of the chest. Writtenhad a good informed post-operative consent forcourse the publication and was discharged from the WrittenEmergent informed drainage consent is important for the publication to prevent from and/or the reverse the cardiovascular consequences. patient or immediate relatives could not be obtained patient or immediate relatives could not be obtained despite all reasonable attempts. Every effort has been despite all reasonable attempts. Every effort has been Discussionmade to protect the privacy of our patient. madeReferences to protect the privacy of our patient. compromise due to acute accumulation of pus in the Tension empyema leads to severe cardio-respiratory 1. Leigh-Smith S, Harris T. Tension Pneumothorax- Time For a Re-Think? Emerg Med J. 2005;22(1):8- thepleural earliest space reports leading of thisto severe rare condition respiratory is attributed distress, 16 mediastinal shift, and cardiovascular collapse. One of 2. Ootaki Y, Okada M, Yamashita C, et al. Tension two other published reports on tension empyema in Hemothorax Caused by a Ruptured Aneurysm of theto Holloway English literature in 1986 (7).(8, 9). Since then there have been the Descending Thoracic Aorta: Report Of A Case. Surg Today. 2000;30(6):558-60. 3. Ford JM, Stamey TA. Tension Hemothorax absentAny patient breath who sounds, complains a dull ofpercussion chest pain, note, severe and Following Translumbar Aortography. Arch Surg. dyspnea and tachycardia, with findings of hypotension, 1961;83(5):741-5. 4. Weber SM, Aihara R, Hirsch EF. Case of tracheal deviation to the opposite hemithorax without Traumatic Tension Urohemothorax. J Trauma. a hemothorax,history of trauma, empyema thoraco-abdominal or hydrothorax. procedure Presence 2003;54(6):1253. or thoracic surgery may have a ‘tension’ caused by 5. Negus RA, Chachkes JS, Wrenn K. Tension Hydrothorax and Shock in a Patient With a empyemaof fever, productive as noted in cough this case or andrecent in the treatment case report for Malignant Pleural Effusion. Am J Emerg Med. bypneumonia Ahern and or Miller TB may(8). be indicative of a tension in1990;8(3):205-7. Two Pediatric Patients. Paediatr Anaesth. An urgent thoracostomy should be performed before 6. Wheeler AD, Tobias JD. Tension Chylothorax 7. Holloway NM. Tension Pyothorax and Acute 2007;17(5):488-91. cardio-respiratory arrest ensures. In this case and utilizedothers, earlier.thoracostomy Bramley saved and colleagues the patient, reported but acould case Empyema. Crit Care Nurse. 1986;6(6):65-72. ofhave a 48 prevented year old cardio-respiratoryman who presented arrest with hadrespiratory it been 8. Ahern TL, Miller GA. Tension Pyothorax Causing Cardiac Arrest. West J Emerg Med. 2009;10(1):61. 9. Bramley D, Dowd H, Muwanga C. Tension distress and developed cardiac arrest, which was Empyema Causing Cardiac Arrest. Emerg Med J. 2005; 22(12):919-20. 110laterThe reversed ANNALS ofby AFRICAN emergent SURGERY. tube Julythoracostomy 2015 Volume 12 (9). Issue 2 The ANNALS of AFRICAN SURGERY. July 2015 Volume 12 Issue 2 111.
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