Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.
Title: General Thoracic Surgery, 6th Edition
Copyright 2005 Lippincott Williams & Wilkins
> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section XI - The Pleura > Chapter 60 - Tuberculous and Fungal Infections of the
Tuberculous and Fungal Infections of the Pleura
Mycobacterial and fungal infections of the pleural space are uncommon disorders in the Western world. Pleural tuberculosis (TB) is most often a side
Although expertise from a large number of cases is obviously lacking, the general guidelines used for treatment of any empyema also apply to tuberculous and fungal empyema. A first step is to clean gross contamination, either with tube thoracostomy or
In this discussion, we describe separately tuberculous empyema,
empyema, and finally miscellaneous conditions, because the patients
Tuberculous infection of the pleura appears as a disease of the past when one refers to the paucity of recent
During primary TB, pleural effusions appear in approximately 8% of patients. The fluid is usually serofibrinous, and this condition should be called tuberculous pleuritis .
During reactivation of TB, pleural infection turns to a true empyema, characterized by an
opaqueand purulent effusion. Such tuberculous empyemas may be either pure or mixed. In the case of bronchopleural fistula, other microorganisms can infectthe pleura together with Mycobacterium tuberculosis .
The particular setting of late complications of collapse therapy for TB, which are infrequently
encounterednowadays, presentsvarying complex problems.
According to Jereb and colleagues (1991) , the pleural space is the second most common site of extrapulmonary TB,
the first being the lymphatic system. Pleural infection, as noted by Weir and Thornton (1985) , is supposed to originate from subpleural pulmonary lesions. The clinical presentation is well known. General signs include low-grade
Positive diagnosis relies on direct sampling of the pleural fluid and on pleural biopsies. Gross analysis of pleural fluid reveals an exudative fluid with a protein level in excess of 40 g/L and a white
In summary, the diagnostic criteria defined by Langston and associates (1967) are still valuable today. Tuberculous pleuritis may be assumed for one or more of the following specific findings: positive tuberculin skin test result; secretions positive for M. tuberculosis , sputum, or gastric content; pleural fluid positive for M. tuberculosis; and pleural disease consistent with tuberculous granuloma on histologic study of biopsy or resected tissue.
The natural history of tuberculous pleuritis is usually
Determination of the appropriate timing of surgical intervention was clearly defined in 1967, and no obvious reason exists to change anything in Langston and associates' (1967) criteria: (a) Decortication is indicated when thoracentesis fails to yield fluid or fails to alter radiographic appearance; (b) the extent of pleural involvement should be
equivalent to one-third or one-fourth of the hemithorax and cast a clearly discernible shadow in the posterior
Fig. 60-1. Posteroanterior chest radiograph showing a large left pleural effusion. Needle biopsy disclosed tuberculous granuloma initially. The effusion failed to resolve after 4 months of adequate treatment.
Fig. 60-2. Same patient as seen in Fig. 60-1 . Computed tomographic scan demonstrated a thickened visceral pleural peel entrapping the lung and requiring decortication for reexpansion.
Technical aspects of decortication are discussed in Chapter 61. In our opinion, a generous thoracotomy is still required. It remains preferable to proceed with the lung inflated for precise peeling of the visceral pleura to achieve optimal reexpansion. At present, this seems not to be easily reproducible with
Pleural reactivation of TB has been a threat in patients who did not receive major antituberculous drug therapy. Moreover, chronic empyema is frequently complicated by bronchopleural fistula, leading to a so-called mixed empyema characterized by a contamination with both
and common pyogens. Chronic empyema following TB adequately treated with antituberculous antibiotics is seldom associated with reactivation of TB in the pleural space. For example, none of the 22 patients treated by
Diagnosis is easy in patients with known sequelae of TB. Low-grade fever, constitutional complaints, and increasing dyspnea with or without chest pain are the major symptoms. Abundant sputum suggests bronchopleural fistula. On chest radiography, the obvious finding is an increase in the extent of the pleural involvement; the appearance of an air fluid level heralds a bronchopleural fistula. Thoracentesis yields purulent fluid, which should be sent routinely for both bacterial and fungal cultures. Thoracentesis may be difficult in patients with a calcified pleura and requires an
As soon as empyema is confirmed, adequate drainage should be instituted. Our preference is the tube thoracostomy, whereas others prefer immediate open thoracostomy. We limit open thoracostomy to the severely ill patient with a poor operative risk, because it may jeopardize subsequent decortication. In patients with documented reactivation of TB, the classic principle ”to convert sputum cultures with medical treatment before resection ”should still be applied as recommended by Treasure and Seaworth (1995) .
The first question is to determine whether the underlying lung is reexpandable.
have found that a patent bronchopleural fistula does not preclude decortication.
Table 60-1. Treatment Plan for Chronic Mycobacterial or Fungal Empyema
The second question is to determine whether parenchymal resection is required. Metatuberculous lungs are relatively stiff, and loss of volume leads to residual pleural space, which represents a factor for persistent empyema postoperatively. Therefore, combined parenchymal resections should
As we and our colleagues (1995b) have pointed out, the postoperative course after decortication with or without additional parenchymal resection may be complicated
Creating an open window thoracostomy initially is an important decision, because decortication cannot be performed in a second stage. However,
Garcia-Yuste and colleagues (1998)
suggest that two-stage management with thoracostomy and subsequent muscle plombage of the cleaned residual space is a reasonable alternative in cases unsuitable for decortication. Poor general health status and extensive calcifications precluding decortication are indications for this type of management. In the case of a largely destroyed but asymptomatic lung, two-stage myoplasty may help avoid the
Regardless of the type of surgical management decided on, adjuvant antituberculous treatment is mandatory in cases of documented reactivation of TB.
Late Pleural and Extrapleural Complications of Collapse Therapy
Until the early 1960s, when major antituberculous drugs became available and
The first stage of collapse therapy was creation of an artificial intrapleural pneumothorax; because of the spontaneous resorption of the intrapleural air, reinjections of air were required at 2-week intervals. The first indication for thoracoscopic surgery was apical adhesiolysis to promote apical collapse, as reported by Dumarest and co-workers in 1945. When extensive apical adhesions precluded adequate collapse with intrapleural pneumothorax, extrapleural pneumolysis was the preferred procedure. Similarly, as carried out by
, the collapse space was
Late infectious complications at the site of previous intrapleural or extrapleural pneumothorax present as either progressively acquired swelling of the residual pocket ( Fig. 60-3 )
or appearance of an air fluid level because of a bronchopleural fistula. One-half of the patients are symptomatic and complain of fever, increasing dyspnea, pain, or hemoptysis; productive cough usually indicates bronchopleural fistula. In asymptomatic patients, the diagnosis is made when comparing consecutive surveillance chest films, as pointed out by us and our associates (1995a). Surprisingly, the pleural fluid is sterile on culture in more than one-half the patients. Furthermore, the incidence of proven tuberculous empyema is relatively low. In our experience (1995a), 13 of 28 patients had positive microbiology results, and only 4 had proved pleural TB. Similarly, Schmid and De Haller (1986) observed a single case of reactivated TB in a series of 15 patients. These observations are consistent with earlier data reported by Neff and Buchanan (1975) , which showed that tuberculous empyema was a rather usual early complication of collapse therapy but did not contribute significantly to the late morbidity.
Fig. 60-3. Bilateral tension effusion at the site of a right-sided intrapleural and a left-sided extrapleural pneumothorax.
The preferred mode of treatment of late empyema is decortication. The underlying lung is expected to reexpand because no previous parenchymal resection has been performed. Simple open window drainage is not satisfactory per se but is a fair treatment for debilitated and
Decortication is well tolerated, although it is complicated by prolonged air leaks in most patients. We and our colleagues (1995b) found that the average drainage time was 16 days; however, drainage time was increased to a mean of 20 days in symptomatic patients and in patients with positive microbiology results. The reexpansion potential of such chronically entrapped lungs is surprising but may be anticipated from careful inspection of CT of the underlying lung (
). Technical details do not diverge from those of any decortication. Briefly, double-lumen tube intubation is mandatory to prevent flooding of the
directly over the lung; the thickened pleura is progressively freed and excised from the center to the periphery. One should refrain from resecting any lung, because the previous tuberculous areas have scarred over the years. We recommend triple drainage connected to strong suction (100 to 150 mm Hg), because air leaks stop only when the apposition of pleural surfaces is restored. Because compliance of such lungs is decreased, strong suction is required to shift the mediastinum and elevate the diaphragm. Antituberculous therapy is mandatory and should be guided by sensitivity studies. The functional recovery after such procedures is debated. We do not anticipate any restoration of lung function. In our opinion, the aim of the operation is to use the lung as a natural prothesis to fill the pleural space and to resolve the empyema and, of course, avoid extrapleural pneumonectomy.
Fig. 60-4. Patient with tuberculous empyema complicating a previous intrapleural pneumothorax. A. Mediastinal window. A broad pleural peel is clearly outlined. B. Parenchymal window obviates relatively normal underlying lung tissue prone to reexpansion after decortication.
Late complications occurring in extraperiosteal plombage cavities were more frequently frank infections; in 1997 we reported eight proved infections in a total of 10 exudates; four of them were tuberculous empyemas. When infection occurs, the usual finding is recent onset of swelling along the thoracoplasty incision or in the subclavicular area; infection facilitates
Fig. 60-5. Extraperiosteal plombage with methyl methacrylate balls. Late infectious complication with exudative distention of the collapse space.
Fig. 60-6. Same patient as seen in Fig. 60-5 . Freshly removed plombage material.
Pleural infection with
is a rather infrequent disease;
Kearon and colleagues (1987)
listed only 30 cases in an exhaustive review of the literature. Even in the immunodeficient setting of lung
Pleural aspergillosis presents in two clinical pictures that differ considerably. Acute Aspergillus empyema develops usually during the immediate postoperative course after an intrapleural thoracic procedure and presents with findings similar to any postoperative pleural infection. Late Aspergillus empyema presents similarly to pulmonary aspergilloma as a chronic process of the saprophytic type. The following section refers mainly to our personal data, originally published in 1992(a).
Acute Aspergillus Empyema
As noted by Herring and Pecora (1976) , acute Aspergillus empyema most often occurs after a surgical procedure undertaken
to treat an aspergilloma. We have reported seven cases of acute pleural infection (1992a). Five of them resulted from gross intraoperative contamination, with four patients being operated on for a known aspergilloma. A fifth patient was operated on for spontaneous hemopneumothorax and underwent resection of an apical bulla; retrospectively, a small mycetoma was identified by review of the
The most common operation
A threat of pneumonectomy exists in patients with aspergilloma. These operations are characterized by major intraoperative difficulties because of the usually dense and highly
The most common clinical finding after partial lung resection is prolonged air leak and persistent drainage of fluid; in addition, fever and weight loss are usual. The residual pleural space hosting the infection is not always apparent on standard chest radiography. More particularly, anterior spaces most often require CT studies to be identified. After pneumonectomy, the signs of empyema are well known to all thoracic surgeons: General malaise, fever, and pallor identify the patient at risk. Infection is confirmed by elevated white blood cell count and persisting high C-reactive protein levels, as reported by Icard and associates (1994) . Chest radiography shows a rapid increase of the pleural air fluid level because of increased exudation of pleural fluid; the mediastinum is occasionally shifted toward the contralateral lung.
Diagnosis of Aspergillus empyema is easily confirmed by appropriate analysis of pleural fluid samples. Serodiagnosis is less reliable, because it may be negative at the early stages of the disease.
Cure of acute Aspergillus empyema requires sterilization and complete and definitive obliteration of the pleural space. Various strategies such as pleural lavage through a chest tube, surgical d bridement, and open window thoracostomy achieve a satisfactory gross cleaning of the pleural space. But the final decision as to how to obliterate the space depends on the reexpansion potential of the remaining lung. After resections less than lobectomy, expansion is clearly possible as soon as air leaks have sealed. In such patients, conservative management with antifungal treatment has a fair chance for success. According to Chatzimichalis and co-workers (1998) , because of the hyperemia of the acutely infected pleura, the tissue penetration of itraconazole is satisfactory and sufficiently high local concentrations are easily obtained, similar to invasive pulmonary aspergillosis. A lone case of success of treatment with aerosolized liposomal amphotericin B has been reported by Purcell and Corris (1995) ; high local tissue concentrations are expected in the presence of a bronchopleural fistula.
The problem is different in patients who have undergone a lobectomy. Clearly, intraoperative seeding results from parenchymal tears because of a difficult dissection. This means that such patients had complex aspergilloma, as pointed out by
Daly and colleagues (1986)
, and that the remaining lung is expectedly sclerotic with reduced reexpansion potential. In favorable cases, institution of a pneumoperitoneum sufficiently
empyema after pneumonectomy does not differ from management of postpneumonectomy empyema in general. Once the diagnosis is established, the pleural space must be drained. Aggressive management is mandatory to obtain quick cleaning of gross purulent material. Most authors proceed with an open window thoracostomy as described by
Clagett and Geraci (1963)
. In our current practice, we prefer surgical d bridement followed by irrigations through a chest tube. It is questionable whether a
Chronic Aspergillus Empyema
Chronic Aspergillus empyema is fostered by a residual pleural space communicating with the bronchial tree. The cavity is penetrated by aerosolized fungal material similar
to parenchymal cavities. Further development of the fungus is favored by progressive erosion of the
The common problem in these patients is that medical therapy with itraconazole is likely to fail. The first reason is that tissue penetration in chronic lesions
Two clinical presentations are discussed, corresponding to postresectional empyema and empyema in previous collapse spaces. Chronic postresectional empyema may be
A positive diagnosis relies on direct identification of Aspergillus species or serodiagnosis. Sampling of pleural fluid is easy in patients with hydropneumothorax only. Fortunately, serodiagnosis is most reliable because it is nearly always positive in patients with chronic infection. Our current criteria for Aspergillus infection are the following: either at least two precipitations on immunoelectrophoresis or a single precipitation with positive catalase activity. In our previous series (1992a), the average number of precipitations was 7.2 (range, 2 to 15); all but one patient had a positive result for catalase activity.
Treatment options differ between postresectional and postcollapse empyema. In any event, the underlying lung should be left in place when feasible, because a significantly increased risk for mortality and major morbidity exists after pneumonectomy in patients with preoperative empyema; this has been estimated to be close to 40% by Halezeroglu (1997) and Conlan (1995) and their associates, as well as by Odell and Henderson (1985) . Furthermore, according to McGovern and colleagues (1988) , the risk of completion pneumonectomy in this situation is prohibitive. The operative mortality of 9.4% after completion pneumonectomy for cancer was increased to 27.6% after completion pneumonectomy for benign disease in the Mayo Clinic experience. Similarly, the prevalence of empyema was 20.7% and 9.3%, respectively, for benign and malignant disease, and the prevalence of bronchopleural fistula was 17.2% and 3.1%. Therefore, further resection is only legitimized when persisting infectious lesions such as lung abscess or bronchiectases would otherwise jeopardize the outcome. In extreme situations, completion pneumonectomy and immediate thoracoplasty have been advocated by Utley (1993) .
Fig. 60-7. Aspergillus empyema caused by bronchopleural fistula complicating an intrapleural pneumothorax. Note the apical pneumothorax and basal effusion, determining a midthoracic air fluid level. Extensive pleural calcifications are visible; translucent trapped lung is packed against the hilum.
In postresectional empyema, the remaining lobe is usually fibrosed because of previous TB or radiation therapy. Therefore, decortication is likely to fail. Muscle transfers are less than optimal in these malnourished patients with marked chronic illness; besides, as previously noted, the latissimus dorsi muscle has usually been sacrificed during the initial thoracotomy. Although some successes have been obtained with omental transfer, as reported by Shirakusa and associates (1990) , we would add some caveats to this technique. In malnourished patients, the tissue volume is spare. Harvest of the omentum exposes the patient to the additional risk of laparotomy. When the omentum is used, one should avoid a direct passage through the diaphragm to prevent herniation
of abdominal viscera, as we noted (1992b). It is mandatory to use indirect tunneling, either through Morgagni's hiatus or through the phrenohepatic ligaments as suggested by Jurkiewicz and Arnold (1977) .
Fig. 60-8. Aspergillus empyema caused by bronchopleural fistula complicating an intrapleural pneumothorax. Same patient as seen in Fig. 60-7 . A. Mediastinal window: thickened parietal and visceral pleura with extensive calcifications. B. Parenchymal window: The trapped lung tissue is nearly normal and did reexpand after decortication.
The most appropriate management should include careful curettage of all fungal material, followed by a retailoring of the chest wall with thoracoplasty. Many authors, such as Gr goire and colleagues (1987) , recommend leaving the first rib in place to avoid scoliosis. However, others, including Loynes (1972) , believe that scoliosis is determined by extensive rib resections and resection of the transverse processes of the vertebra. We stress the need to routinely resect the first rib, as do Hopkins and colleagues (1985) and Horrigan and Snow (1990) . Incomplete apical collapse is a concern when the first rib is left in place. Of course, such operations are risky because of the disabled status of these patients. In our experience, mortality of thoracoplasty has been 7%, caused by respiratory infection. More than one-half the patients in our series (1992a) experienced major perioperative bleeding (>1,500 mL) because of the usual hypervascularization of aspergillized cavities; preoperative embolization as suggested by Hughes and associates (1986) usually fails to reduce intraoperative bleeding because the perilesional vascular network is supplied by multiple pedicles, as pointed out by Chen and colleagues (1997) . We suggest generous rib resection, because more than 40% of our patients had persistent space problems after thoracoplasty.
The postoperative course is usually prolonged, with an average hospital stay of 49 days in our experience; this is the result of the disease rather than of the procedure used. However, long-
Treatment of long-term complications of residual collapse spaces is initiated with tube thoracostomy and irrigations. CT scan reveals some expandable underlying parenchyma in most cases, although perfusion scan shows a dramatic decrease of perfusion (see
). Knowing the risk of pneumonectomy through an empyema (1995a), we advocate decortication in the latter cases. Inexperienced surgeons might be frightened by the sight of the residual lung with multiple parenchymal leaks, as it presents at the conclusion of the operation. Triple drainage with strong suction, and a good deal of patience, lead finally to
Several other fungal diseases, such as blastomycosis, histoplasmosis, cryptococcosis, and sporotrichosis, may occasionally involve the pleura during acute pulmonary infection with pleural perforation. Patients with AIDS are particularly prone to such infections. The main problem in these patients is appropriate microbiological diagnosis. With adequate antifungal treatment, the infection should resolve without any need for surgical management except for drainage of large effusions.
Two agents, Coccidioides immitis and Candida albicans , are of particular interest. Coccidioidomycosis may cause diffuse lung destruction similar to TB and may result in similar surgical problems. The presence of yeast cells within a pleural effusion suggests the presence of an esophagopleural fistula.
Pleural infection with
seldom has been referred to in the literature. A review published by Drutz and Catanzaro (1978a, 1978b) describes two situations depending on the natural history of disease. An acute infection appears in 40% of infected patients and mimics an influenza-like acute respiratory infection. The pleural effusion that may appear
The difficulties of chronic pulmonary coccidioidomycosis with empyema are
Though usually seen in immunocompromised individuals, such as patients with AIDS or
Sehti and Takaro (1978)
reported that an esophagopleural fistula complicates approximately 0.5% of pneumonectomies. This complication is relatively unknown, although Takaro and colleagues reported its occurrence in their collective review in 1960. Intraoperative
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