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Background: Neutrophil extracellular traps (NETs) increasingly are implicated in acute and chronic conditions involving multiple organ systems., Research Question: Are NET concentrations higher in parapneumonic effusions compared with effusions of other origin and does this reflect the inflammatory nature of these effusions?, Study Design and Methods: Patients (N = 101) seeking hospital treatment for undifferentiated pleural effusion underwent pleural fluid classification based on cytologic analysis results, biochemical findings, microbiological characteristics, and clinical judgement. Concentrations of NET markers (extracellular DNA [eDNA], citrullinated histone H3 [citH3]), neutrophils (α-defensins), and inflammation (IL-1β)-related proteins were quantified by enzyme-linked immunosorbent assay. Differences between groups were analyzed using the Kruskal-Wallis one-way analysis of variance. Correlations used Spearman coefficient. Receiver operating characteristic (ROC) curves were calculated., Results: Effusions were classified into four groups: parapneumonic (n = 18), malignant (n = 35), transudative (n = 22), and unclassifiable (n = 26). Concentrations of NETs markers were significantly higher in the parapneumonic group compared with malignant, transudative, and unclassifiable groups (median eDNA, 12.8 ng/mL vs 0.77 ng/mL, 0.44 ng/mL, and 0.86 ng/mL [P < .001]; and median citH3, 127.1 ng/mL vs 0.44 ng/mL, 0.34 ng/mL, and 0.49 ng/mL [P < .001]). citH3 and eDNA were correlated highly with lactate dehydrogenase (LDH; Spearman r = 0.66 and r = 0.73, respectively; P < .001) and moderately negatively correlated with pH (r = -0.55 and r = -0.62, respectively; P < .001). α-Defensins and IL-1β were higher in the parapneumonic group than in other groups (median α-defensins, 124.4 ng/mL vs 4.7 ng/mL,7 ng/mL, and 6.9 ng/mL [P < .001]; and median IL-1β, 145 pg/mL vs 1.87 pg/mL, 1.39 pg/mL, and 2.6 pg/mL [P < .001]) and moderately correlated with LDH (r = 0.60 and r = 0.57; P < .001). ROC curves showed high sensitivity and specificity for NET markers for prediction of parapneumonic effusion., Interpretation: High levels of some NET-related mediators in parapneumonic effusions correlate with inflammation. Effusions of other causes do not show high levels of NETs. These results may have treatment implications because NETs may be an important contributor to the inflammation and viscosity of parapneumonic effusions and may help us to understand the therapeutic benefit of deoxyribonuclease in empyema., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Case Presentation: A 52-year-old man was referred to our hospital for cough, fever, chest pain, and progressive dyspnea. He has worked as a full-time security staff at a community center and was in a normal state of health until 11 months prior to referral when he began experiencing cough, expectoration, a high-grade fever (up to 39.7°C), chills, and left chest pain. He visited the local hospital several times with suspected lung cancer. Bronchoscopy showed chronic inflammatory changes in his bronchi. He was given a course of antibiotics, but his fever had not subsided. The patient had visited a bamboo rat farm and consumed bamboo rat meat one year previously. He had never smoked., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

An 18-year-old African American male subject presented to an acute care clinic with 3 days of productive cough, chills, pleuritic right chest pain, sore throat with hoarseness, congestion, and intermittent shortness of breath. He recently relocated to Texas from Georgia to undergo basic military training. He denied any other recent travel or contact with persons with pulmonary TB or other respiratory illnesses. His medical history was significant for glucose-6-phosphate dehydrogenase deficiency and sickle cell trait., (Published by Elsevier Inc.)

Background: The frequencies of etiologic bacterial agents of intrapleural infections reported until now have been widely varied, largely depending on the implemented detective methods. The aims of this study were to evaluate bacterial etiologies of bacterial pleurisy using a cultivation-independent method., Methods: Pleural fluids were collected from 42 febrile patients with hemipleural effusion. The bacterial flora was analyzed by a clone library method using amplified fragments of the 16S ribosomal RNA gene (rDNA) with universal primers in addition to conventional cultivation methods., Results: Forty-two specimens were obtained from 26 patients with bacterial pleurisy, seven with mycobacterial pleurisy, and nine with other pleural effusions. In the 26 bacterial cases, 16 (61.5%) showed positive results for 16S rDNA sequencing analysis, of which 11 (42.3%) were also positive for cultivation method. In seven (43.8%) of the 16 polymerase chain reaction-positive cases, anaerobic phylotypes were predominantly detected. Anaerobic phylotypes (six of these seven cases) were not detected by cultivation method. In nine (34.6%) of the 26 bacterial pleural cases, the results from the clone library methods were not accordant with those of the cultivation method. In seven of these nine cases, the discrepancies between the two detection methods were due to the existence of anaerobes., Conclusion: The clone library analysis using the 16S rDNA of pleural fluid showed a higher incidence of anaerobic bacteria in infectious pleurisy than that previously expected and provided additional bacterial information for cultivation methods.

Background: Limited understanding of the presentation and course of influenza A(H5N1) infection in humans hinders evidence-based management., Methods: We reviewed the case records of patients admitted to the Persahabatan Hospital (RSP), Jakarta, Indonesia, with influenza A(H5N1) confirmed by real-time polymerase chain reaction., Results: Twenty-two previously well patients, aged 3 to 47 years (median 24.5 years), were identified. All attended a clinic or hospital after a median of 2 days of illness (range 0-7). Times to first dose of oseltamivir (three died before receiving oseltamivir) were 2 to 12 days (median 7 days), administered mostly (n = 15) at RSP. Nineteen patients required mechanical ventilation. Deaths numbered 18 (case fatality = 82%) occurring within hours to 6 days of RSP admission, corresponding to 6 to 16 days of illness. Admission hyperglycemia ( >or= 140 mg/dL), unrelated to steroids or known underlying diabetes mellitus, and elevated D-dimer levels (0.81-5.2 mg/L, upper limit of normal < 0.5 mg/L) were present in 14/21 (67%) and 20/21 (95%) patients, respectively. Fibrinogen concentrations were mostly low/normal at 129.9 to 517.9 mg/dL (median 241.1, normal 200-400 mg/dL), whereas C-reactive protein (9/11) and ferritin (6/8) levels were increased. Risk factors for death (univariate analysis) included: (1) increased D-dimers, (2) hyperglycema, (3) increased urea, (4) more extensive chest radiograph shadowing, and (5) lower admission oxygen saturation., Conclusions: Early diagnosis and effective treatment of human influenza A(H5N1) infection remains challenging. Most patients were referred late with advanced disease. Oseltamivir had limited clinical impact. Elevated D-dimer levels, consistent with fibrinolysis, and hyperglycemia warrant more research to determine their underlying mechanisms and optimal treatment.

Background: It is generally recommended that pleural fluid samples from pleural effusions of unknown cause be cultured for bacteria, mycobacteria, and fungi. However, the utility of this practice has been not been adequately assessed., Design: Retrospective review., Setting: Tertiary care, referral medical center., Patients: Five hundred twenty-five patients undergoing diagnostic thoracentesis at Mayo Medical Center, Rochester, MN, over a 12-month period from July 1, 2001, to June 30, 2002., Interventions: None., Measurements and Results: Among 525 patients undergoing diagnostic thoracenteses, 476 patients (91%) had one or more cultures performed on their pleural fluid specimens. Thirty-nine positive results (3.0% of 1,320 cultures) occurred in 35 of these 476 patients (7.4%). After excluding likely contaminants, true pathogens were identified in only 19 of 1,320 pleural fluid cultures (1.4%) belonging to 15 patients (3.2% of those who had cultures performed on their pleural fluid specimen). These positive results included 2.3% of aerobic bacterial, 1.2% of anaerobic bacterial, 1.4% of fungal, and 0% of mycobacterial cultures. Microbiologic smears performed on these pleural fluid samples included 357 Gram stains, 109 fungal smears (potassium hydroxide), and 232 acid-fast smears with positive yields of 2.5%, 0%, and 0%, respectively. These positive findings represented 1.3% of all smears performed. Of the specimens obtained from outpatient thoracenteses, only one had a true-positive result (0.8%). Only 1.1% (four specimens) of the cultures performed on free-flowing effusions demonstrated true pathogens; three of these four specimens grew fungi., Conclusions: The positive yield of microbiologic smears and cultures on pleural fluid specimens is low, particularly in the outpatient setting and in patients with free-flowing effusions. Microbiologic testing of pleural fluid specimens should be ordered more selectively.

Objective: To evaluate the role of intrapleural streptokinase in the management of complicated parapneumonic effusions in children., Design: Prospective comparative study., Setting: Cheng Kung University Hospital, a tertiary medical center in Tainan, Taiwan., Patients and Methods: We enrolled as our prospective study group 20 consecutive children with complicated parapneumonic effusions who received intrapleural streptokinase treatment between August 2000 and July 2002. We also retrospectively analyzed a comparison group of 22 consecutive children with complicated parapneumonic effusions who received chest tube drainage without streptokinase treatment from January 1992 to July 2000. We then compared the clinical manifestations and outcome of these two patient groups. The patient population (21 boys and 21 girls) ranged in age from 9 to 130 months (mean age, 41.5 +/- 26.3 months [mean +/- SD]). The characters of pleural effusion showed no difference between the two groups. Nineteen patients had positive findings for Streptococcus pneumoniae, 2 patients had positive findings for Staphylococcus aureus, 2 patients had positive findings for Pseudomonas aeruginosa, and 19 patients had undetermined pathogens. All patients were treated with appropriate antibiotics., Results: More pleural fluid was drained from the streptokinase group than from the comparison group during streptokinase treatment (816 +/- 481 mL vs 279 +/- 238 mL, p < 0.01). The duration of fever after chest tube insertion was also significantly lower in the study group (5.3 +/- 3.1 days vs 7.9 +/- 4.6 days, p < 0.05). Only two patients in the streptokinase group required surgical intervention compared with nine patients in the comparison group (p < 0.05). No major side effects were noticed after streptokinase instillation., Conclusion: Intrapleural fibrinolytic treatment with streptokinase is safe and effective, and it can obviate the need for surgery in most cases. The combination treatment should be attempted early on, when complicated parapneumonic effusion is first diagnosed.

Background: Tuberculous pleural effusion occurs in 30% of patients with tuberculosis (TB). Rapid diagnosis of a tuberculous pleural effusion would greatly facilitate the management of many patients. Polymerase chain reaction (PCR) has been used to detect Mycobacterium tuberculosis in pleural fluid with highly variable sensitivity., Objective: To improve our laboratory diagnosis of tuberculous pleural effusion., Methods: We applied PCR to detect DNA specific for M tuberculosis in 33 of the studied pleural biopsy specimens using an IS986-based primer that was specific for mycobacterium complex, and compared it to the results of pleural fluid and biopsy cultures performed on either Lowenstein-Jensen (LJ) medium or BACTEC 12B liquid medium (Becton Dickinson Microbiology Systems; Cockeysville, MD), Ziehl-Neelsen (ZN) staining, and histopathology in 45 patients with pleural effusion., Results: Of the 45 patients with pleural effusion who were studied, 26 patients received diagnoses of tuberculous pleural effusion that had been confirmed by either culture and or histopathology, 10 patients received diagnoses of exudative effusion due to causes other than TB, and 9 patients received diagnoses of transudative effusion. Histopathology of the pleural biopsy specimen had a sensitivity of 53.8%. The sensitivity of the ZN staining of pleural fluid and biopsy specimens was 0.0% and 3.8%, respectively. The sensitivity of the culture on both BACTEC 12B liquid medium and LJ medium was higher in pleural biopsy specimens (92.3%) than in pleural fluid specimens (15.4%; p > 0.001). The improvements of the BACTEC culture system improved and shortened the detection time of M tuberculosis in pleural biopsy specimens. PCR of pleural biopsy specimens had 90% sensitivity and 100% specificity. The positive predictive value and the negative predictive value for pleural biopsy specimen cultures were 100% and 90.5% vs 100% and 86.7% for pleural biopsy specimen PCRs., Conclusion: The overall accuracy of PCR of pleural biopsy was similar to the results of pleural biopsy culture, however, PCR of the pleural biopsy was much faster in reaching diagnosis. PCR of pleural biopsy is a useful method when used in combination with the BACTEC culture system and histopathologic examination of pleural biopsy to reach a rapid diagnosis of tuberculous pleural effusion.

Objectives: Tuberculosis, a reemergent killer, is threatening to assume serious proportions all over the world, particularly in view of the AIDS pandemic. The detection of mycobacterial DNA by polymerase chain reaction (PCR) in clinical samples is a promising approach for the rapid diagnosis of tuberculous infections. The aims of this study were to evaluate PCR for detection of Mycobacterium tuberculosis in pleural fluids and to correlate the results with adenosine deaminase activity (ADA) estimation and acid-fast bacilli (AFB) screening., Methods: The sensitivity and specificity of PCR in detection of mycobacterial DNA in 20 samples of tuberculous pleural effusion were evaluated using 40 samples of nontubercular pleural effusion as controls. The results were correlated with the ADA in all 60 pleural fluids. In addition, AFB detection by Ziehl-Neelsen staining on cytospin smears of all pleural fluids was also compared., Results: Of the 20 samples of tuberculous pleural effusion, mycobacterium could be detected by AFB staining in 4 samples. Fourteen samples were PCR positive. None of the samples from the control group were AFB or PCR positive. The sensitivity of PCR, therefore, was 70.0% with specificity of 100% (positive predictive value, 100%; negative predictive value, 86.95%). The sensitivity of AFB screening was at best 20%. The mean of ADA values in tubercular pleural effusions was 63.21 U/L (SD, 33.01), and the mean in the control samples was 51.1 U/L (SD, 29.71). Taking a cut-off value of 50 U/L, both the sensitivity and specificity of ADA estimation in diagnosing tuberculosis were only 55%., Conclusion: PCR represents a rapid and sensitive method for the detection of mycobacterial DNA in tuberculous pleural effusions. AFB screening has low sensitivity, and ADA estimation has both low sensitivity and specificity. Therefore, when the clinical suspicion is high and smear result is negative, but the signs and symptoms of M tuberculosis are apparent, PCR is the method of choice for identifying the infection.

The scarcity of mesothelial cells is a well-known characteristic of tuberculous pleural effusions. We report three HIV-infected patients with tuberculous pleural effusions, in which mesothelial cells were found in significant numbers in the pleural fluid. Clinicians should be aware that the altered immune responses that occur in HIV-infected patients may affect the cytologic profile of tuberculous pleural effusions, and they should be cautious not to exclude this diagnosis based solely on the presence of mesothelial cells in the fluid.

Study Objectives: To determine the predicting factors for outcome of tube thoracostomy in patients with complicated parapneumonic effusion (CPE) or empyema., Design and Settings: Retrospective chart review over a 55-month period at a tertiary referred medical center., Patients and Measurements: The medical charts of patients with empyema or CPE were reviewed. Data including age, gender, clinical symptoms, important underlying diseases, leukocyte count, duration of preadmission symptoms, interval from first procedure to second procedure, the time from first procedure to discharge (recovery time), the amount of effusion drained, administration of intrapleural streptokinase, chest tube size and position, loculation of pleural effusion, and characteristics and culture results of pleural effusion were recorded and compared between groups of patients with successful and failed outcome of tube thoracostomy drainage., Results: One hundred twenty-one patients were selected for study. One hundred of these patients had received tube thoracostomy drainage with 53 successful outcomes and 47 failed outcomes of chest tube drainage. Nineteen patients received decortication directly, and the other two received antibiotics alone. Univariate analysis showed that pleural effusion leukocyte count, effusion amount, and loculation of pleural effusion were significantly related to the outcome of chest tube drainage. Multiple logistic regression analysis demonstrated that loculation and pleural effusion leukocyte count < or = 6,400/uL were the only independent predicting factors related to failure of tube thoracostomy drainage., Conclusions: Loculation and pleural effusion leukocyte count < or = 6,400/microL were independent predicting factors of poor outcome of tube thoracostomy drainage. These results suggest that if the initial attempt at chest tube drainage fails, early surgical intervention should be considered in good surgical candidates with loculated empyema or pleural effusion with leukocyte count < or = 6,400/microL.

Study Objectives: To describe the age distribution, clinical, laboratory, radiographic, and bacteriologic findings of pediatric patients with tuberculous pleural effusion., Design: A retrospective study., Patients and Methods: We have identified all cases of primary pulmonary tuberculosis in children < 18 years, reported to the health department. We have collected information from medical records regarding demographics, clinical findings, bacteriologic results, and evolution. Chest radiographs obtained at the time of initial evaluation were reviewed independently by two groups of radiologists who were blind to the clinical and epidemiologic data., Results: Between January 1983 and December 1996, 175 children < 18 years were diagnosed as having primary pulmonary tuberculosis. Among them, 39 patients (22.1%) showed pleural effusion on chest radiograph. The mean age of patients with tuberculous pleural effusion was significantly higher (13.52+/-0.5 years vs 6.97+/-0.42 years). The sensitivity of the tuberculin test is 97.4% for an induration > or = 5 mm. Pleural fluid analysis shows a lymphocytic exudative effusion. Chest radiograph review showed unilateral pleural effusion in all cases. Pleural effusion was the sole radiographic manifestation in 41% of cases. Parenchymal disease is associated in 23 cases (59%). Bacteriologic confirmation of tuberculosis was achieved in 22 cases (56.4%). Cultures of pleural fluid and biopsy material both yielded Mycobacterium tuberculosis in 15 of 34 (44.1%) and 12 of 18 (66.6%), respectively, for samples under study. Pleural biopsy specimens showed granulomatous inflammation in 18 of 23 cases (78.3%). Antituberculous therapy for 6 to 9 months was effective in all cases. Transient side effects occurred in 1 of 39 patients (2.9%)., Conclusions: Pleural effusion accounts for 22.1% of cases of pediatric pulmonary tuberculosis. Parenchymal consolidation is the most common associated radiographic finding. Bacteriologic confirmation was achieved in 56.4% of cases. A short course of chemotherapy is effective.

Study Objectives: To determine the optimal number of pleural biopsy (PLBX) specimens for a diagnosis of tuberculous pleurisy., Design: Retrospective review., Setting: County hospital., Methods: We reviewed all percutaneous needle biopsy specimens of the parietal pleura in 30 patients who had tuberculous pleurisy. Data are reported as mean+/-SEM and statistical comparisons are done with the Mann-Whitney test. We accepted p<0.05 as statistically significant., Results: The number of biopsy specimens obtained from each patient ranged from 4 to 10 with 1 sample submitted for mycobacterial culture and the rest submitted for histologic study. Sixty percent of patients had pleural cultures positive for Mycobacterium tuberculosis and 80% had diagnostic histology. Overall pleural biopsy sensitivity (histology and culture) for tuberculous pleurisy was 87%. On average, 40.4%+/-4.7% of all PLBX specimens contained pleura. Diagnostic PLBX procedures compared to false-negative procedures produced more tissue specimens (7.1+/-0.3 vs 4.8+/-0.5, p=0.005) containing more pleural specimens (2.4+/-0.2 vs 0.8+/-0.5, p=0.01). If only PLBX procedures yielding more than six tissue specimens (n=18) or more than two pleural specimens (n=12) were analyzed, then the diagnostic sensitivity of PLBX for pleural tuberculosis was 100%. There seemed to be a direct relationship between the sensitivity of PLBX and the number of specimens submitted., Conclusions: The sensitivity of percutaneous needle biopsy for diagnosis of tuberculous pleurisy is highest when more than six specimens are obtained which, on average, contain more than two specimens of parietal pleura. There are no conclusive data indicating how many tissue specimens to submit for mycobacterial culture, but one specimen seems sufficient.

Introduction: It has long been believed that pleural fluid must be directly aspirated into a heparinized syringe to obtain an accurate value. Many operators aspirate 30 to 60 mL of pleural fluid into a syringe without heparin, and then place 1 mL into a heparinized syringe from which the pH is determined. We postulated that this technique does not cause a clinically significant difference in pleural pH values., Methods: Patients undergoing thoracentesis in the outpatient clinic, general ward, and medical ICU were eligible. After the initial entry of the needle into the pleural space, a heparinized syringe was used to obtain pleural fluid for pH determination. A 60-mL syringe was then used to aspirate additional pleural fluid for biochemical analysis and culture. At the end of the procedure, a second aliquot of pleural fluid was placed into a heparinized syringe for pH determination. A difference of 0.1 in pH was taken as clinically important., Results: Twenty-one pleural fluid samples were obtained from 20 patients. Pleural fluid pH determinations were within 0.1 in all but one patient. The mean pH for the directly collected group was 7.39 (25%: 7.35; 75%: 7.45). The mean for the indirectly collected group was 7.41 (25%: 7.35; 75%: 7.45). The difference between the two means (0.02; 95% confidence interval, 0.0368 to 0.00131) was statistically significant but clinically unimportant (p=0.037)., Conclusions: Pleural fluid can be collected in a large syringe and then placed into a heparinized syringe to assess pH. This is useful information because the use of just one syringe saves time and reduces the risk of iatrogenic complications.

During a 5-year study period, we diagnosed pulmonary tuberculosis in two (2%) of 94 lung and heart-lung transplant recipients. Each infection occurred 3 months after bilateral lung transplantation in the presence of evidence implicating donor-to-recipient transmission of the pathogen. The radiographic patterns of pulmonary tuberculosis were subtle: narrowing of the middle lobe bronchus of the right lung caused by an endobronchial granulomatous mass (n = 1) and a focal cluster of small nodules in the upper lobe of the left lung and small bilateral pleural effusions (n = 1). Each patient achieved complete clinical and radiographic response after antituberculous therapy. We conclude that Mycobacterium tuberculosis may be transmitted directly by a donor lung and may involve bronchial mucosa, pulmonary parenchyma, and pleura.

A 72-year-old man presented with malaise, weight loss, and cough. Chest radiograph revealed bilateral pleural effusions. On thoracentesis, the left effusion was a clear yellow exudate with more than 90% lymphocytes, and the right effusion was a grossly bloody exudate with more than 90% neutrophils. Cultures of both effusions grew Mycobacterium tuberculosis.

Prior attempts to create an animal model of empyema by direct inoculation of bacteria alone into the pleural space have been unsuccessful. The animals either died of overwhelming sepsis or cleared the infection from the pleural space without development of an empyema. We hypothesized that injection of bacteria with a nutrient agar into the pleural space would allow the bacteria to remain in the pleural space for an extended time period, permitting an empyema to develop. The bacterium Pasteurella multocida in brain heart infusion (BHI) agar was injected into the right hemithorax of 12 New Zealand white male rabbits. Our preliminary studies showed that the animals died in less than 7 days if they were not given parenteral antibiotics. For this reason, the rabbits were given penicillin, 200,000 U, IM, every 24 h starting 24 h after bacterial injection. Pleural fluid was sampled by thoracentesis at 12, 24, 48, 72, and 96 h after bacterial injection. Pleural fluid pH, glucose, lactate dehydrogenase (LDH), leukocyte count, and Gram's stain and culture (in one half of the animals) were obtained at each time point. Pleural biopsy specimens were obtained at autopsy after 96 h. The mean pleural fluid pH reached a nadir of 7.01 at 24 h and remained less than 7.1 throughout the experiment. The mean pleural fluid glucose level reached a nadir of 10 mg/dL at 24 h. The mean pleural fluid LDH peaked at 21,000 IU/L at 24 h and the mean pleural fluid leukocyte count peaked at 12 h with a value of 67,000 cells per cubic millimeter. Gram's stains revealed organisms and cultures were positive for growth in all animals at 12 and 24 h. Some animals had positive Gram's stains and growth on cultures up to 72 h after bacterial injection. At autopsy, all rabbits injected with bacteria had gross pus in the right pleural space and had developed a thick pleural peel. Microscopic specimens of the pleura revealed large numbers of leukocytes (primarily polymorphonuclear lymphocytes) with invasion of the adjacent lung and chest wall. In conclusion, this model more closely mimics the empyema that occurs in humans, relative to previous animal models. This model appears appropriate for additional randomized studies in which different methods for the treatment of empyema can be evaluated.

Video-assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural disease. Since 1990, we have performed VATS procedures to manage a variety of pathologic pleural processes in 306 patients. The 99 patients with complex empyemas or hemothoraces are the focus of this report. Seventy-six patients with complex empyemas (including 26 chronic) were approached with VATS after inadequate chest tube drainage. The causes associated with the thoracic empyemas were parapneumonic collections in 47, after hemothorax in 8, infected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged bronchopleural fistula following spontaneous pneumothorax in 4, chronic drainage of malignant pleural effusions in 4, and chronic drainage of pleural effusion in 2 patients undergoing chemotherapy. Ages ranged from 14 to 78 years. Sixty-three patients (83%) were treated with thoracoscopic drainage +/- decortication alone. Thirteen patients (17%) required subsequent thoracotomy for decortication, including 12 of the 26 (46%) chronic empyemas known to be greater than 3 weeks old. Chest tubes were removed 3.3 +/- 2.9 days postoperatively in 67 patients; 9 patients (12%) were sent home with empyema tubes. Postoperative hospital stay for these patients with empyema averaged 7.4 +/- 7.2 days. There were five deaths, all related to progressive sepsis from associated pneumonia (6.6%). Twenty-three patients underwent thoracoscopic evacuation of hemothoraces that resulted following open heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3. All were successfully treated by thoracoscopic drainage and pleural debridement alone. Chest tubes were removed 2.8 +/- 0.5 days postoperatively and hospital stay averaged 4.3 +/- 1.9 days. There were no complications; one patient with a hemothrax (after heart transplant) died of unrelated causes. In our experience, VATS has been highly successful in the early management of empyemas and hemothoraces. Conversion to open thoracotomy must always be anticipated, especially when approaching chronic empyemas.

To investigate the etiology of pleural effusions in our region, we undertook a prospective study of patients with this condition in our centers. During a 5-year period, we studied 642 pleural effusion patients aged 57.1 +/- 21.1 years, of whom 401 were men aged 56.5 +/- 21 years and 241 were women aged 57.8 +/- 21.4 years; the male/female ratio was 1.6:1. The most frequent cause of pleural effusion was tuberculosis (25%), followed by neoplasia (22.9%) and congestive heart failure (17.9%). The etiology of 48 cases (7.5%) remained uncertain. In the neoplastic effusion group, the most frequent locations of the primary tumor were lung (32.6%), breast (11.5%), lymphoma (10.8%), and ovary (7.5%); in 21 cases (14.3% of the neoplastic group), it was not possible to identify the primary tumor. The 111 patients aged younger than 40 years with tuberculous effusions made up 69.4% of tuberculous effusion cases and the same percentage of patients younger than 40 years; the proportion of effusions that were tuberculous peaked in the 11- to 30-year-old age group and declined steadily thereafter. Of the patients with neoplastic effusions, 83% were older than 50 years; the proportion of effusions that were neoplastic rose steadily from zero in the 0- to 30-year-old age group to a peak among 60- to 70-year-olds. The age-wise distribution of effusions secondary to congestive heart failure was similar to that of neoplastic effusions. Of the effusions secondary to congestive heart failure, 86% (99/115) affected the right pleura or both, and 83% of effusions secondary to pulmonary thromboembolism (15/18) affected the right side. Neoplastic, tuberculous, parapneumonic, empyematous, and other exudative effusions showed no preference for either side. Of the 97 bilateral effusions, 77 (79.4%) were secondary to heart failure (59, 60.8%) or neoplasia (18, 18.6%). We conclude that in our region, the most frequent cause of pleural effusion is tuberculosis, followed by neoplasia and congestive heart failure. We suggest that all those interested in pleural disease should determine the etiologic pattern of pleural effusion in their region with a view to the adoption of regionally optimized diagnostic and therapeutic attitudes.

Serious infections caused by Staphylococcus aureus in HIV-infected patients have been reported. Contributing factors in the development of invasive S aureus infections include a high rate of skin and nasal colonization, frequent dermatologic disease, and the use of intravenous catheters. The authors report three cases of S aureus pericarditis in HIV-infected patients. While cases of viral, mycobacterial, and malignant pericardial effusions in HIV-infected patients have been reported, a review of the literature disclosed only three cases of bacterial pericarditis. Despite appropriate antibiotic therapy and drainage, a patient's condition may abruptly deteriorate and progress to tamponade. Early recognition of bacteremia and pericarditis and monitoring for cardiac tamponade, along with aggressive treatment, can result in a favorable outcome, but mortality remains high, particularly when S aureus is the causative agent.

Pneumocystis carinii pneumonia (PCP) is the most common pulmonary complication of AIDS and is typically diagnosed by the identification of P carinii organisms in sputum, bronchoalveolar lavage fluid, or tissue obtained with transbronchial biopsy. We describe two HIV-seropositive patients with pleural effusions in whom the diagnosis of P carinii infection was made by examination of pleural fluid. Pleural effusions associated with PCP are very unusual but can provide a source of diagnostic material particularly in those HIV patients who have development of a spontaneous pneumothorax and require chest tube insertion.

The etiology, microbiologic findings, and management of 82 episodes of empyema treated by our unit over a period of 6 years were analyzed. Average patient age was 54 years. Eighty-two percent had underlying disease such as alcoholism (29 percent), malignancy (23 percent), and diabetes mellitus (20 percent). Sixty (73 percent) had an empyema develop secondary to a bronchopulmonary infection. Other etiologies were as follows: infradiaphragmatic sepsis, five cases; iatrogenic, ten cases; and idiopathic, seven cases. Cultures were positive in 76 cases and negative in the remaining 6 (2 positive Gram stains, 1 positive under bacilloscopy, and 3 were sterile). Anaerobes were isolated from 25 and aerobes from 47 of the positive cultures. A single bacteria was isolated from 43 and multiple organisms (average: 2.63/case) grew on the remaining 33 positive cultures. Length of hospitalization averaged 37 days. Seven patients received antibiotics only, thoracentesis was performed on three, intercostal chest tube drainage was required in 72, and more aggressive surgery was performed on 12 patients (7 with fibrothorax and 5 with pneumonectomy). Streptokinase was instilled into the pleural space of eight patients with good results. Pleural drainage superinfection occurred at a rate of 8.5 percent. Nine patients died; the remaining recovered. Only three deaths came about as a direct result of the empyema.

Extrapulmonary pneumocystosis recently has been reported in a number of tissues. Most cases occurred in patients receiving aerosolized pentamidine prophylaxis. We report a case of disseminated pneumocystosis presenting as a large pleural effusion without apparent lung involvement where Pneumocystis carinii was the only pathogen identified. The absence of parenchymal lesions on chest x-ray film, the lack of hypoxemia and the minimal uptake of gallium all argue against significant lung involvement. The patient was successfully treated with chest tube drainage, intravenous and inhaled pentamidine and orally administered dapsone and trimethoprim. The addition of inhaled pentamidine to intravenously administered pentamidine may have increased pleural fluid levels substantially and its use coincided with the patient's improvement.

Respondents at an interactive symposium on pleural space infections (n = 339) at the 1991 American College of Chest Physicians Annual Scientific Assembly recorded their personal management preferences for hypothetical patients with empyema. The group's preference was to treat pleural sepsis from an anaerobic multiloculated empyema by pleural decortication (49 percent); however, open thoracotomy with directed chest tube placement (22 percent), chest tube placement with intrapleural streptokinase (14 percent), placement of a single chest tube into the largest pleural loculus (8 percent), and placement of multiple small-bore catheters with computed tomographic guidance (7 percent) all had proponents. In the case of a multiloculated empyema not completely drained by a first chest tube in a nontoxic patient, the preference was drainage by a second chest tube, either a small-bore (42 percent) or a large-bore (36 percent) tube. The heterogeneity of responses suggests that prospective trials comparing treatment modalities are needed.

The objective of the study was to determine if residual pleural thickening after treatment for pleural tuberculosis could be predicted from the pleural fluid findings at the time of the initial thoracentesis. Forty-four patients initially diagnosed as having pleural tuberculosis between January 1986 and January 1988 were separated into two groups: the 23 patients in group 1 had residual pleural disease, while the 21 patients in group 2 had no residual pleural disease after treatment for their pleural tuberculosis was completed. The clinical characteristics of the two different groups did not differ significantly, but the patients in group 1 tended to be a little sicker in that the duration of their symptoms was longer, their hemoglobin values were lower, and weight loss and cough were more frequent. There were no significant differences in the pleural fluid findings in the two different groups. The mean pleural fluid protein level was 5.40 +/- 0.58 g/dl for group 1 and 5.17 +/- 0.80 g/dl for group 2, while the mean pleural fluid glucose level was 78.6 +/- 19.5 mg/dl for group 1 and 79.5 +/- 20.1 mg/dl for group 2. The mean pleural fluid lactate dehydrogenase (LDH) level in group 1 was 593 +/- 498 IU/L, while the mean level for group 2 was 491 +/- 198 IU/L. The presence of residual pleural thickening was not related to the chemotherapeutic regimen or the performance of a therapeutic thoracentesis. From this study we conclude that approximately 50 percent of patients with pleural tuberculosis will have residual pleural thickening when their therapy is completed, but that one cannot predict which patients will have residual pleural thickening from either their clinical characteristics or their pleural fluid findings.

We reviewed the records of 1,738 cases of tuberculosis seen during the period from 1968 to 1988 in Mobile, Alabama. Seventy cases of tuberculous pleural effusion were identified and constituted 4.9 percent of all disease due to Mycobacterium tuberculosis during this period. Tuberculous pleural effusion was diagnosed if the patient had M tuberculosis cultured from sputum, pleura, or pleural fluid and had a roentgenographic pleural effusion without an alternative explanation for the presence of the effusion. The diagnosis of tuberculous pleural effusion was made in the absence of a positive culture if the patient had an undiagnosed lymphocytic exudative pleural effusion and all clinical and roentgenographic abnormalities resolved on antimycobacterial chemotherapy. The mean age of all patients was 47 +/- 18.4 years. The 70 cases were evenly divided between 35 that were accompanied by roentgenographic pulmonary parenchymal infiltrates and 35 that occurred in the absence of parenchymal infiltrates. We conclude that cultures of all potentially diagnostic specimens (sputum, pleural fluid, and pleura) and an intermediate-strength skin test, are sensitive tests for the diagnosis of tuberculous pleural effusion. In addition, the age of patients with tuberculous pleural effusion appears to be increasing.

Study Objective: To evaluate the accuracy of PLA with a thin needle in the bacteriologic diagnosis of patients with lung abscess and in demonstrating possible coexistence of an underlying lung carcinoma, and the influence of this technique in the treatment and outcome of these patients., Design: Case series., Setting: Tertiary university referral center., Patients: Consecutive sample of 50 patients with clinical picture suggestive of pulmonary infection and single or multiple cavitation of at least 1 cm in diameter on chest x-ray films, and lack of clinical suspicion of active pulmonary tuberculosis. One patient was excluded from the study after demonstration of tuberculosis by PLA., Interventions: Lung aspirates were obtained under fluoroscopic guidance by introduction of a 22-gauge disposable spinal needle within the abscess cavity and were immediately transported to the bacteriology laboratory and pathology department for processing. All patients were initially treated with clindamycin. Tobramycin was added in all those patients with hospital-acquired infection, lack of foulness of sputum, and those who were initially severely ill. Definite treatment was based on the results of bacteriologic cultures., Measurements and Main Results: Cultures of LAs were positive in 82 percent (40/49) of patients. In 20 cases the isolates were monobacterial (13 aerobic bacteria and seven anaerobic). In the remaining 20 cases, cultures grew more than one kind of bacteria (four exclusively aerobic, five exclusively anaerobic, and 11 mixed), with an average of 3.25 types of bacteria per case. Anaerobes were found as a single bacteria or associated with other aerobic bacteria in only 58 percent (23/40). The results of LA cultures led to change in the initial antibiotic trial in 23 patients (47 percent). Of ten cases in which bronchogenic carcinoma was demonstrated, cytologic study of LA was done in nine, and eight had positive cytologic yield. Pneumothorax occurred in seven cases (14 percent) as the sole complication., Conclusions: (1) Percutaneous lung aspiration had a high diagnostic yield and accuracy in our series, with a relatively low incidence of complications. (2) Anaerobic bacteria were less frequently implicated in our cases than previously reported. This finding led to significant changes in the initial empiric antibiotic treatment.

We devised a dot blot assay to evaluate the IgG and IgA response to P32, a recently isolated antigen specific to mycobacteria. Pleural fluids and the corresponding sera were tested, obtained from five patients with pleural tuberculosis proven by direct examination and/or culture and from 14 patients with pleural effusions of other origins. We measured the total IgG and IgA levels in all samples and determined the anti-P32 titer after adjusting IgG and IgA respectively to the same levels in all samples. Those pleural fluids and sera from tuberculous patients contained a higher proportion of anti-P32 antibodies than samples obtained from nontuberculous control subjects; in those patients, the proportion of anti-P32 antibodies was generally higher in pleural effusion fluid than in serum.

In a retrospective study of 15 patients who were treated with collapse therapy for pulmonary tuberculosis on an average 30 years previously, we found 16 instances of exudation in the residual pocket: four were sterile and without fistula, ten had bronchial fistulae, one had an esophageal fistula, and one was a tuberculous empyema without fistula. Among the 11 exudations with bronchial or esophageal fistulae, none contained tubercle bacilli, six were infected with pyogenic microorganisms, and five remained sterile. In 12 cases, the diagnosis was suggested by chest x-ray film. Four of nine exudates which remained sterile and three of the seven infected ones could be stabilized by conservative measures; the others required a decortication, sometimes with parenchymal resection. This study shows that in late exudative complications of old collapse therapy, an initial conservative treatment can be curative in about 45 percent of the cases.

Cryptococcus neoformans was isolated from 65 patients: 11 had meningitis, 11 had disseminated cryptococcosis without meningitis, and 43 had C neoformans isolated from the respiratory tract. Predisposing conditions and the diagnostic value of cultures from various sites and of the latex agglutination test on cerebrospinal fluid and serum are analyzed for patients with extrapulmonary disease. Nine patients had pleural effusions; the effusion was cultured in six and yielded C neoformans in four. None of 11 deaths among 43 patients with respiratory tract isolates could be attributed to cryptococosis. The 32 survivors were nor treated with antifungal agents. Twenty-six of 43 patients with respiratory isolates had various bronchopulmonary disorders, with chronic obstructive pulmonary diseases and asthma the most common (28 percent). Seven of 28 patients (25 percent) with roentgenographically detected lung lesions had carcinoma of the lung. Roentgenographic evidence of a lung lesion and C neoformans grown from the respiratory tract warrant a further search for carcinoma of the lung.

We reviewed the case records of 22 patients from whose pleural fluid a nontuberculous Mycobacterium (NTM) was isolated. Three patients had pleural effusions definitely due to NTM infection, with evidence of NTM infection in other tissues; 16 had pleural effusions of known etiology unrelated to the isolated NTM and no other evidence of NTM infection; and three had pleural effusions of undetermined etiology and no other evidence of NTM infection. The case histories of the three patients with pleural effusions due to NTM are presented and the significance of the isolation of NTM from the remaining 19 patients is discussed. Criteria are proposed for evaluating the significance of NTM isolated from pleural fluid.

The initial radiographic features of 188 patients with pulmonary infections due to Mycobacterium tuberculosis were compared to 184 patients with M kansasii and 100 patients with M intracellularis infections. The patients were all from the University of Texas Health Center at Tyler, all had at least two positive sputum cultures and no other potential pathogen, and none had a past medical history of any type of tuberculosis. The comparison showed that all three organisms have a strong tendency to produce cavitary infiltrates in the posterior portions of the upper lobes. No distinctive or pathognomonic feature could be found. The atypical organisms were more likely to produce thin-walled cavities and far advanced unilateral disease, but both of these patterns also occurred with M tuberculosis. Endobronchial spread and volume loss were common in all three diseases. The only definite difference seems to be the absence of a primary or juvenile form of atypical tuberculosis and a much greater incidence of empyema and postprimary pleural effusions with M tuberculosis. In an individual case, the roentgenographic manifestations of the three diseases are indistinguishable.