Sifa Medical Journal

CASE REPORT
Year
: 2015  |  Volume : 2  |  Issue : 1  |  Page : 18--20

Neonatal empyema thoracis in an African child: A case report


Ibrahim Aliyu1, Ismail Mohammed Inuwa2,  
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Surgery, Cardiothoracic Unit, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria

Correspondence Address:
Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Nigeria

Abstract

Neonatal empyema thoracis is a rare infection, it may follow chest infection, and staphylococcus aureus is the predominant organism implicated; however the case of a 4-day-old boy who presented with persistent fever and worsening difficulty in breathing with oxygen desaturation in which the offending organism was unidentified but responded remarkably following chest tube insertion and drainage of the pus is reported.



How to cite this article:
Aliyu I, Inuwa IM. Neonatal empyema thoracis in an African child: A case report .Sifa Med J 2015;2:18-20


How to cite this URL:
Aliyu I, Inuwa IM. Neonatal empyema thoracis in an African child: A case report . Sifa Med J [serial online] 2015 [cited 2021 Sep 21 ];2:18-20
Available from: https://www.imjsu.org/text.asp?2015/2/1/18/145815


Full Text

 Introduction



Empyema thoracis is defined as the presence of pus in the plural cavity, [1] and it is commoner in children who are immunocompromised, such as in malnutrition and following measles infection; [2],[3] it may occur as a complication of pneumonia following infection from organisms like Staphylococcus aureus, Escherichia coli, hemolytic group B Streptococcus, hemolytic group A Streptococcus, Klebsiella spp. and Serratia spp.[4],[5] However, empyema thoracis is rare in the newborn period; [6],[7] why this is so is not completely understood, but it is suggested that immaturity of the immune system in early life may limit localization of infection to the pleural space and the capacity of the pleura to produce enough exudates is also limited. These factors therefore influence the incidence of neonatal empyema thoracis, which is reported as low, [5] but this does not explain why it occurs more in malnourished older children who are also immune deficient. Hence, the case of a 4-day-old male who was successfully managed of neonatal empyema thoracis in our institution is reported.

 Case Report



A 4-day-old male presented with fever and difficulty with breathing; he was delivered at term at home. The pregnancy and delivery were not adversely eventful; he was previously seen in a primary health facility and had antibiotics for 48 hours before referral. He was tachypnoeic with bilateral crepitations and was also tachycardiac with 1st and 2nd heart sounds. Full blood count showed neutrophilia, and his chest X-ray showed opacity of the right hemi-thorax [Figure 1] while thoracocentesis revealed frank pus. Therefore, he was managed for neonatal empyema thoracis.{Figure 1}

Chest tube thoracostomy [Figure 2] under local anesthesia (xylocaine) was done, and 100 ml of pus was drained using size 18 tube; this was removed on the 5 th post-operative day and total of 165 ml of pus was drained with marked clinical and radiologic improvement; microscopy of the aspirate showed numerous pus cells but blood culture and that of the aspirate yielded no growth. He was treated for neonatal pneumonia and had paranteral ampicillin and cloxacillin; he was discharged 3 weeks later with no residual complication [Figure 3].{Figure 2}{Figure 3}

 Discussion



Empyema thoracis may result from infection of the pleural cavity, surrounding lung tissues or mediastinum eliciting a parapneumonic inflammatory reaction with accumulation of exudative fluid in the plural space; this becomes populated by neutrophils resulting in pus formation.

The clinical signs may be limited in the newborn period; therefore, the typical stony dull percussion note observed in older children may be absent in the newborn. Similarly, the typical homogenous opacity with obliteration of the costo-phrenic and cardio-phrenic angles on the chest X-ray may also be absent as were observed in the index case; therefore, a high index of suspicion should be entertained.

Neonatal empyema has a high mortality rate; [5] however, our patient survived because of the aggressive measures undertaken. The etiological agent from previous reports had implicated both gram-positive and gram-negative organisms with staphylococcus auras been most predominant. [3],[5] However, cultures were negative in the index case because of prior antibiotics used before referral to our health facility.

There is no generally accepted guideline for management of neonatal empyema thoracis, and unlike in older children, it is not clear if the guidelines from the British Thoracic Society/American College of Chest Physicians is applicable to newborns. [8] Although some clinicians have successfully management it conservatively, [9] others have ensured adequate chest drainage, [10] with good outcome; in our case, the pus was drained because the patient was deteriorating despite antibiotic therapy and he made remarkable improvement afterward, therefore treatment can be individualized.

 Conclusion



Though neonatal empyema thoracis is a rare newborn infection, it should be considered in a newborn with chest infection that fails to respond with conventional treatment, and both conservative and surgical approach could be adapted.

References

1Ahmed AE, Yacoub TE. Empyema thoracis. Clin Med Insights Circ Respir Pulm Med 2010;4:1-8.
2Mishra OP, Varshney K, Usha, Ali Z, Nath G, Pathak VK, et al. Immune status with empyema thoracis. Indian J Pediatr 2004;71:301-5.
3Hassan I, Mabogunje O. Paediatric empyema thoracis in Zaria, Nigeria. Ann Trop Paediatr 1992;12:265-71.
4Nohara F, Nagaya K, Asai H, Tsuchida E, Okamoto T, Hayashi T et al. Neonatal pleural empyema caused by emm type 6 group A streptococcus. Pediatr Int 2013;55:519-21.
5Gupta R, Faridi MM, Gupta P. Neonatal empyema thoracis. Indian J Pediatr 1996;63:704-6.
6Bechamps GJ, Lynn HB, Wenzel JE. Empyema in children: Review of Mayo Clinic experience. Mayo Clin Proc 1970;45:43-50.
7Freij BJ, Kusmiesz H, Nelson JD, McCracken GH Jr. Parapneumonic effusions and empyema in hospitalized children: A retrospective review of 227 cases. Pediatr Infect Dis 1984;3:578-91.
8Balfour-Lynn IM, Abrahamson E, Cohen G, Hartley J, King S, Parikh D, et al; Paediatric Pleural Diseases Subcommittee of the BTS Standards of Care Committee. BTS guidelines for the management of pleural infection in children. Thorax 2005;60 Suppl 1:i1-21.
9Lohmeier K, Mayatepek E, Hoehn T. Neonatal pleural empyema in an extremely low birth weight infant. J Matern Fetal Neonatal Med 2009;22:940-2.
10St. Peter SD, Tsao K, Spilde TL, Keckler SJ, Harrison C, Jackson MA, et al. Thoracoscopic decortication vs. tube thoracostomy with fibrinolysis for empyema in children: A prospective, randomized trial. J Pediatr Surg 2009;44:106-11.