A CASE OF FUNGAL EMPYEMA

Dr. Sugata DasguptaMD, FNB (Critical Care Medicine)

Fungal Empyema

• Not largely reported or studied• Mainly isolated case reports• Mostly in patients with severe underlying

diseases / immunocompromised / malignancy

• Can have a fulminant course with sepsis, organ dysfunction, respiratory failure, persistent pleural collections & high mortality

Largest data

• Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC; Fungal empyema thoracis : An emerging clinical entity; Chest 2000;117:1672-8

• Commonest : abdominal / thoracic surgery, GI perforation, bronchopulmonary infection

• Mostly in pts with severe underlying diseases• Crude mortality rate : 73%

OUR PATIENT

Our patient

• 55 year old lady

• Admission : 5F( /HDU) : 19/6/10 ICU : 9/7/10

• Past History : GERD, Laparoscpoic Nissen’s Fundoplication 8 years ago

Chief Complaints & History of present illness on Hospital admission

• Right sided chest pain/SOB/Fever/Dysphagia

• 8.6.10 = Redo Laparoscopic Fundoplication• Symptoms started after surgery• 9.6.10 = Gastrograffin : Distal Oesophageal

leak (oesophageal perforation)• 16.6.10 = Barium : leak + Right Pleural Effusion• Cefazolin Ig 8/24 + Metronidazole 500mg 8/24• 19.6.10 = Admission to 5F (/HDU)

Clinical Examination & Investigations

• Fever, tachypnoea, tachycardia, normotension• Chest : dullness & ↓breath sounds on right• Abdomen : slightly tender epigastrium• Other systems : NAD• Blood : WBC 26.9, CRP 240, ↑ AST/ALT/AP• CXR : Rt. Pleural Effusion, small Lt. effusion, No

pneumomediastinum / diffuse mediastinal widening / subcutaneous emphysema

• ABG : Hypoxemia in Room Air

Investigations (continued)

• CECT : perforation with dye leakage at GE junction + Large Right Hydropneumothorax with underlying collapse / consolidation + Small Left effusion (No mediastinal air / air-fluid levels / diffuse mediastinal widening)

• Right Pleural Fluid (12F pigtail) : Empyema : Yeast + viridans streptococci

• Blood / Urine / Sputum : Sterile

Clinical Course : first TEN days

• 19.6.10-22.6.10 = Metronidazole 500 mg 1V 12/24 + Ampicillin 1g IV 6/24 ; TPN

• Remained septic with fever + increasing counts & CRP ; worsening SOB +↑ing O₂ requirements; worsening LFTs

• 23.6.10 = Pip-Tazo 4.5g IV 8/24• Blood / Urine / Sputum : Sterile• Echocardiography : Normal study

Clinical Course : first TEN days• 25.6.10 = Endoscopic Oesophageal Stent + Rt.

28F ICD ↓GA• 28.6.10 = Pleural Fluid : Candida albicans (No

sensitivity report); Pip-Tazo + Fluconazole 400 mg IV OD; Gastrograffin : No leak , oral + TPN

• 30.6.10 = CECT : ↓ Right Pleural Collection + persistent Left pleural effusion ; No leakage

• SOB improved, but still septic with fever, persistent leukocytosis,↑CRP; deranged LFTs

Clinical Course : next TEN days• Progressively decreasing ICD output; clinically

persistent bilateral pleural effusion + sepsis• Blood / Sputum / Urine : always sterile• Rt Pleural Fluid : persistently C. albicans (with

CONS once : Vanco, Doxy); Lt : sterile exudate• 6.7.10 = CECT : Persistent Rt. Hydropneumo

(not much change from last CT) + Left effusion• 6.7.10 = USG guided Bilateral 8F Pigtails• Worsening sepsis, SOB with ↑WOB, AHRF

Clinical Course : next TEN days

• 8.7.10 : Fluconazole off, Caspofungin started (70 mg IV on D1→ 50mg IV OD) + Pip-tazo on

• 9.7.10 = Right Thoracotomy + Pleural debridement (2 28F + 2 15F ICDs) + Feeding Jejunostomy ↓GA (OLV with Lt sided DLT)

• ICU (Intubated) : ventilated (4 Rt +1 Lt drains)• 9.7.10 = Caspo 50 mg IV OD + Vancomycin 1g IV

12/24 + Meropenem 1g IV 8/24• Pleural tissue : C.albicans, Lt effusion: sterile

Clinical Course in the ICU

• 11.7.10 = Extubated, Jejunostomy feeds• 12.7.10 = Tachypnoea,↑WOB, Hypoxemia :

Reintubated; C. albicans grown in 1 drain fluid• 13.7.10 = CECT : Persistent Right pleural

collection as thick enhancing rind / loculated fluid in oblique fissure + Left pleural Effusion

• Afebrile; leukocytosis + ↑CRP; deranged LFTs• Blood / DTA / Urine / Left Pleural fluid : sterile

Clinical Course in the ICU

• ↓Albumin ; Fluid overload : Albumin, Filtered• Difficult weaning ; Tracheostomy on 19.7.10• Still growing C. albicans from 1 drain fluid• 21.7.10 = CECT : Rt hydropneumo reduced ,

but loculated collections + Lt Effusion reduced• Sequential drain removal, slowly weaned off• 23.7.10 = Rt Intrapleural STK 250000 U 1dose• 24.7.10 = Antibiotics stopped; Caspofungin on

Clinical Course in the ICU : Presently

• Clinically getting better; 40 days of hospital stay• Tracheostomy / High flow / Weaned off • Right 28F ICDs (2) still present , Left ICD out• Afebrile, Counts, LFTs normalizing, still ↑CRP• 24.7.10 = Pleural fluid : totally culture sterile • C/O reflux : ? Stent (5cm above leak to 2-3cm in

stomach) • Stent removal scheduled on 30.7.10

DISCUSSION

Empyema following oesophageal perforation

• Mainly reported along with other radiological features of acute mediastinitis

• Mainly bacterial: anaerobes / aerobes (Staph, β/α haemolytic strep / GNB) / mixed

• Fungal : few case reports : mostly malignancy / immunocompromised / fungaemia

• Mostly isolated : Candida (albicans>tropicalis)

Nissen’s Fundoplication

• Oesophageal / gastric perforation (Open 1%, Lap 2%; Mortality : 26% in Open, Nil in Lap)

• Empyema following perforation after Lap Fundoplication : very few reports : bacterial

• Fungal Empyema without other radiological features of acute mediastinitis following Oesophageal perforation after Laparoscopic Fundoplication in immunocompetent adult ?

Management issues

• Antifungals + Tube Thoracostomy +/- Surgery• Candida Empyema without Candidemia : No

definite guideline on choice / route / duration of Antifungals in 2009 1DSA Guidelines

• Pleural penetration : Fluconazole , Ampho : good; Echinocandins : not largely studied, good efficacy in invasive candidiasis

• ? Reasonable to treat like Candidemia

Management Issues

• Fluconazole 800mg (12 mg/kg) loading → 400 mg/ day (6mg/kg/d) (if susceptible)

• C. glabrata or krusei / severely ill / recent azole exposure = IV Echinocandin (Caspo 70mg on D1→50mg/d / Micafungin 100mg/d / Anidulafungin 200 mg loading→ 100 mg/d)

• Alternatives : LFAmB (3-5mg/kg/d) qid / AmB-d 0.5-1mg/kg/d) bid / Vori 400mg (6mg/kg) bid 2 doses→ 200mg (3mg/kg) bid

Management issues

• Echinocandin: ?clinical improvement / 1-2wks• Change to Fluconazole / Voriconazole (if

susceptible) may be appropriate

• ? Total duration of antifungals : Pleural Fluid Culture + Drainage + Clinical improvement

• 14 days after culture sterility / drain removal + total resolution of pleural collection with clinical improvement : may be appropriate

Controversies : in retrospect

• Interval between oesophageal perforation & definitive treatment : predictor of outcome : Were we late ? (Leak : 9.6.10; Stent : 25.6.10)

• Empiric Antifungals (with antibiotics) on detection of distal oesophageal perforation ?

• Yeast : 20.6.10; C. albicans + Fluconazole : 28.6.10 ; Could have been started on 20.6.10?

Controversies : in retrospect

• Single dose of Intrapleural Streptokinase ?o MIST1 Trial (NEJM 2005;352(9):865-74): No

effect on mortality / LOS / need for surgeryo Before surgical drainage ; 3 days (BTS ; ACCP)

• Persistently deranged LFT (↑AST/ALT/AP/Bi) : sepsis / azole (off) / ↓Caspo dose ? / LFAmB ?

QUESTIONS