World J Surg. May;35(5) doi: /s Approach to empyema necessitatis. Akgül AG(1), Örki A, Örki T, Yüksel M, Arman B. INTRODUCTION: Empyema necessitatis (EN) occurs when an empyema extends through the parietal pleura into the surrounding tissues. EN has become less. Empyema necessitans is a rare long-term complication of poorly or uncontrolled empyema thoracis characterized by the dissection of pus.

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EN is an empyema that diffuses to extrapleural spaces and involves chest pain. Our finding also contrasted with the report [ 4 ] that most cases occur in immunocompromised patients because our case was seronegative for HIV.

However, chest CECT could not be done in many centres, including ours, due to lack of facilities in most developing countries. Surgery plays a critical role in the management of empyema necessitatis in selected patients.

Subscribe to Table of Contents Alerts. There was wheezing heard in lower part of right chest cage. Surgical management in children.

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Approach to empyema necessitatis.

Developmental and nutritional history was uneventful. Fibrosis was seen in the apexes especially in empyena right one Figure 2. Heart sounds were normal. Low diagnostic yield of gastric aspirate for acid fast bacilli and negative Mantoux test due to anergy associated with malnourished children make it difficult to diagnose tuberculosis in this case.

A rare presentation of empyema necessitatis

Empyema necessitans complicating pleural effusion is rare in our environment. An evidence of lump in the vicinity of chest along with clinical and plain radiographic signs of empyema thoracic is highly diagnostic of empyema necessitatis. He has been addicted to opium for 14 years, both orally and by inhalation, and he had a history of 2 years in jail.

This is an open access article distributed under the Neceszitatis Commons Attribution Licensewhich permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Empyema can extend to the surrounding structures; the reported sites necessitatix chest wall, peritoneum, pericardium, retroperitoneum, esophagus, empymea, abdominal wall, paravertebral space, vertebrae, bronchus, breast and diaphragm.


There was a history of fever, cough and respiratory distress 10 days back, followed by the appearance of a lump in the right cervical region. The air-entry was reduced on the right side.

Management options include closed or open drainage of the pleural space to prevent fibrosis and to facilitate expansion of the lung. Another systemic examination was normal.

Hecessitatis initial diagnosis of pleural effusion with empyema necessitans secondary to pulmonary tuberculosis in anaemic heart failure was made Figure 1. CT scan findings are as follows: The most common nontubercular etiological agent is Staphylococcus [ 3 ].

Jecessitatis resultant subcutaneous abscess may eventually rupture through the skin. The examination of the right cervical region showed an abscess cavity from which a small amount of pus was coming out during the inspiratory phase of the respiration. Chest X-ray and ultrasound can give clues regarding empyema necessitatis but not in every case.

Empyema necessitatis due to methicillin-resistant Staphylococcus aureus: If the typical changes in the CT scan are found, histopathologic nfcessitatis would be indicated [ 15 ].

The patient has been smoking cigarettes per day for 15 years.

Except for two patients, one with multisystem failure and one with squamous cell carcinoma, all were discharged with no complications. The treatment is combination of drainage and standard anti-TB treatment. Sonography is a cost-benefit way that can show subcostal necrosis and associated soft tissue abscesses [ 13 ].

Articles Cases Courses Quiz. Sometimes the patients can have multiple masses that can be painful [ 489 ]. The initial treatment of empyema necessitatis includes tube-thoracostomy with incision-drainage of the abscess cavity or debridement of the involved part and institution of parenteral broad spectrum antibiotics according to the culture and sensitivity. Culture of Mycobacterium tuberculosis was positive too. Parenchymal reticular densities were sign of an active process.


Diagnosis without surgery is usually difficult, because acid-fast bacillus smear and culture, FNA, and PCR have false negative results [ 16 ].

Approach to empyema necessitatis.

The patient is symptom-free during a follow up of six months time. To receive news and publication updates for Case Reports in Pediatrics, enter your necessihatis address in the box below.

It may either occur due the virulence of the organism or may be facilitated by previous thoracic surgery e. Pulmonary infections with Gram negative organisms like Proteus spp.

After 40 days of anti-TB treatment, the patient came back with worse conditions Figure 5. He was febrile This disease can be found in both immunocompromised and immunocompetent individuals but is usually seen in the immunocompromised individuals. Abstract Empyema necessitans EN is a kind of empyema that diffuses to extrapleural space and can involve chest pain.

Relapse of infection is due to incomplete excision of ribs or infected pleura, which can take place 10 years after the surgery. Pyogenic empyema necessitatis with bronchopleural fistula.

Pus Ziehl-Neelsen stains revealed no acid fast bacilli and Mantoux test was nonreactive. The CECT scan is the diagnostic study of choice with lung and mediastinal windows and reveals the extent and nature empysma the disease like demonstrating a communication of empyema into subcutaneous tissue [ 38 — 10 ]. Smear and Ziehl-Neelsen stains from subcutaneous aspiration were positive for TB.

The dramatic resolution of symptoms in this case with anti- Proteus antibiotics could also suggest empyema necessitans complicating pleural effusion secondary to Proteus species.