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Empyema Necessitans in the Setting of Pneumonia and Parapneumonic Effusion
Empyema Necessitans in the Setting of Pneumonia and Parapneumonic Effusion SAUD I. AHMED, MD; RIA E. GRIPALDO, MD; OLADIPO A. ALAO, MD
ABSTRACT: Empyema necessitans is a rare complication of pleural space infections and occurs when the infected fluid dissects spontaneously into the chest wall from the pleural space. This process may result from bronchopleural extension of a peripheral lung infection. These
cases result from inadequate treatment of an empyema and usually occur after a necrotizing pneumonia or pulmonary abscess. We present two cases of empyema thoracic necessitans. [Am J Med Sci 2007;333(2):106– 108.]
Case Reports
tion of left lower lung lobe with a hint of a lytic lesion of T11 thoracic vertebra. The CT scan of thoracic spine confirmed osteomyelitis of T11 vertebra (Figure 2) along with a fluid collection on the left side of vertebral body. A chest tube was placed on the left side, draining 1 L of fluid in 4 days. Subsequently, the patient was found to have a new pansystolic murmur over the tricuspid area. He was treated for presumed endocarditis, considering the positive blood cultures and a new heart murmur (two major Duke’s criteria). A transesophageal echocardiogram showed tricuspid regurgitation but no vegetations on mitral, tricuspid, or aortic valves. The patient was treated with oxacillin for 6 weeks. A repeat CT scan of chest after 8 weeks showed complete resolution of pleural effusion and pus collection in the anterior pleural space (Figure 1B). There was also marked improvement in the osteomyelitis of the T11 thoracic vertebra.
Case 1 Our first patient is a 45-year-old diabetic African American man with no history of intravenous drug use who was admitted to Harlem Hospital Center with complaints of generalized body aches and polyarthralgia, especially involving both knee joints, of 3 weeks’ duration. This was associated with fever, rigors, chills, and anorexia of 4 days’ duration. On initial examination, the patient was tachypneic, tachycardic, and febrile with a temperature of 39°C (102.3°F). Crackles were heard on auscultation of left lower chest. The right knee was swollen, tender and fluctuant. The laboratory data showed leucocytosis with a marked increase in polymorphonuclear neutrophils (PMNs). White blood cell count was 24 ⫻ 109/L with 96% neutrophils; hematocrit was 35, and erythrocyte sedimentation rate was 110 mm/hr. Due to polyarthralgia and high erythrocyte sedimentation rate, connective tissue disease workup was ordered, but it did not reveal any definitive diagnosis. Purified protein derivative and HIV test findings were negative. Chest x-ray showed left lower lobe infiltrates. Synovial fluid analysis from the right knee was consistent with reactive arthritis. The patient was prescribed ceftriaxone and azithromycin for community-acquired pneumonia. Blood cultures grew methicillin-sensitive Staphylococcus aureus and the patient was switched to oxacillin. A transthoracic echocardiogram showed no vegetations on the heart valves. On the sixth day of admission, the patient complained of shortness of breath and a sharp pain in the left upper chest. Examination was remarkable for reproducible chest wall tenderness in the second intercostal space on the left side with crepitus. The breath sounds and vocal resonance were reduced on the entire left side with dullness to percussion. A repeat chest x-ray showed large left-sided pleural effusion. Diagnostic and therapeutic thoracocentesis showed an exudative pleural fluid with no bacteria seen on Gram stain or in the cultures. Acid fast stain was also negative, as was the cytologic finding. A computed tomography (CT) scan of the chest showed pus collection in the left anterior pleural space extending to the chest wall through second intercostal space (Figure 1A). There was also consolida-
From the Department of Internal Medicine and Infectious Diseases, Harlem Hospital Center, New York, New York. Submitted February 5, 2006; accepted in revised form October 11, 2006. Correspondence: Saud I. Ahmed, MD, Columbia University at Harlem Hospital Center, 506 Lenox Ave, Box 27, Bronx, NY, 10037.
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Case 2 Our second patient is a 47-year-old man from West Africa with no significant past medical history. He presented to the emergency department with a 7-day history of left upper back swelling associated with tenderness, intermittent subjective fever and chills. He also had intermittent cough productive of scanty whitish sputum without any weight loss, anorexia, or hemoptysis. On initial examination, the patient was hemodynamically stable but had a temperature of 39.4°C (103°F). The only remarkable finding on physical examination was a 6 by 4 cm firm and tender swelling located in the left upper back, medial to the patient’s scapula without any significant erythema or warmth. The initial laboratory data showed leukocytosis. White blood cell count was 16.7 ⫻ 109/L, with 79.8% neutrophils and 9.8% lymphocytes. The hematocrit was 49.2. Chest x-ray indicated left-sided pleural effusion with no infiltrates, whereas the CT scan was consistent with loculated pleural effusion extending into the left upper paraspinal muscles (empyema necessitans) with underlying infiltrates (Figure 3). A CTguided aspiration of the swelling produced frank pus. Blood and fungal cultures were collected that did not grow any organisms later. The patient was also placed in respiratory isolation considering the possibility of pulmonary tuberculosis until three samples of sputum for AFB smears revealed no acid-fast bacilli. Meanwhile, the patient was prescribed ceftriaxone and clindamycin. The option of chest tube drainage was considered but was deferred because the pleural effusion was loculated. The fluid obtained on CT-guided aspiration of the pleural space grew methicillin-sensitive Staphylococcus aureus, so the patient’s antibiotics were changed to oxacillin. The patient’s condition improved during hospitalization on antibiotics and repeated CT-guided February 2007 Volume 333 Number 2
Ahmed et al
Figure 1. Computed tomography scan of the chest (A) before treatment (B) after treatment.
aspiration of loculated pleural fluid and the back swelling. Follow-up imaging showed complete resolution of empyema.
Discussion Empyema necessitans is a rare complication of pleural space infection that occurs mostly due to inadequate treatment of such infections when the infected fluid dissects through the chest wall. Pleural involvement associated with bacterial infections include simple parapneumonic effusions (PPE), complicated PPE, and pleural empyema. Early diagnosis and antibiotic therapy of pneumonia will, in most cases, make the course of the disease uncomplicated, and simple PPE often resolves with antibiotic therapy alone. In 5% to 10% of patients, PPE becomes more complicated and leads to empyema,1 which might later on lead to empyema necessitans. The mortality rate among patients with empyema ranges between 5.4% and 22%.2,3 Mortality-related prognostic factors include age, causative bacteriological agents such as Streptococcus milleri, comorbid conditions, and history of operation.4,5 The emergence of antibiotic-resistant organisms and increase in the frequency of nosocomial infections make therapeutic choices for effective empiri-
Figure 2. Osteomyelitis of T11 vertebra.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
cal antibiotic therapy more difficult. Sometimes, empyema develops or is recognized after the patient has already received antibiotics; culture and Gram stain findings may be falsely negative in this situation. Reported rates of anaerobic bacteria isolated from pleural fluid have ranged from 38% to 76%6,7; however, culture results are often polymicrobial, with anaerobic bacteria also isolated.8 There has been an increasing number of Staphylococcus aureus infections over the years.9,10 The cases of empyema necessitans that have been reported in the literature were caused by Streptococcus milleri and Actinomysis.11–13 Bacteriologic data are sparse in the antibiotic era, but data from the preantibiotic era suggest that tuberculosis is the most common cause of empyema necessitans in older patients and pyogenic bacteria in younger patients.14 It has been postulated that empyema necessitans tends to rupture in the upper anterior part of the chest, as in our first case, because the lung is more adherent posteriorly at the apex and the base.14 Therapy for empyema thoracis is determined by the stage. In the early exudative phase of empyema,
Figure 3. Computed tomography scan showing empyema necessitans of left upper paraspinal muscle before treatment.
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Empyema Necessitans
repeated drainage may be adequate. However, during the fibropurulent phase thoracocentesis is always unsatisfactory and closed chest tube drainage is often necessary. Mandal et al15 used thoracocentesis as the primary procedure in 20 cases out of 179 primary empyema patients with a cure rate of 90%. If empyema necessitans develops, then radiologically guided aspiration or open drainage of pus collection in the chest wall is an appropriate treatment with antibiotic coverage and tube thoracostomy for drainage of empyema thoracis. In some situations, as in our first case, drainage of the thoracic wall component may not be necessary. It is evident from the studies that streptokinase and urokinase decrease empyema viscosity, allow drainage more easily and improve radiologic findings.16,17 Chin and Lim18 showed that fibrinolytic therapy increased the volume of fluid drained from pleural empyema but did not markedly reduce morbidity and mortality. Davies et al19 found that the reduction in the largest linear dimension of the pleural fluid collection was greater in the regimen of the 3-day streptokinase group when compared with the control group, but the duration of the hospital stay and the time to normalization of the total white blood cell count and temperature were found to be similar for both groups. Both Lim and Chin20 and Davies et al19 found that streptokinase had no effect on length of hospitalization and mortality rate when compared to drainage with chest tube alone. The U.K. Controlled Trial of intrapleural Streptokinase for Pleural Infection showed that among the 427 patients who received streptokinase or placebo, there was no significant difference between the groups in the proportion of patients who died or needed surgery, a result that suggested no clinically significant benefit of streptokinase.21 Although the role of fibrinolytic therapy in the management of empyema is unclear, its possible role in management of empyema necessitans appears even less clear. We are not aware of any published reports of its use in the management of this now rare complication of pulmonary infection. References 1. Bauwens AMM, de Graaff CS, Boersma WG. Pleural effusion and empyema as complications of pneumonia. Nederlands Tijdschrift Voor Geneeskunde 2002;146:464.
108
2. Yim APC. Paradigm shift in empyema management. Chest 1999;115:611–2. 3. Helfritzsch H, et al. Stage-adapted therapy of pleural empyema. Results during 1992–1998. Zentralblatt Fur Chirurgie 2000;125:454. 4. Mwandumba HC, Beeching NJ. Pyogenic lung infections: factors for predicting clinical outcome of lung abscess and thoracic empyema. Curr Opin Pulm Med 2000;6:234. 5. Lindstrom ST, Kolbe J. Community acquired parapneumonic thoracic empyema: predictors of outcome. Respirology 1999;4: 173. 6. Varkey B, et al. Empyema thoracis during a ten-year period. Analysis of 72 cases and comparison to a previous study (1952 to 1967). Arch Intern Med 1981;141:1771. 7. Barlett JG, Thadepalli SLGH, Finegold SM. Bacteriology of empyema. Lancet 1974;1:338–40. 8. Gavazzi G, et al. Empyeme pleural chez le sujet age: deux types de presentation clinique. [Empyema thoracis in very old patients: reports of two clinical presentations.] Rev Med Intern 2001;22:1124. 9. Alfageme I, et al. Empyema of the thorax in adults: etiology, microbiologic findings, and management. Chest 1993;103:839. 10. Ozol D, Soa EE. Retrospective analysis of 79 empyema patients. Solunum 1999;3:90–4. 11. Marinella MAHG, Standiford TJ. Empyema necessitans due to Streptococcus milleri. Clin Infect Dis 1996;23:203–4. 12. Davies ALMW, Piland JH, et al. Thoracic actinomycosis presenting as empyema necessitans. Del Med J 1987;59: 649–7. 13. DD D. Actinomycosis of the chest wall. Ultrasound findings in empyema necessitans. Chest 1986 Nov;86:779–80. 14. EA S. Empyema necessitans. Bull Seaview Hosp 1940;6:1–49. 15. Mandal AK, et al. Outcome of primary empyema thoracis: therapeutic and microbiologic aspects. Ann Thorac Surg 1998;66:1782. 16. Chin NK, Lim TK. Treatment of complicated parapneumonic effusions and pleural empyema: a four-year prospective study. Singapore Med J 1996;37:631. 17. Barletta JF. Streptokinase and urokinase for the treatment of pleural effusions and empyemas. Ann Pharmacother 1999; 33:495. 18. Lim NK, Ca TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest 1997;111:275–9. 19. Davies RJ, et al. Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997;52:416–21. 20. Lim TK, Chin NK. Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in pleural sepsis. Eur Respir J 1999;13:514. 21. Maskell NAD, Christopher WH, et al. U.K. Controlled Trial of Intrapleural Streptokinase for Pleural Infection. N Engl J Med 2005;352:865–74.
February 2007 Volume 333 Number 2
ABSTRACT: Empyema necessitans is a rare complication of pleural space infections and occurs when the infected fluid dissects spontaneously into the chest wall from the pleural space. This process may result from bronchopleural extension of a peripheral lung infection. These
cases result from inadequate treatment of an empyema and usually occur after a necrotizing pneumonia or pulmonary abscess. We present two cases of empyema thoracic necessitans. [Am J Med Sci 2007;333(2):106– 108.]
Case Reports
tion of left lower lung lobe with a hint of a lytic lesion of T11 thoracic vertebra. The CT scan of thoracic spine confirmed osteomyelitis of T11 vertebra (Figure 2) along with a fluid collection on the left side of vertebral body. A chest tube was placed on the left side, draining 1 L of fluid in 4 days. Subsequently, the patient was found to have a new pansystolic murmur over the tricuspid area. He was treated for presumed endocarditis, considering the positive blood cultures and a new heart murmur (two major Duke’s criteria). A transesophageal echocardiogram showed tricuspid regurgitation but no vegetations on mitral, tricuspid, or aortic valves. The patient was treated with oxacillin for 6 weeks. A repeat CT scan of chest after 8 weeks showed complete resolution of pleural effusion and pus collection in the anterior pleural space (Figure 1B). There was also marked improvement in the osteomyelitis of the T11 thoracic vertebra.
Case 1 Our first patient is a 45-year-old diabetic African American man with no history of intravenous drug use who was admitted to Harlem Hospital Center with complaints of generalized body aches and polyarthralgia, especially involving both knee joints, of 3 weeks’ duration. This was associated with fever, rigors, chills, and anorexia of 4 days’ duration. On initial examination, the patient was tachypneic, tachycardic, and febrile with a temperature of 39°C (102.3°F). Crackles were heard on auscultation of left lower chest. The right knee was swollen, tender and fluctuant. The laboratory data showed leucocytosis with a marked increase in polymorphonuclear neutrophils (PMNs). White blood cell count was 24 ⫻ 109/L with 96% neutrophils; hematocrit was 35, and erythrocyte sedimentation rate was 110 mm/hr. Due to polyarthralgia and high erythrocyte sedimentation rate, connective tissue disease workup was ordered, but it did not reveal any definitive diagnosis. Purified protein derivative and HIV test findings were negative. Chest x-ray showed left lower lobe infiltrates. Synovial fluid analysis from the right knee was consistent with reactive arthritis. The patient was prescribed ceftriaxone and azithromycin for community-acquired pneumonia. Blood cultures grew methicillin-sensitive Staphylococcus aureus and the patient was switched to oxacillin. A transthoracic echocardiogram showed no vegetations on the heart valves. On the sixth day of admission, the patient complained of shortness of breath and a sharp pain in the left upper chest. Examination was remarkable for reproducible chest wall tenderness in the second intercostal space on the left side with crepitus. The breath sounds and vocal resonance were reduced on the entire left side with dullness to percussion. A repeat chest x-ray showed large left-sided pleural effusion. Diagnostic and therapeutic thoracocentesis showed an exudative pleural fluid with no bacteria seen on Gram stain or in the cultures. Acid fast stain was also negative, as was the cytologic finding. A computed tomography (CT) scan of the chest showed pus collection in the left anterior pleural space extending to the chest wall through second intercostal space (Figure 1A). There was also consolida-
From the Department of Internal Medicine and Infectious Diseases, Harlem Hospital Center, New York, New York. Submitted February 5, 2006; accepted in revised form October 11, 2006. Correspondence: Saud I. Ahmed, MD, Columbia University at Harlem Hospital Center, 506 Lenox Ave, Box 27, Bronx, NY, 10037.
106
Case 2 Our second patient is a 47-year-old man from West Africa with no significant past medical history. He presented to the emergency department with a 7-day history of left upper back swelling associated with tenderness, intermittent subjective fever and chills. He also had intermittent cough productive of scanty whitish sputum without any weight loss, anorexia, or hemoptysis. On initial examination, the patient was hemodynamically stable but had a temperature of 39.4°C (103°F). The only remarkable finding on physical examination was a 6 by 4 cm firm and tender swelling located in the left upper back, medial to the patient’s scapula without any significant erythema or warmth. The initial laboratory data showed leukocytosis. White blood cell count was 16.7 ⫻ 109/L, with 79.8% neutrophils and 9.8% lymphocytes. The hematocrit was 49.2. Chest x-ray indicated left-sided pleural effusion with no infiltrates, whereas the CT scan was consistent with loculated pleural effusion extending into the left upper paraspinal muscles (empyema necessitans) with underlying infiltrates (Figure 3). A CTguided aspiration of the swelling produced frank pus. Blood and fungal cultures were collected that did not grow any organisms later. The patient was also placed in respiratory isolation considering the possibility of pulmonary tuberculosis until three samples of sputum for AFB smears revealed no acid-fast bacilli. Meanwhile, the patient was prescribed ceftriaxone and clindamycin. The option of chest tube drainage was considered but was deferred because the pleural effusion was loculated. The fluid obtained on CT-guided aspiration of the pleural space grew methicillin-sensitive Staphylococcus aureus, so the patient’s antibiotics were changed to oxacillin. The patient’s condition improved during hospitalization on antibiotics and repeated CT-guided February 2007 Volume 333 Number 2
Ahmed et al
Figure 1. Computed tomography scan of the chest (A) before treatment (B) after treatment.
aspiration of loculated pleural fluid and the back swelling. Follow-up imaging showed complete resolution of empyema.
Discussion Empyema necessitans is a rare complication of pleural space infection that occurs mostly due to inadequate treatment of such infections when the infected fluid dissects through the chest wall. Pleural involvement associated with bacterial infections include simple parapneumonic effusions (PPE), complicated PPE, and pleural empyema. Early diagnosis and antibiotic therapy of pneumonia will, in most cases, make the course of the disease uncomplicated, and simple PPE often resolves with antibiotic therapy alone. In 5% to 10% of patients, PPE becomes more complicated and leads to empyema,1 which might later on lead to empyema necessitans. The mortality rate among patients with empyema ranges between 5.4% and 22%.2,3 Mortality-related prognostic factors include age, causative bacteriological agents such as Streptococcus milleri, comorbid conditions, and history of operation.4,5 The emergence of antibiotic-resistant organisms and increase in the frequency of nosocomial infections make therapeutic choices for effective empiri-
Figure 2. Osteomyelitis of T11 vertebra.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
cal antibiotic therapy more difficult. Sometimes, empyema develops or is recognized after the patient has already received antibiotics; culture and Gram stain findings may be falsely negative in this situation. Reported rates of anaerobic bacteria isolated from pleural fluid have ranged from 38% to 76%6,7; however, culture results are often polymicrobial, with anaerobic bacteria also isolated.8 There has been an increasing number of Staphylococcus aureus infections over the years.9,10 The cases of empyema necessitans that have been reported in the literature were caused by Streptococcus milleri and Actinomysis.11–13 Bacteriologic data are sparse in the antibiotic era, but data from the preantibiotic era suggest that tuberculosis is the most common cause of empyema necessitans in older patients and pyogenic bacteria in younger patients.14 It has been postulated that empyema necessitans tends to rupture in the upper anterior part of the chest, as in our first case, because the lung is more adherent posteriorly at the apex and the base.14 Therapy for empyema thoracis is determined by the stage. In the early exudative phase of empyema,
Figure 3. Computed tomography scan showing empyema necessitans of left upper paraspinal muscle before treatment.
107
Empyema Necessitans
repeated drainage may be adequate. However, during the fibropurulent phase thoracocentesis is always unsatisfactory and closed chest tube drainage is often necessary. Mandal et al15 used thoracocentesis as the primary procedure in 20 cases out of 179 primary empyema patients with a cure rate of 90%. If empyema necessitans develops, then radiologically guided aspiration or open drainage of pus collection in the chest wall is an appropriate treatment with antibiotic coverage and tube thoracostomy for drainage of empyema thoracis. In some situations, as in our first case, drainage of the thoracic wall component may not be necessary. It is evident from the studies that streptokinase and urokinase decrease empyema viscosity, allow drainage more easily and improve radiologic findings.16,17 Chin and Lim18 showed that fibrinolytic therapy increased the volume of fluid drained from pleural empyema but did not markedly reduce morbidity and mortality. Davies et al19 found that the reduction in the largest linear dimension of the pleural fluid collection was greater in the regimen of the 3-day streptokinase group when compared with the control group, but the duration of the hospital stay and the time to normalization of the total white blood cell count and temperature were found to be similar for both groups. Both Lim and Chin20 and Davies et al19 found that streptokinase had no effect on length of hospitalization and mortality rate when compared to drainage with chest tube alone. The U.K. Controlled Trial of intrapleural Streptokinase for Pleural Infection showed that among the 427 patients who received streptokinase or placebo, there was no significant difference between the groups in the proportion of patients who died or needed surgery, a result that suggested no clinically significant benefit of streptokinase.21 Although the role of fibrinolytic therapy in the management of empyema is unclear, its possible role in management of empyema necessitans appears even less clear. We are not aware of any published reports of its use in the management of this now rare complication of pulmonary infection. References 1. Bauwens AMM, de Graaff CS, Boersma WG. Pleural effusion and empyema as complications of pneumonia. Nederlands Tijdschrift Voor Geneeskunde 2002;146:464.
108
2. Yim APC. Paradigm shift in empyema management. Chest 1999;115:611–2. 3. Helfritzsch H, et al. Stage-adapted therapy of pleural empyema. Results during 1992–1998. Zentralblatt Fur Chirurgie 2000;125:454. 4. Mwandumba HC, Beeching NJ. Pyogenic lung infections: factors for predicting clinical outcome of lung abscess and thoracic empyema. Curr Opin Pulm Med 2000;6:234. 5. Lindstrom ST, Kolbe J. Community acquired parapneumonic thoracic empyema: predictors of outcome. Respirology 1999;4: 173. 6. Varkey B, et al. Empyema thoracis during a ten-year period. Analysis of 72 cases and comparison to a previous study (1952 to 1967). Arch Intern Med 1981;141:1771. 7. Barlett JG, Thadepalli SLGH, Finegold SM. Bacteriology of empyema. Lancet 1974;1:338–40. 8. Gavazzi G, et al. Empyeme pleural chez le sujet age: deux types de presentation clinique. [Empyema thoracis in very old patients: reports of two clinical presentations.] Rev Med Intern 2001;22:1124. 9. Alfageme I, et al. Empyema of the thorax in adults: etiology, microbiologic findings, and management. Chest 1993;103:839. 10. Ozol D, Soa EE. Retrospective analysis of 79 empyema patients. Solunum 1999;3:90–4. 11. Marinella MAHG, Standiford TJ. Empyema necessitans due to Streptococcus milleri. Clin Infect Dis 1996;23:203–4. 12. Davies ALMW, Piland JH, et al. Thoracic actinomycosis presenting as empyema necessitans. Del Med J 1987;59: 649–7. 13. DD D. Actinomycosis of the chest wall. Ultrasound findings in empyema necessitans. Chest 1986 Nov;86:779–80. 14. EA S. Empyema necessitans. Bull Seaview Hosp 1940;6:1–49. 15. Mandal AK, et al. Outcome of primary empyema thoracis: therapeutic and microbiologic aspects. Ann Thorac Surg 1998;66:1782. 16. Chin NK, Lim TK. Treatment of complicated parapneumonic effusions and pleural empyema: a four-year prospective study. Singapore Med J 1996;37:631. 17. Barletta JF. Streptokinase and urokinase for the treatment of pleural effusions and empyemas. Ann Pharmacother 1999; 33:495. 18. Lim NK, Ca TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest 1997;111:275–9. 19. Davies RJ, et al. Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997;52:416–21. 20. Lim TK, Chin NK. Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in pleural sepsis. Eur Respir J 1999;13:514. 21. Maskell NAD, Christopher WH, et al. U.K. Controlled Trial of Intrapleural Streptokinase for Pleural Infection. N Engl J Med 2005;352:865–74.
February 2007 Volume 333 Number 2