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Early Congestive Heart Failure due to Origin of the Right Coronary Artery from the Pulmonary Artery
17 18
19 20
reaction in am yloidosi s: a histologic method to assist in differentiating forms of this disease. Lah Invest 1977: 36:274-81 Celli B, Ruh inow A, Cohen A, Brody J. Patterns of pulmonary involvement in syste mic amylo idosis. Chest 1978; 74:543-47 Kline L, Dise C . Ferro T, Han sen-Flaschen J. Diagnosis of pulmonary amyloidosis hy transhmnchial hiopsy. Am Rev Respir Dis 1985: 132:191-94 Kyle A, Bayrd E. Amyloidosis : review of 23 cases . Medicine 1975: 54:271-99 Yood RA, Skinner M, Ruhinow A, Talarico L, Cohen AS. Bleeding manifestations in 100 pati ents with amyloidosis. JAMA 1983; 249:1322-24
Early Congestive Heart Failure due to Origin of the Right Coronary Artery from the Pulmonary Artery* Ugo Va/ro, M.D .; Bruno Marino , M .D .; Giuseppe De Simone , M.D .; and Carlo Marcellettt, M .D .
We describe a two-month-old infant with early congestive heart failure due to anomalous origin of the right coronary artery from the pulmonary artery. The diagnosis was made by two-dimensional and color flow Doppler echocardlography, confirmed by angiocardiography, and the case was successfully corrected at surgery. As opposed to the more frequent anomalous origin of the left coronary artery from the pulmonary trunk, this anomaly generally does not cause any typical clinical finding, often becoming an autoptic or surgical surprise after infancy or in adult age. (Che,t 1992; 1610-12) CDE = color Doppler echocardiography; RCA = right coronary artery
X
omalous origin of the right coronary artery (RCA) from the pulmonary trunk is a very rare malformation described for the first time by Brooks.' In the 43 cases reported in the literature (Table 1), the anomaly was recognized at autopsy, during surgery due to other cardiac malformations, at angiography," and recently at two-dimensional echocardiography' (2DE), and using Doppler color flow echocardiography (CDE).' As opposed to the more frequent anomalous origin of the left coronary artery from the pulmonary trunk, this anomaly generally does not cause any typical clinical finding , often becoming an autoptic or surgical surprise after infancy or in adult age.' However, some cases of cardiac arrest" and sudde n death are reported."? Our report concerns the diagnosis by echocardiography (2DE and CDE) and the surgery in a two-month-old infant with early congestive heart failure due to anomalous origin of the RCA.
FIGURE 1. Short axis parasternal view demonstrating the dilated left coronary artery (LeA) normally arisin~ from the aorta (AO). dilatation with severe hypokinesia of the left ventricle and reduced ejection fraction (31 percent). There was severe mitral valve regurgitation , the left coronary artery was d ilated (Fill: I), while the RCA appeared to course anterior to the aorta to join the pulmonary trunk (Fig 2). The CDE showed a diastolic retrograde How pattern without ind icating a trivi al "steal effect " from the coronary circulation into the pulmonary artery ( F i ~ 3). Or igin of the RCA from the pulmonary artery with poor intereoronary collate ral system was subsequently confirmed by cineangiography. A min imal left-to-rtght shunt (QplQs = 1.311) was also demonstrated. The anomal y was succ essfully corrected by a direct reimplantation of the RCA together with a cufTof the adjacent pulmonary artery into the aorta
CASE REPORT
The patient was adm itted to our department for severe cardiac failur e with gallop rhythm and a 216 loud murmur at the apex. An electrocardiogram (ECG) showed sinus tachycardia and signs of lateral ischemia with deep Q waves in the inferior leads, and chest roentgenogram showed cardiomegaly At 2DE there was a marked ·From the Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesu Hospital , Rome, Ital y. Reprint reque sts: Dr. Marino, Cardiologia, Ospedale Bambino Gesti, P::.. S. Onofrio 4, Rome , Italy 00/65 1610
FIGURt: 2. Short axis parusternal view showing the anomalous oriJ.,'in of the right coronary art ery (RCA) from the pulmonary trunk (PT). AO= aorta. Early CHF (Vtllro 8/ 8/)
Table I-Cae. Reported in the UterGture* Year
Author
1885
Brooks Brooks Monckeberg Schley Jordan Cronk Rowe Pribble Burroughs Meng Ranniger Rhantigan Wald Wald TIngelstad Eugster StopOcuchen Blieden Fujikawa Bregman Bortolotti Lerberg Lerberg Lerberg Bermudez Dall'Aglio Luisi Burakowskii Salomon Baggioni Glanz Chantepie Coo Mintz Donaldson Donaldson Huang Suzuki Worsham Shah Bellorini Mahdyoon Brouwer Vairo this report
1914 1925 1950 1951 1960 1961 1962 1965 1967 1971 1971 1972 1973 1974 1974 1975 1976 1978 1979
1979 1979 1980 1981
1981
1981
1981
1982
1982
1983 1983 1985 1985
1985
1986
1988
1989 1990 1991
AgelSex
3Oy1M 61yIM 74yIM 00y1M 7yIM
6Oy1F
16yIM 6yIF 59y1F 42ylF 17yIF 12yIM 64ylF
25ylF 22ylF l1yIM 2yIM 72yIM 22ylF 4molM 35ylF 4Oy1M
18yIM 47yIM 2yIF 4molM 18molM
6yIF 65ylF 34ylM 72yIF 4molF 2molM
Clinical Presentation Cited by BeUorini Cited by Bellorini None CHF CHF HM HM Angina 8M Cited by Donaldson 8M HM HM SD HM CHF Cited by Bellorini Cited by Donaldson Cited by Bellorini CA HM 8M CD 8M Cited by Donaldson 8M CHF Cited by Bellorini HM Angina Cited by Bellorini HM Cited by Bellorini Angina HM 8M SD Cited by Bellorini HM CHF HM-ASD Angina HM CHF
Associated Defects
ASD AO.PULM.W +ASD TOF TOF+PDA
AO.PULM.W
AO.PULM.W VSD
TOF TOF
AO.PULM.W
Diagnosis Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Intraop Autopsy Intraop Intraop Angiogr Autopsy Angiogr Autopsy Angiogr Angiogr Angiogr Intraop Angiogr Angiogr Angiogr Autopsy Autopsy Angiogr Angiogr Intraop
Surgery
Ligation Reimplantation
Reimplantation Aortocoronary bypass
Reimplantation Reimplantation Reimplantation
Reimplantation Reimplantation
Angiogr Angiogr
Ugation
Angiogr Angiogr Angiogr Angiogr Angiogr Autopsy
Reimplantation
Echo + angiogr Echo + angiogr Angiogr Angiogr Angiogr Echo + angiogr
Reimplantation Reimplantation Reimplantation
Reimplantation Reimplantation
Reimplantation Reimplantation
·CHF =congestive heart failure; 8M =heart murmur; ASD =atrial septal defect; Intraop =intraoperative; AO.PUL, W =aortopulmonary window; VSD =ventricular septal defect; TOF =tetralogy of Fallot; PDA =patent ductus arteriosus; Angiogr =angiography; SD =sudden death; CD =crib death; CA =cardiac arrest; PS =pulmonary stenosis; Echo =echocardiography under cardiopulmonary bypass. The postoperative period was not complicated, and the patient was discharged from the hospital after ten days of recovery with marked improvement of the cardiac function. Two months after surgery, the patient was in good clinical condition and at echocardiography the ejection fraction (EF) was 72 percent. DISCUSSION
Among the previously reported cases of anomalous origin of the RCA from the pulmonary trunk, only five presented clinical signs in infancy; three of them had an associated congenital heart disease (Table 1). The early congestive heart failure characteristic of anomalous origin of the left coronary
artery" and so rare in infants with anomalous origin of the RCA (Table 1), may be due, in our patient, to the poor intercoronary collateral system shown by angiocardiography or to the "dominance" of the RCA for the supply of the left ventricular myocardium. Although the noninvasive diagnosis of this rare anomaly by means of 2DE and CDE is feasible,3,4 for a complete preoperative evaluation of the intercoronary collateral systern, we suggest also the use of angiocardiography, if possible using the stop-flow technique. 10 The surgical reimplantation of the anomalous RCA in infancy may allow as in our patient, marked improvement of cardiac function. CHEST I 102 I 5 I NOVEMBER. 1992
1811
Empyema following Percutaneous Catheter Drainage of UPPer Abdominal Abscess* Scott L. Samelson. M.D.;t and Mark K. Fergmon, M.D., F.C.C.P.*
Percutaneous catheter drainage is a standard therapy Cor management of selected intra-abdominal abscesses. We describe three patients in whom this technique cauaed complicated thoracic empyemas. All patients required th0racotomy for decortication despite initial thoracostomy tube drainage. In each case, the percutaneously placed drainage catheter was found traversing the costophrenic angle, leading to direct communication between the pleural space and the abscess cavity. Review of the anatomic relationships of the inferior pleural margin to the lower ribs may help (Clam 1992;1612-14) prevent this technical error. CT ... computed tomognphYI PeD. percutaneous catheter drainage;
FIGURE 3. Right oblique subcostal view. Color How mapping shows a retrograde pattern demonstrating retrograde systolic and diastolic How from the right coronary artery (RCA) into the pulmonary trunk (P1). REFERENCES
2
3
4
5
6
7
8
9
10
Brooks II . Two cases of an abnormal coronary artery of the heart arising from the pulmonary artery: with some remarks upon the effects of this anomaly in producing cirsoid dilatation of the vessels. J Anat 1885; 20:26-9 Hanniger K. Thilenius OG. Cassels DE . Angiographie diagnosis of anomalous right coronary artery arising from the pulmonary trunk . Radiolo~ 1967; 88:29-31 Worsham C . Sanders Sf, Burger BM . Ongtn of the right eoronary artery from the pulmonary trunk: diagnosls by twodimensional echoeardiography Am J Cardiol 1985; 55:232-33 Shah RM. Nanda NC . Hsiung MC. Moos S. Roitman D . Identification of anomalous origin of the right coronary artery from the pulmonary trunk by color How mapping, Am J Cardiol 1986; 57:366-67 Fisher EA . Sepehri B. Lendrum B. Luken J. Two-dimensional eehocardiography visualization of the leli coronary artery in anomalous ongin of the left coronary artery from the pulmonary artery. Circulation 1981; 63:698-704 Bregman D. Brennan J. Stnger A. Vinci J. Parodi EN. Cassarella WJ. et al. Anomalous origin of the right coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg 1976; 72:62630 Wald S. Stonecipher K. Baldwin BJ. Nutler DO. Anomalous origin of the right coronary artery from the pulmonary artery. Am J Cardiol 1971; 27:677-81 Lerberg DB. Ogden JA. Zuherhuhler JR. Bahnson HT. Anomalous oril.'in of the right coronary artery from the pulmonary artery. Ann Thorae Surg 1979; 27:87-94 Huang TY. Hsueh Y. Tsung SH . Endocardial fibroelastosis and myocardial calcification secondary to anomalous right coronary artery aristng from the pulmonary trunk . Hum Pathol 1985; 16:959-60 Vairo U. Di Donato RM. Marino B. Pasquini L. Di Carlo D. Ballerini L. Balloon occlusion of the ascending aorta for angiographtc visualization of the coronary arteries in neonates with transposition of the great arteries. Am Heart J 1991; 121:917-19
1812
WBC. white blOod ceO count
T
he number of patients undergoing percutaneous catheter drainage (peD) of Intra-abdominal abscesses from hepatic, renal, pancreatic, diverticular, and posttraumatic causes is increasing. The results compare favorably to open surgical drainage, with success rates of 85 to 100 percent and complication rates of 0 to 5 percent for peD.I-3 Known complications include hemorrhage, hemothorax, pneumothorax, elevated intracerebral pressure, and subcutaneous abscess."? As interventional radiologists have grown more aggressive in their approach to abdominal abscesses, we have recognized empyema as a new serious thoracic compliFor editorial comment see page 1316 cation of percutaneous drainage. This report describes our recent experience with the problem of empyema following PCD. CASE REPORTS Three instances of PCD that resulted in thoracic empyema occurred over a two-year period. Their case reports follow. CASE
1
A 64'yellN>ld man was transferred from another institution with a three-week history of right upper quadrant pain. fever to 4O"C. and leukocytosis with left shift (WBC of 13.8 with 30 bands). Computed tomography (Cf) revealed a probable liver abscess. Because the patient continued to spike fevers, PCD was performed. Purulent material was obtained from the liver lesion and Enterococcus grew on culture. Intravenous antibiotics were administered. The patient's condition temporarily improved, but after three days, he again began to spike fevers , Serial chest roentgenograms revealed progressive opacification of the right side of the chest, for which a chest tube was placed. Purulent Huid was obtained with a pH of *From the Department of Surgery. the Univenity of Chicago, Chicago. tCardlothoraeic Fellow. tAssociate Professor of Surgery.
Reprint requests: Dr. MgUSon, University of Chicago. MC 5035, 5841 South Maryland. Chicago 6Q637
19 20
reaction in am yloidosi s: a histologic method to assist in differentiating forms of this disease. Lah Invest 1977: 36:274-81 Celli B, Ruh inow A, Cohen A, Brody J. Patterns of pulmonary involvement in syste mic amylo idosis. Chest 1978; 74:543-47 Kline L, Dise C . Ferro T, Han sen-Flaschen J. Diagnosis of pulmonary amyloidosis hy transhmnchial hiopsy. Am Rev Respir Dis 1985: 132:191-94 Kyle A, Bayrd E. Amyloidosis : review of 23 cases . Medicine 1975: 54:271-99 Yood RA, Skinner M, Ruhinow A, Talarico L, Cohen AS. Bleeding manifestations in 100 pati ents with amyloidosis. JAMA 1983; 249:1322-24
Early Congestive Heart Failure due to Origin of the Right Coronary Artery from the Pulmonary Artery* Ugo Va/ro, M.D .; Bruno Marino , M .D .; Giuseppe De Simone , M.D .; and Carlo Marcellettt, M .D .
We describe a two-month-old infant with early congestive heart failure due to anomalous origin of the right coronary artery from the pulmonary artery. The diagnosis was made by two-dimensional and color flow Doppler echocardlography, confirmed by angiocardiography, and the case was successfully corrected at surgery. As opposed to the more frequent anomalous origin of the left coronary artery from the pulmonary trunk, this anomaly generally does not cause any typical clinical finding, often becoming an autoptic or surgical surprise after infancy or in adult age. (Che,t 1992; 1610-12) CDE = color Doppler echocardiography; RCA = right coronary artery
X
omalous origin of the right coronary artery (RCA) from the pulmonary trunk is a very rare malformation described for the first time by Brooks.' In the 43 cases reported in the literature (Table 1), the anomaly was recognized at autopsy, during surgery due to other cardiac malformations, at angiography," and recently at two-dimensional echocardiography' (2DE), and using Doppler color flow echocardiography (CDE).' As opposed to the more frequent anomalous origin of the left coronary artery from the pulmonary trunk, this anomaly generally does not cause any typical clinical finding , often becoming an autoptic or surgical surprise after infancy or in adult age.' However, some cases of cardiac arrest" and sudde n death are reported."? Our report concerns the diagnosis by echocardiography (2DE and CDE) and the surgery in a two-month-old infant with early congestive heart failure due to anomalous origin of the RCA.
FIGURE 1. Short axis parasternal view demonstrating the dilated left coronary artery (LeA) normally arisin~ from the aorta (AO). dilatation with severe hypokinesia of the left ventricle and reduced ejection fraction (31 percent). There was severe mitral valve regurgitation , the left coronary artery was d ilated (Fill: I), while the RCA appeared to course anterior to the aorta to join the pulmonary trunk (Fig 2). The CDE showed a diastolic retrograde How pattern without ind icating a trivi al "steal effect " from the coronary circulation into the pulmonary artery ( F i ~ 3). Or igin of the RCA from the pulmonary artery with poor intereoronary collate ral system was subsequently confirmed by cineangiography. A min imal left-to-rtght shunt (QplQs = 1.311) was also demonstrated. The anomal y was succ essfully corrected by a direct reimplantation of the RCA together with a cufTof the adjacent pulmonary artery into the aorta
CASE REPORT
The patient was adm itted to our department for severe cardiac failur e with gallop rhythm and a 216 loud murmur at the apex. An electrocardiogram (ECG) showed sinus tachycardia and signs of lateral ischemia with deep Q waves in the inferior leads, and chest roentgenogram showed cardiomegaly At 2DE there was a marked ·From the Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesu Hospital , Rome, Ital y. Reprint reque sts: Dr. Marino, Cardiologia, Ospedale Bambino Gesti, P::.. S. Onofrio 4, Rome , Italy 00/65 1610
FIGURt: 2. Short axis parusternal view showing the anomalous oriJ.,'in of the right coronary art ery (RCA) from the pulmonary trunk (PT). AO= aorta. Early CHF (Vtllro 8/ 8/)
Table I-Cae. Reported in the UterGture* Year
Author
1885
Brooks Brooks Monckeberg Schley Jordan Cronk Rowe Pribble Burroughs Meng Ranniger Rhantigan Wald Wald TIngelstad Eugster StopOcuchen Blieden Fujikawa Bregman Bortolotti Lerberg Lerberg Lerberg Bermudez Dall'Aglio Luisi Burakowskii Salomon Baggioni Glanz Chantepie Coo Mintz Donaldson Donaldson Huang Suzuki Worsham Shah Bellorini Mahdyoon Brouwer Vairo this report
1914 1925 1950 1951 1960 1961 1962 1965 1967 1971 1971 1972 1973 1974 1974 1975 1976 1978 1979
1979 1979 1980 1981
1981
1981
1981
1982
1982
1983 1983 1985 1985
1985
1986
1988
1989 1990 1991
AgelSex
3Oy1M 61yIM 74yIM 00y1M 7yIM
6Oy1F
16yIM 6yIF 59y1F 42ylF 17yIF 12yIM 64ylF
25ylF 22ylF l1yIM 2yIM 72yIM 22ylF 4molM 35ylF 4Oy1M
18yIM 47yIM 2yIF 4molM 18molM
6yIF 65ylF 34ylM 72yIF 4molF 2molM
Clinical Presentation Cited by BeUorini Cited by Bellorini None CHF CHF HM HM Angina 8M Cited by Donaldson 8M HM HM SD HM CHF Cited by Bellorini Cited by Donaldson Cited by Bellorini CA HM 8M CD 8M Cited by Donaldson 8M CHF Cited by Bellorini HM Angina Cited by Bellorini HM Cited by Bellorini Angina HM 8M SD Cited by Bellorini HM CHF HM-ASD Angina HM CHF
Associated Defects
ASD AO.PULM.W +ASD TOF TOF+PDA
AO.PULM.W
AO.PULM.W VSD
TOF TOF
AO.PULM.W
Diagnosis Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Intraop Autopsy Intraop Intraop Angiogr Autopsy Angiogr Autopsy Angiogr Angiogr Angiogr Intraop Angiogr Angiogr Angiogr Autopsy Autopsy Angiogr Angiogr Intraop
Surgery
Ligation Reimplantation
Reimplantation Aortocoronary bypass
Reimplantation Reimplantation Reimplantation
Reimplantation Reimplantation
Angiogr Angiogr
Ugation
Angiogr Angiogr Angiogr Angiogr Angiogr Autopsy
Reimplantation
Echo + angiogr Echo + angiogr Angiogr Angiogr Angiogr Echo + angiogr
Reimplantation Reimplantation Reimplantation
Reimplantation Reimplantation
Reimplantation Reimplantation
·CHF =congestive heart failure; 8M =heart murmur; ASD =atrial septal defect; Intraop =intraoperative; AO.PUL, W =aortopulmonary window; VSD =ventricular septal defect; TOF =tetralogy of Fallot; PDA =patent ductus arteriosus; Angiogr =angiography; SD =sudden death; CD =crib death; CA =cardiac arrest; PS =pulmonary stenosis; Echo =echocardiography under cardiopulmonary bypass. The postoperative period was not complicated, and the patient was discharged from the hospital after ten days of recovery with marked improvement of the cardiac function. Two months after surgery, the patient was in good clinical condition and at echocardiography the ejection fraction (EF) was 72 percent. DISCUSSION
Among the previously reported cases of anomalous origin of the RCA from the pulmonary trunk, only five presented clinical signs in infancy; three of them had an associated congenital heart disease (Table 1). The early congestive heart failure characteristic of anomalous origin of the left coronary
artery" and so rare in infants with anomalous origin of the RCA (Table 1), may be due, in our patient, to the poor intercoronary collateral system shown by angiocardiography or to the "dominance" of the RCA for the supply of the left ventricular myocardium. Although the noninvasive diagnosis of this rare anomaly by means of 2DE and CDE is feasible,3,4 for a complete preoperative evaluation of the intercoronary collateral systern, we suggest also the use of angiocardiography, if possible using the stop-flow technique. 10 The surgical reimplantation of the anomalous RCA in infancy may allow as in our patient, marked improvement of cardiac function. CHEST I 102 I 5 I NOVEMBER. 1992
1811
Empyema following Percutaneous Catheter Drainage of UPPer Abdominal Abscess* Scott L. Samelson. M.D.;t and Mark K. Fergmon, M.D., F.C.C.P.*
Percutaneous catheter drainage is a standard therapy Cor management of selected intra-abdominal abscesses. We describe three patients in whom this technique cauaed complicated thoracic empyemas. All patients required th0racotomy for decortication despite initial thoracostomy tube drainage. In each case, the percutaneously placed drainage catheter was found traversing the costophrenic angle, leading to direct communication between the pleural space and the abscess cavity. Review of the anatomic relationships of the inferior pleural margin to the lower ribs may help (Clam 1992;1612-14) prevent this technical error. CT ... computed tomognphYI PeD. percutaneous catheter drainage;
FIGURE 3. Right oblique subcostal view. Color How mapping shows a retrograde pattern demonstrating retrograde systolic and diastolic How from the right coronary artery (RCA) into the pulmonary trunk (P1). REFERENCES
2
3
4
5
6
7
8
9
10
Brooks II . Two cases of an abnormal coronary artery of the heart arising from the pulmonary artery: with some remarks upon the effects of this anomaly in producing cirsoid dilatation of the vessels. J Anat 1885; 20:26-9 Hanniger K. Thilenius OG. Cassels DE . Angiographie diagnosis of anomalous right coronary artery arising from the pulmonary trunk . Radiolo~ 1967; 88:29-31 Worsham C . Sanders Sf, Burger BM . Ongtn of the right eoronary artery from the pulmonary trunk: diagnosls by twodimensional echoeardiography Am J Cardiol 1985; 55:232-33 Shah RM. Nanda NC . Hsiung MC. Moos S. Roitman D . Identification of anomalous origin of the right coronary artery from the pulmonary trunk by color How mapping, Am J Cardiol 1986; 57:366-67 Fisher EA . Sepehri B. Lendrum B. Luken J. Two-dimensional eehocardiography visualization of the leli coronary artery in anomalous ongin of the left coronary artery from the pulmonary artery. Circulation 1981; 63:698-704 Bregman D. Brennan J. Stnger A. Vinci J. Parodi EN. Cassarella WJ. et al. Anomalous origin of the right coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg 1976; 72:62630 Wald S. Stonecipher K. Baldwin BJ. Nutler DO. Anomalous origin of the right coronary artery from the pulmonary artery. Am J Cardiol 1971; 27:677-81 Lerberg DB. Ogden JA. Zuherhuhler JR. Bahnson HT. Anomalous oril.'in of the right coronary artery from the pulmonary artery. Ann Thorae Surg 1979; 27:87-94 Huang TY. Hsueh Y. Tsung SH . Endocardial fibroelastosis and myocardial calcification secondary to anomalous right coronary artery aristng from the pulmonary trunk . Hum Pathol 1985; 16:959-60 Vairo U. Di Donato RM. Marino B. Pasquini L. Di Carlo D. Ballerini L. Balloon occlusion of the ascending aorta for angiographtc visualization of the coronary arteries in neonates with transposition of the great arteries. Am Heart J 1991; 121:917-19
1812
WBC. white blOod ceO count
T
he number of patients undergoing percutaneous catheter drainage (peD) of Intra-abdominal abscesses from hepatic, renal, pancreatic, diverticular, and posttraumatic causes is increasing. The results compare favorably to open surgical drainage, with success rates of 85 to 100 percent and complication rates of 0 to 5 percent for peD.I-3 Known complications include hemorrhage, hemothorax, pneumothorax, elevated intracerebral pressure, and subcutaneous abscess."? As interventional radiologists have grown more aggressive in their approach to abdominal abscesses, we have recognized empyema as a new serious thoracic compliFor editorial comment see page 1316 cation of percutaneous drainage. This report describes our recent experience with the problem of empyema following PCD. CASE REPORTS Three instances of PCD that resulted in thoracic empyema occurred over a two-year period. Their case reports follow. CASE
1
A 64'yellN>ld man was transferred from another institution with a three-week history of right upper quadrant pain. fever to 4O"C. and leukocytosis with left shift (WBC of 13.8 with 30 bands). Computed tomography (Cf) revealed a probable liver abscess. Because the patient continued to spike fevers, PCD was performed. Purulent material was obtained from the liver lesion and Enterococcus grew on culture. Intravenous antibiotics were administered. The patient's condition temporarily improved, but after three days, he again began to spike fevers , Serial chest roentgenograms revealed progressive opacification of the right side of the chest, for which a chest tube was placed. Purulent Huid was obtained with a pH of *From the Department of Surgery. the Univenity of Chicago, Chicago. tCardlothoraeic Fellow. tAssociate Professor of Surgery.
Reprint requests: Dr. MgUSon, University of Chicago. MC 5035, 5841 South Maryland. Chicago 6Q637