- Email: [email protected]
Primary Clostridial Pneumonia and Empyema
390
JOSEPH E. HARDISON
of partial anomalous venous drainage, absence of right superior cava, and persistent left superior cava was present with an intact atrial septum. This has not been reported previously. The second patient had a left-to-right shunt via a secundum atrial septal defect and anomalous pulmonary drainage. This type of anomaly has been described previously.7,s Usually the left innominate vein receives the anomalous channel as a single vessel passing anterior to the left pulmonary hilus. 9 The electrocardiographic and roentgenologic features of partial anomalous venous drainage are similar to those seen in isolated septum secundum defect. REFERENCES
FIGURE 2. Partial anomalous drainage of left upper lobe into left innominate vein. The lower lobe drains normally into left atrium. An atrial septal defect is present (schematic drawing). CASE 2 A 21-year-old white man, was hospitalized in July, 1967 because of a non-cardiac ailment. The significant physical and laboratory examinations disclosed blood pressure of 140/70 nun Hg, a basal systolic ejection murmur (3/6) and fixed splitting of the second heart sound. Right axis of +100° and a rRS' pattern in V1 was evident on the electrocardiogram. By roentgenograms and cardiac fluoroscopy borderline pronrlnence of the pulmonary vasculature and a normal size heart were noted. Cardiac catheterization data demonstrated left-to-right shunt (Table 1) which reversed with a Valsalva maneuver. Freon and cardiogreen studies and selective angiography demonstrated an anomalous pulmonary venous drainage from the left upper lobe to the left innominate vein, as well as an atrial septal defect. These anatomic findings were confirmed during surgical closure of the atrial septal defect and anastomoses of the anomalous pulmonary veins to the left auricular appendage (Fig 2). DISCUSSION
In 1739, Winslow2 reported the first patient with partial abnormal pulmonary venous connections. The overall incidence of this abnormality is 0.5 percent of patients with congenital heart lesions. 3 The types of anomalous venous drainage have been reviewed extensively in recent years. 4 -6 Our first patient is unusual in that the triad
1 EDWARDS, J.E., CAREY, L.S., NEUFELD, H.E.) AND LESTER, R.C.: Congenital Heart Disease, (Vol. I), W. B. Saunders Co., Philadelphia and London, 1965. 2 WINSLOW, J.B., cited by HUDSON, R.E.B.: Cardiovascular Pathology, (Vol. II), The Williams and Wilkins Co., Baltimore, 1965. 3 GASUL, B.M., ARCILLA, R.A. AND LEV, M.: Heart Disease in Children, J. P. Lippincott Co., Philadelphia and Montreal, 1966. 4 GOTT, V.L., LESTER, R.B., LILLEHEI, C.W., AND VARCO, R.L.: Total anomalous pulmonary return. An analysis of thirty cases, Circulation, 13:543, 1956. 5 CARLING, R.C., ROTHNEY, W.B., AND CRAIG, J.M.: Total pulmonary venous drainage into the right side of the heart. Report of 17 autopsied cases not associated with other major cardiovascular anomalies, J. Lab. Invest., 6: 44,1957. 6 BLAKE, H.A., HALL, R.J., AND MANION, W.C.: Anomalous pulnlonary venous return, Circulation, 32:406, 1965. 7 GRISH~rAN, A., BRAHMS, S.A., CORDON, A. AND KING, F.H.: ]. Mt. Sinai Hospital, 17:336, 1950. 8 LEPREE, R.H., THO~fSON, C., AND KOHLER, C.M.: Anomalous vascular patterns found with atrial septal defect, J. Thoracic Cardiovasc. Surg., 43:354, 1962. 9 HICKlE, J.B., CI~fLETTE, T.M.D., AND BACON, A.P.C.: Anolualous pulmonary venous drainage, Brit. Heart J., 18:365, 1956. Reprint requests: Dr. Minneapolis 55404
Crismer,
Mount Sinai Hospital,
Primary Clostridial Pneumonia and Empyema Joseph E. Hardison, M.D. O
Primary Clostridium pneumonia and empyema developed in a patient with diabetes mellitus following a period of unconsciousness. Surgical drainage and high dose penicillin therapy resulted in cure.
infection of the lung and pleura by P rimary Clostridium perfringens is rare. Goldberg and Rifkind1 reviewed seven previously reported cases o Assistant
Chief, Hematology Section, Veterans Administration Hospital; Assistant Professor of Medicine (Hematology), Emory University School of Medicine, Atlanta.
CHEST, VOL. 57, NO.4, APRIL 1970
CLOSTRIDIAL PNEUMONIA AND EMPYEMA
391
and added two additional cases in 1965. The following case report describes spontaneous Clostridium perfringens pneumonia and empyema in a diabetic who was treated with surgical drainage and high dose penicillin and survived. CASE REPORT
A 56-year-old Negro man, a diabetic on 30 units of NPH insulin, was admitted to the Atlanta Veterans Administration Hospital on March 12, 1965. One week prior to admission, folIowing an episode of unexplained unconsciousness, he developed the sudden onset of right pleuritic chest pain, fever, night sweats and hemoptysis. There was no history of trauma. On initial physical examination, blood pressure was 120/80, pulse 120 and regular, and oral temperature 101°F. Numerous dental caries and poor oral hygiene were noted. He was acutely ill and complaining of right pleuritic chest pain. Fundi contained hemorrhages, exudates and microaneurysms. There was dullness to percussion and decreased tactile fremitus over the lower half of the right chest posteriorly. Fine rales and expiratory wheezing were heard in this area. The cardiac impulse was enlarged and sustained, and an S4 gallop was visible and audible. The remainder of the physical examination was not remarkable. Initial Laboratory Data: Urinalysis, 1+ albumin, 2+ sugar, occasional red blood celIs and 10-15 white blood celIs per high power field. Unfortunately a white blood cell count was not obtained. Hemoglobin, 9.6 gm percent; hematocrit, 32 rom. Serum bilirubin 1.8 with indirect of 0.35. BUN 15 mg percent. Chest x-ray film: right middle and right lower lobe infiltrates and right loculated pleural effusion (Fig 1). Gram stain of sputum: many red blood celIs and segmented white blood cells with scant numbers of gram negative and gram positive organisms.
FIGURE 1. Chest x-ray film on admission showing right middle and lower lobe infiltrates and a loculated pleural effusion.
CHEST, VOL. 57, NO.4, APRIL 1970
FIGURE 2. Chest x-ray film six weeks after discharge from the hospital showing almost complete clearing. Patient wa.~ asymptomatic. Hospital Course: The patient was initially begun on oral tetracylinc 500 mg every six hours. Gas and 30 ml of a dark red brown putrid smelling fluid were aspirated from the right chest on the third hospital day. Twenty million units of aqueous penicillin IV/24 hours was begun on the fourth hospital day because of the identification of a pure culture of Clostridium perfringens in the pleural fluid. Clostridium perfringens was also subsequently grown from bronchial washings and on several other occasions from pleural drainage. Blood cultures before and during treatment were negative. The patient continued febrile, and a thoracotomy hlbe was placed into the empyema cavity on the eighth hospital day and intra-pleural aqueous penicillin was added to his therapy. Following this, he remained afebrile and penicillin therapy was discontinued on the 19th hospital day. His course was complicated by the development of a hronchopleural fistula which was managed by open thoracotomy, resection of the eighth rib and insertion of Frye tubes into the empyema cavity. The bronchopleural fistula closed, and he was discharged feeling well after a hospital stay of 87 days. Chest x-ray examination at this time showed much improvement. He was seen again six weeks later and was doing well. Chest x-ray film at that time was almost completely clear (Fig 2). Three years later, he was admitted for congestive heart failure and the chest x-ray film was negative with the exception of cardiomegaly. Thirteen days after admission, the hematocrit and hemoglohin had fallen from the initial values of 32 mm and 9.6 gm percent to 26 mm and 7.8 gm percent. There was no evidence of bleeding. The reticulocyte count at this time was 8..'5 percent. The erythrocytes were found to be C6PD deficient. Transfusions were not given, and the hematocrit I!radually rose to 37 mm as he improved.
392
JOSEPH E. HARDISON DISCUSSION
Pre-existing chronic disease and opportunity for aspiration of mouth contents seem to be important factors in the pathogenesis of primary Clostridium perfringens pneumonia. 1 The patient reported here had diabetes mellitus and developed symptoms of respiratory infection following a period of unconsciousness. The mainstay of treatment of Clostridium perfringens infection is surgical drainage and penicillin. 2 Of the nine patients reviewed by Goldberg and Rifldnd, l three died. Neither of the three received antibiotics, antitoxin, or adequate surgical drainage. Antitoxin was used in only one patient. Antibiotics used in the survivors included penicillin, sulfadiazine, oxacillin, chloramphenicol, and erythromycin. The use of antibiotics other than penicillin is probably not indicated unless penicillin allergy exists. The use of antitoxin in the treatment of Clostridium perfringens infections is controversia1. 2 Goldberg and Rifkind1 are of the opinion that antitoxin is not necessary in the treatment of this form of the disease, and this author agrees. Primary clostridial pneumonia is an aggressive necrotizing process often complicated by development of empyema, pyopneumothorax, and bronchopleural fistula. 1 Our patient developed both empyema and a bronchopleural fistula. Hospital stay is often prolonged. The chest x-ray film may show several air fluid
levels and because of gas production it may be difficult to tell if these are in the lung or due to a pyopneumothorax. Due to loculation of fluid and gas in the pleural space, herniation of bowel into the chest may be erroneously suspected. 8 The pleural fluid is characteristically dark red to brown, thin and foul smelling, but may also be frank pus. 1 As in our case, aspiration of the pleural space may result in a "gush of foul smelling gas." Anemia was frequently present in the reported cases. Our patient had progressive anemia with a brisk reticuloycytosis and G6PD deficient red blood cells. The anemia returned toward normal as the patient improved. That the anemia was in part due to hemolysis of G6PD deficient red blood cells secondary to infection is probable, but was not proved. 4 REFERENCES
1 GOLDBERG, N.M. AND RIFKIND, D.: Clostridial empyema, Arch. Intern. Med., 115:421, 1965. 2 MACLENNAN, J.D.: The histotoxic clostridial infections of Juan, Bacteriol. Rev., 26:177, 1962. 3 SWEETING, J. AND ROSENBERG, L.: Primary clostridial pneumonia, Ann. Intern. Med., 51:805, 1959. 4 BURKA, E.R., ZEKULON, W. AND MARKS, P.A.: Clinical spectrnnl of hemolytic anemia associated with glucose-6phosphate dehydrogenase deficiency, Ann. Intern. Med., 64:817, 1966. Request reprints: Dr. Hardison, Veterans Administration Hospital, P.O. Box 29457, Atlanta, Georgia 30329.
ANNOUNCEMENT The Fourth Biennial Scientific Meeting of the California Society of Anesthesiologists has been scheduled for the Sahara Tahoe Hotel, Stateline, South Shore, Lake Tahoe, Nevada, June 12-14, 1970. Panel discussions will include "Medical Education and Anesthesiology," "The Anesthesiologist and Emergency Care," and "Preoperative Evaluation of the Surgical Patient." Members of the faculty will include Drs. Henrik H.
Bendixen, F. William Blaisdell, John J. Bonica, Hamilton S. Davis, AHred A. DeLorimier, Cecil Grey, Ernest P. Guy, William K. Hamilton, John C. Hutchinson, M. T. Jenkins and Max Weil. Dr. Leroy W. Coffroth is chainnan. For additional information, please write: Mr. Norman R. Catron, Executive Secretary, California Society of Anesthesiologists, 100 South Ellsworth Avenue, San Mateo, California 94401.
CHEST, VOL. 57, NO.4, APRIL 1970
JOSEPH E. HARDISON
of partial anomalous venous drainage, absence of right superior cava, and persistent left superior cava was present with an intact atrial septum. This has not been reported previously. The second patient had a left-to-right shunt via a secundum atrial septal defect and anomalous pulmonary drainage. This type of anomaly has been described previously.7,s Usually the left innominate vein receives the anomalous channel as a single vessel passing anterior to the left pulmonary hilus. 9 The electrocardiographic and roentgenologic features of partial anomalous venous drainage are similar to those seen in isolated septum secundum defect. REFERENCES
FIGURE 2. Partial anomalous drainage of left upper lobe into left innominate vein. The lower lobe drains normally into left atrium. An atrial septal defect is present (schematic drawing). CASE 2 A 21-year-old white man, was hospitalized in July, 1967 because of a non-cardiac ailment. The significant physical and laboratory examinations disclosed blood pressure of 140/70 nun Hg, a basal systolic ejection murmur (3/6) and fixed splitting of the second heart sound. Right axis of +100° and a rRS' pattern in V1 was evident on the electrocardiogram. By roentgenograms and cardiac fluoroscopy borderline pronrlnence of the pulmonary vasculature and a normal size heart were noted. Cardiac catheterization data demonstrated left-to-right shunt (Table 1) which reversed with a Valsalva maneuver. Freon and cardiogreen studies and selective angiography demonstrated an anomalous pulmonary venous drainage from the left upper lobe to the left innominate vein, as well as an atrial septal defect. These anatomic findings were confirmed during surgical closure of the atrial septal defect and anastomoses of the anomalous pulmonary veins to the left auricular appendage (Fig 2). DISCUSSION
In 1739, Winslow2 reported the first patient with partial abnormal pulmonary venous connections. The overall incidence of this abnormality is 0.5 percent of patients with congenital heart lesions. 3 The types of anomalous venous drainage have been reviewed extensively in recent years. 4 -6 Our first patient is unusual in that the triad
1 EDWARDS, J.E., CAREY, L.S., NEUFELD, H.E.) AND LESTER, R.C.: Congenital Heart Disease, (Vol. I), W. B. Saunders Co., Philadelphia and London, 1965. 2 WINSLOW, J.B., cited by HUDSON, R.E.B.: Cardiovascular Pathology, (Vol. II), The Williams and Wilkins Co., Baltimore, 1965. 3 GASUL, B.M., ARCILLA, R.A. AND LEV, M.: Heart Disease in Children, J. P. Lippincott Co., Philadelphia and Montreal, 1966. 4 GOTT, V.L., LESTER, R.B., LILLEHEI, C.W., AND VARCO, R.L.: Total anomalous pulmonary return. An analysis of thirty cases, Circulation, 13:543, 1956. 5 CARLING, R.C., ROTHNEY, W.B., AND CRAIG, J.M.: Total pulmonary venous drainage into the right side of the heart. Report of 17 autopsied cases not associated with other major cardiovascular anomalies, J. Lab. Invest., 6: 44,1957. 6 BLAKE, H.A., HALL, R.J., AND MANION, W.C.: Anomalous pulnlonary venous return, Circulation, 32:406, 1965. 7 GRISH~rAN, A., BRAHMS, S.A., CORDON, A. AND KING, F.H.: ]. Mt. Sinai Hospital, 17:336, 1950. 8 LEPREE, R.H., THO~fSON, C., AND KOHLER, C.M.: Anomalous vascular patterns found with atrial septal defect, J. Thoracic Cardiovasc. Surg., 43:354, 1962. 9 HICKlE, J.B., CI~fLETTE, T.M.D., AND BACON, A.P.C.: Anolualous pulmonary venous drainage, Brit. Heart J., 18:365, 1956. Reprint requests: Dr. Minneapolis 55404
Crismer,
Mount Sinai Hospital,
Primary Clostridial Pneumonia and Empyema Joseph E. Hardison, M.D. O
Primary Clostridium pneumonia and empyema developed in a patient with diabetes mellitus following a period of unconsciousness. Surgical drainage and high dose penicillin therapy resulted in cure.
infection of the lung and pleura by P rimary Clostridium perfringens is rare. Goldberg and Rifkind1 reviewed seven previously reported cases o Assistant
Chief, Hematology Section, Veterans Administration Hospital; Assistant Professor of Medicine (Hematology), Emory University School of Medicine, Atlanta.
CHEST, VOL. 57, NO.4, APRIL 1970
CLOSTRIDIAL PNEUMONIA AND EMPYEMA
391
and added two additional cases in 1965. The following case report describes spontaneous Clostridium perfringens pneumonia and empyema in a diabetic who was treated with surgical drainage and high dose penicillin and survived. CASE REPORT
A 56-year-old Negro man, a diabetic on 30 units of NPH insulin, was admitted to the Atlanta Veterans Administration Hospital on March 12, 1965. One week prior to admission, folIowing an episode of unexplained unconsciousness, he developed the sudden onset of right pleuritic chest pain, fever, night sweats and hemoptysis. There was no history of trauma. On initial physical examination, blood pressure was 120/80, pulse 120 and regular, and oral temperature 101°F. Numerous dental caries and poor oral hygiene were noted. He was acutely ill and complaining of right pleuritic chest pain. Fundi contained hemorrhages, exudates and microaneurysms. There was dullness to percussion and decreased tactile fremitus over the lower half of the right chest posteriorly. Fine rales and expiratory wheezing were heard in this area. The cardiac impulse was enlarged and sustained, and an S4 gallop was visible and audible. The remainder of the physical examination was not remarkable. Initial Laboratory Data: Urinalysis, 1+ albumin, 2+ sugar, occasional red blood celIs and 10-15 white blood celIs per high power field. Unfortunately a white blood cell count was not obtained. Hemoglobin, 9.6 gm percent; hematocrit, 32 rom. Serum bilirubin 1.8 with indirect of 0.35. BUN 15 mg percent. Chest x-ray film: right middle and right lower lobe infiltrates and right loculated pleural effusion (Fig 1). Gram stain of sputum: many red blood celIs and segmented white blood cells with scant numbers of gram negative and gram positive organisms.
FIGURE 1. Chest x-ray film on admission showing right middle and lower lobe infiltrates and a loculated pleural effusion.
CHEST, VOL. 57, NO.4, APRIL 1970
FIGURE 2. Chest x-ray film six weeks after discharge from the hospital showing almost complete clearing. Patient wa.~ asymptomatic. Hospital Course: The patient was initially begun on oral tetracylinc 500 mg every six hours. Gas and 30 ml of a dark red brown putrid smelling fluid were aspirated from the right chest on the third hospital day. Twenty million units of aqueous penicillin IV/24 hours was begun on the fourth hospital day because of the identification of a pure culture of Clostridium perfringens in the pleural fluid. Clostridium perfringens was also subsequently grown from bronchial washings and on several other occasions from pleural drainage. Blood cultures before and during treatment were negative. The patient continued febrile, and a thoracotomy hlbe was placed into the empyema cavity on the eighth hospital day and intra-pleural aqueous penicillin was added to his therapy. Following this, he remained afebrile and penicillin therapy was discontinued on the 19th hospital day. His course was complicated by the development of a hronchopleural fistula which was managed by open thoracotomy, resection of the eighth rib and insertion of Frye tubes into the empyema cavity. The bronchopleural fistula closed, and he was discharged feeling well after a hospital stay of 87 days. Chest x-ray examination at this time showed much improvement. He was seen again six weeks later and was doing well. Chest x-ray film at that time was almost completely clear (Fig 2). Three years later, he was admitted for congestive heart failure and the chest x-ray film was negative with the exception of cardiomegaly. Thirteen days after admission, the hematocrit and hemoglohin had fallen from the initial values of 32 mm and 9.6 gm percent to 26 mm and 7.8 gm percent. There was no evidence of bleeding. The reticulocyte count at this time was 8..'5 percent. The erythrocytes were found to be C6PD deficient. Transfusions were not given, and the hematocrit I!radually rose to 37 mm as he improved.
392
JOSEPH E. HARDISON DISCUSSION
Pre-existing chronic disease and opportunity for aspiration of mouth contents seem to be important factors in the pathogenesis of primary Clostridium perfringens pneumonia. 1 The patient reported here had diabetes mellitus and developed symptoms of respiratory infection following a period of unconsciousness. The mainstay of treatment of Clostridium perfringens infection is surgical drainage and penicillin. 2 Of the nine patients reviewed by Goldberg and Rifldnd, l three died. Neither of the three received antibiotics, antitoxin, or adequate surgical drainage. Antitoxin was used in only one patient. Antibiotics used in the survivors included penicillin, sulfadiazine, oxacillin, chloramphenicol, and erythromycin. The use of antibiotics other than penicillin is probably not indicated unless penicillin allergy exists. The use of antitoxin in the treatment of Clostridium perfringens infections is controversia1. 2 Goldberg and Rifkind1 are of the opinion that antitoxin is not necessary in the treatment of this form of the disease, and this author agrees. Primary clostridial pneumonia is an aggressive necrotizing process often complicated by development of empyema, pyopneumothorax, and bronchopleural fistula. 1 Our patient developed both empyema and a bronchopleural fistula. Hospital stay is often prolonged. The chest x-ray film may show several air fluid
levels and because of gas production it may be difficult to tell if these are in the lung or due to a pyopneumothorax. Due to loculation of fluid and gas in the pleural space, herniation of bowel into the chest may be erroneously suspected. 8 The pleural fluid is characteristically dark red to brown, thin and foul smelling, but may also be frank pus. 1 As in our case, aspiration of the pleural space may result in a "gush of foul smelling gas." Anemia was frequently present in the reported cases. Our patient had progressive anemia with a brisk reticuloycytosis and G6PD deficient red blood cells. The anemia returned toward normal as the patient improved. That the anemia was in part due to hemolysis of G6PD deficient red blood cells secondary to infection is probable, but was not proved. 4 REFERENCES
1 GOLDBERG, N.M. AND RIFKIND, D.: Clostridial empyema, Arch. Intern. Med., 115:421, 1965. 2 MACLENNAN, J.D.: The histotoxic clostridial infections of Juan, Bacteriol. Rev., 26:177, 1962. 3 SWEETING, J. AND ROSENBERG, L.: Primary clostridial pneumonia, Ann. Intern. Med., 51:805, 1959. 4 BURKA, E.R., ZEKULON, W. AND MARKS, P.A.: Clinical spectrnnl of hemolytic anemia associated with glucose-6phosphate dehydrogenase deficiency, Ann. Intern. Med., 64:817, 1966. Request reprints: Dr. Hardison, Veterans Administration Hospital, P.O. Box 29457, Atlanta, Georgia 30329.
ANNOUNCEMENT The Fourth Biennial Scientific Meeting of the California Society of Anesthesiologists has been scheduled for the Sahara Tahoe Hotel, Stateline, South Shore, Lake Tahoe, Nevada, June 12-14, 1970. Panel discussions will include "Medical Education and Anesthesiology," "The Anesthesiologist and Emergency Care," and "Preoperative Evaluation of the Surgical Patient." Members of the faculty will include Drs. Henrik H.
Bendixen, F. William Blaisdell, John J. Bonica, Hamilton S. Davis, AHred A. DeLorimier, Cecil Grey, Ernest P. Guy, William K. Hamilton, John C. Hutchinson, M. T. Jenkins and Max Weil. Dr. Leroy W. Coffroth is chainnan. For additional information, please write: Mr. Norman R. Catron, Executive Secretary, California Society of Anesthesiologists, 100 South Ellsworth Avenue, San Mateo, California 94401.
CHEST, VOL. 57, NO.4, APRIL 1970