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Pyopneumothorax in infants
PYOPNEUIVIOTHOEAX
IN INFANTS
I~EPORT OF A CASE IN A N INFANT SIX D A Y S O L D
L. J. HALPEI~N, M.D. AND I. PILOT, IV[.D. CHICAGO, ILL. CUTE acquired p y o p n e u m o t h o r a x in infants under three months of age is very rare. Our ease represents the third with autopsy findings to be reported in the literature. The two previously described occurred in infants four ~ and nine ~ weeks old respectively. In one the p y o p n e u m o t h o r a x was secondary to bronehopneumonia; in the other to furunculosis. All three yielded a pure culture of S t a p h y l o c o c c u s a u r e u s from the ple~ral exudaie. A fourth case diagnosed by r o e n t g e n o l o g y lacked confirmation at autopsy. Our patient is the youngest on record and illustrates the vagueness of physical findings, the value of x-ray procedure and the necessity of bearing in mind uncommon conditions in the newborn. CASE HISTORY An apparently normal~ full-term~ male infant was delivered on January 22~ 1932, by Dr. Margolis at the Edgewater IIospital. The mother~ a prlmlpara, twenty-two years of age had experienced an uneventful pregnancy. Labor, aided by low forceps delivery, lasted eighteen hours. She was afebrilc t h r o u g h o u t her fourteen days in hospital~ at which time she was discharged. The previous p a t e r n a l and m a t e r n a l histories were of no importance. The i n f a n t weighed 8 pounds, 61~ ounces at birth. He nursed well at the breast and in addition was given small complem e n t a r y feedings of diluted cow ~s milk with dextrimaltoso. The first six days of life were u n e v e n t f u l a n d he h a d gained 3~! ounces ever his b i r t h .weight A t this time a t t e n t i o n was called to a n unexplainable fever of t 0 t ~ F . per rectum. One of us (L. It.) examined the baby the following day. E x a ~ n a : t i o n and C v u r s e . - - T h e i n f a n t was well nourished. The temperature was 101 ~ F. There was marked dyspnea~ unassociated with cyanosis or cough. The essential findings on physical examination included diminished resonance with occasional clicking rgdes at the end of inspiration at the base, posteriorly~ a n d in the axllla over the l e f t lung. B r e a t h sounds were somewhat diminished in these areas, b u t wore distinctly audible t h r o u g h o u t the remainder of the lungs. A slight gelatinous creamy solution in the umbilical stump was p a r t l y hidden by the overlapping skin folds. No evidence of omphaIitis was noted a t a n y time. A tentative diagnosis was m a d e of pleuropneumonia) probably as a p a r t of a septic infection in the newborn. Suspicion was cast on t h e umbilicus as the possible portal of entry. The skin was free f r o m pustular lesions. No change in findings occurred the following day. A n x-ray picture of the chest taken on the third day of illness revealed (Fig. 1) a partial pneumothorax at the lower r i g h t lung and at the periphery of t h e entire ]eft lung. The lung fields appeared uninvolved. Because F r o m the Department of Pediatrics and Pathology and University of Illinois, ColIege of ~r and from the Edgewater Hospital, Chicago. 444
t:IALPEt~I~ AND PILOT:
PYOPNEUi~CIOTIrIORAX
445
of t h e p n e u m o t h o r a x , a n a s s o c i a t e d e m p y e m a was s u s p e c t e d on t h e b a s i s of t h e septic t e m p e r a t u r e , the c h e s t findings o f d i m i n i s h e d r e s o n a n c e a n d b r e a t h sounds, a n d t h e k n o w l e d g e t h a t e m p y e m a o f t h e n e w b o r n is n o t a n u n u s u a l occurrence, part i c u l a r l y a t necropsy.3 B r o n e h o p e n u m o n i a as t h e etiologic f a c t o r a p p a r e n t l y was excluded by t h e x - r a y a p p e a r a n c e . AdditioneA findings on t h e f o u r t h d a y of illness included pain~ evidenced b y c r y i n g w h e n t h e t h i g h s , w h i c h were u s u a l l y flexed on t h e a b d o m e n , were p a s s i v e l y extended. A m o d e r a t e a m o u n t of s o f t p i t t i n g e d e m a o f b o t h lower e x t r e m i t i e s w a s n o t e d a t t h i s t i m e , b u t t h e r e wore no s i g n s o f redness, t e n d e r n e s s or l o c ~ i z e d swelling p r e s e n t i n these r e g i o n s a t a n y time. T h e u r i n e w a s n o r m a l on two successive e x a m i n a t i o n s . T h e blood e x a m i n a t i o n showed
Fig. l . - - P n e u m o t h o r a x in a n e w b o r n ; the a r r o w s point to t h e sites of the p n e u m o thorax.
9Ir~dicat~ a ~ c e ~ Fig. 2 . - - S c h e m a t i c d r a w i n g of findings a t autopsy. l i B . 75 per c e n t ; 1%.B.C. 4,250,000; W.B.O. 18,300, of w h i c h 75 p e r cent were p o l y m o r p h o n u c l e a r cells, 16 p e r cent s m a l l l y m p h o c y t e s a n d 8 p e r c e n t l a r g e lymphocytes. T h e leueocytosis f u r t h e r s t r e n g t h e n e d t h e belief t h a t p u s existed w i t h t h e p n e u m o t h o r a x . S u b s e q u e n t films of t h e chest on t h e s i x t h d a y of illness revealed in a d d i t i o n to t h e p r e v i o u s findings evidences of a s m a l l a m o u n t o f fluid in t h e l e f t chest. D i a p h r a g m a t i c h e r n i a was excluded b y t h e x - r a y picture. Exp l o r a t o r y p u n c t u r e did n o t a p p e a r a d v i s a b l e at this time. T h e i n f a n t c o n t i n u e d to n u r s e well a n d m a d e m o d e s t gains, t h o u g h at t i m e s h a d a w a t e r y stool a n d v o m i t e d occasionally. S u p p o r t i v e m e a s u r e s i n c l u d i n g o x y g e n were r e s o r t e d to at v a r i o n s times. O n t h e e i g h t h d a y of illness, t h e findings o f t h e c h e s t included d i m i n i s h e d r e s o n a n c e to dullness, associated w i t h i n c r e a s e d vocal f r e m i t u s over t h e
446
THE JOURNAL OF PEDIATRICS
whole left side of the chest, particularly the upper anterior three-fourths. Breath sounds were trazasmitted throughout, but diminished at the left base. Tubular breathing was heard below both scapular angles posteriorly. There was marked p i t t i n g edema of the r i g h t lower extremity and anterior abdominal wall. There was no evidence of a n inflammatory process in tl~e region of the abdomen or lower extremities. Death occurred on the n i n t h day of illness. The final clinical diagnosis was acute pyopneumothorax of the left chest; terminal bronehopneumonia; compression atelectasis and phlebitis of the left femoral vein.
A~tops~.--The i n f a n t appeared full term, weighed 8 pounds. The skin was subicteric and was exfoliating over the abdomen. The scrotum and the right thigh were enlarged a n d markedly edematous. The diaphragm on the left side extended to the seventh r i b ; on the right, to the sixth rib. The thymus was not enlarged. The left pleural cavity presented an encapsulated cavity filled with 200 c.c. purulent exudate, extending largely over the lower lobe of left ]ung. The. upper lobe was atelectatic, and the pleural cavity over this lobe contained air and no exudate. (Fig. 2 0 The r i g h t pleura] cavity revealed similarly about 100 c.e. of white pus. The pleura, of left lung was covered with a fibrinous purulent exudate and showed several small subpleural abscesses 3 to 6 nml. in diameter. The lower lobe was partially collapsed. The pleura of the r i g h t lower lobe was covered with purulent exudate and revealed similar subpleural abscesses. The lower lobe was partially atelectatic; the upper and middle were distinctly emphysematous; cut section of both lobes revealed no abscesses or patches of consolidation i a the parenehyma. The bronchi were free of exudate. The esophagus was lmchanged. The peribronchial l y m p h s were enlarged and soft. The h e a r t was of normal size and the valves showed no vegetations. The foramen ovale was closed. The myocardium was soft and light brown. The pericardium was smooth, and the cavity contained no exudate. A deep abscess cavity containing 60 c.c. of white pus led into the deep fascia1 planes of the r i g h t thigh, extending to the retroperitoneal tissue. There were no connections to rectum or bladder, intestines or the bony pelvis. The iliac and femoral vessels were free of thrombi. Th~ liver was slightly enlarged, light brown and soft. Spleen was soft, swollen~ and the markings were obscure. The kidneys were similarly involved by cloudy swelling; the medulla of right adrenal was markedly congested. The pancreas, stomach, duodenal, and intestines revealed no gross changes. The testes were in normal position. The urinary bladder was filled with clear urine. The anatomic diagnosis was as follows: E m p y e m a - - b o t h pleura] cavities; left pneumothorax; multiple subpleural abscesses; bilateral acute fibrinopurulent pleuritis, atelectasis of left lung and ]'ight lower lobe, emphysema of r i g h t upper and middle lobes; deep abscess of the right t h i g h ; cloudy swelling of liver, spleen, kidneys and myocardium; edema of right leg. Cultures made of the h e a r t ' s blood, subpleural abscess and from deep abscess of the thigh all yielded pure cultures of S taphy~o~occ/uv a~'reus. COMMENT Pyopneumothorax
has been
described
more
frequently
p a s t t h r e e y e a r s o f a g e , a n d i t is r e l a t i v e l y r a r e age. 2 The size and shape of the chest in infants not
comparable
to those
coin test, succussion
elicited in older
splash and metallic
fluid and air in the chest are frequently
children
tinkle that
in children
under one year of permit of findings and
adults.
The
we associate with
not obtained
in infants.
In
Johnson's ~ series of pyopneumothorax in ten patients ranging from one month to three years, five gave a positive coin test, four a positive
I-IALPEtgN AND PILOT:
PYOPIVEUNIOTHORAX
447
succussion splash and six t h e metallic tinkle. Percussion findings, absence of diminished b r e a t h sounds t o g e t h e r w i t h a l i m i t a t i o n of expansion on the affected side were described as the i m p o r t a n t findings m o s t f r e q u e n t l y obtained. I t is significant t h a t the i n f a n t f o u r weeks old in his series, w h e r e a diagnosis of p y o p n e u m o t h o r a x w a s substant i a t e d at autopsy, p r e s e n t e d only dullness w i t h s u p p r e s s e d b r e a t h sounds of amp.boric q u a n t i t y but l a c k e d the coin test and o t h e r signs mentioned. All of his cases were t h o u g h t to h a v e p l e u r o p n e u m o n i a f r o m the onset, and b y r u p t u r e of a s u b p l e u r a l abscess p r o d u c e d tile p y o p n e u m o t h o r a x . The use of the x - r a y picture b o t h in o u r ease and in J o h n s o n ' s second case of an i n f a n t u p o n w h o m an a u t o p s y was not made, was the deciding f a c t o r t o w a r d a r r i v i n g at eorr'ect diagnosis. The value of this l a b o r a t o r y m e t h o d used early in infants w h e n physical findings of the chest are c o n f u s i n g is inestimable. I n o u r case, tile d e m o n s t r a t i o n b y this m e a n s of the p n e u m o t h o r a x combined w i t h the a f o r e m e n t i o n e d findings a n d the k n o w l e d g e t h a t e m p y e m a of the newb o r n is not i n f r e q u e n t a p o i n t e d clinically to the diagnosis of a r a r e condition in the newborn. Pus in the chest of the n e w b o r n can be eff e c t i v e l y d r a i n e d w i t h recovery, a The source of p y o p n e u m o t h o r a x in i n f a n t s is sepsis either in the n e w b o r n or in the mother. I n the f o r m e r , the most c o m m o n modes of e n t r y are r e s p i r a t o r y , cutaneous, umbilical or gastrointestinal. T h o u g h the umbilical s t u m p in our case p r e s e n t e d t h e moist m u e o p u m l e n t condition usually e n c o u n t e r e d d i r e c t l y a f t e r the cord separates, the f a c t t h a t b a c t e r i a including staphylococci are f r e q u e n t l y d e m o n s t r a t e d in the e x u d a t e leads us to believe t h a t this m a y h a v e been the source of e n t r y in our' patient, p a r t i c u l a r l y in the absence of o t h e r d e m o n s t r a b l e foei. The m e t a s t a t i c deep abscess of the thigh is a r a r e finding' a n d is i m p o r t a n t and i n t e r e s t i n g in view of the f a c t t h a t no e x t e r n a l i n f l a m m a t o r y signs were present. N e w b o r n infants, are especially susceptible to staphylococcus infection, and in out" case a s e p t i c o p y e m i a developed w i t h localization of a deep abscess in the t h i g h a n d in the pleura. F r o m the p l e u r a l lesions p y o p n e u m o t h o r a x r e s u l t e d f r o m r u p t u r e of the a d j a c e n t p u l m o n a r y tissue. SUMMAI~Y
A case of p y o p n e u m o t h o r a x diagnosed d u r i n g life a n d confirmed by a u t o p s y is r e p o r t e d in an i n f a n t six days old, the y o u n g e s t on record. The condition was a p p a r e n t l y due to s e p t i e o p y e m i a b y the S t a p h y l o coccus a.u.reus which was isolated f r o m the pus f r o m deep abscess of the thigh and the pleura] exudate. IgEFERENCES '1. J o h n s o n , F. E." Am. J. Dis. Child. 33: 740, 1927. 2. R o b a t z , J., ~nd l~osenberg, A.: Am. J. Dis. Child. 41: 1104, 1931. 3. Glaser, J., a n d E p s t e i n , 5.: Am. J. Dis. Child. 41~ 110, 1931. 185 N. WABASH AVENUE.
IN INFANTS
I~EPORT OF A CASE IN A N INFANT SIX D A Y S O L D
L. J. HALPEI~N, M.D. AND I. PILOT, IV[.D. CHICAGO, ILL. CUTE acquired p y o p n e u m o t h o r a x in infants under three months of age is very rare. Our ease represents the third with autopsy findings to be reported in the literature. The two previously described occurred in infants four ~ and nine ~ weeks old respectively. In one the p y o p n e u m o t h o r a x was secondary to bronehopneumonia; in the other to furunculosis. All three yielded a pure culture of S t a p h y l o c o c c u s a u r e u s from the ple~ral exudaie. A fourth case diagnosed by r o e n t g e n o l o g y lacked confirmation at autopsy. Our patient is the youngest on record and illustrates the vagueness of physical findings, the value of x-ray procedure and the necessity of bearing in mind uncommon conditions in the newborn. CASE HISTORY An apparently normal~ full-term~ male infant was delivered on January 22~ 1932, by Dr. Margolis at the Edgewater IIospital. The mother~ a prlmlpara, twenty-two years of age had experienced an uneventful pregnancy. Labor, aided by low forceps delivery, lasted eighteen hours. She was afebrilc t h r o u g h o u t her fourteen days in hospital~ at which time she was discharged. The previous p a t e r n a l and m a t e r n a l histories were of no importance. The i n f a n t weighed 8 pounds, 61~ ounces at birth. He nursed well at the breast and in addition was given small complem e n t a r y feedings of diluted cow ~s milk with dextrimaltoso. The first six days of life were u n e v e n t f u l a n d he h a d gained 3~! ounces ever his b i r t h .weight A t this time a t t e n t i o n was called to a n unexplainable fever of t 0 t ~ F . per rectum. One of us (L. It.) examined the baby the following day. E x a ~ n a : t i o n and C v u r s e . - - T h e i n f a n t was well nourished. The temperature was 101 ~ F. There was marked dyspnea~ unassociated with cyanosis or cough. The essential findings on physical examination included diminished resonance with occasional clicking rgdes at the end of inspiration at the base, posteriorly~ a n d in the axllla over the l e f t lung. B r e a t h sounds were somewhat diminished in these areas, b u t wore distinctly audible t h r o u g h o u t the remainder of the lungs. A slight gelatinous creamy solution in the umbilical stump was p a r t l y hidden by the overlapping skin folds. No evidence of omphaIitis was noted a t a n y time. A tentative diagnosis was m a d e of pleuropneumonia) probably as a p a r t of a septic infection in the newborn. Suspicion was cast on t h e umbilicus as the possible portal of entry. The skin was free f r o m pustular lesions. No change in findings occurred the following day. A n x-ray picture of the chest taken on the third day of illness revealed (Fig. 1) a partial pneumothorax at the lower r i g h t lung and at the periphery of t h e entire ]eft lung. The lung fields appeared uninvolved. Because F r o m the Department of Pediatrics and Pathology and University of Illinois, ColIege of ~r and from the Edgewater Hospital, Chicago. 444
t:IALPEt~I~ AND PILOT:
PYOPNEUi~CIOTIrIORAX
445
of t h e p n e u m o t h o r a x , a n a s s o c i a t e d e m p y e m a was s u s p e c t e d on t h e b a s i s of t h e septic t e m p e r a t u r e , the c h e s t findings o f d i m i n i s h e d r e s o n a n c e a n d b r e a t h sounds, a n d t h e k n o w l e d g e t h a t e m p y e m a o f t h e n e w b o r n is n o t a n u n u s u a l occurrence, part i c u l a r l y a t necropsy.3 B r o n e h o p e n u m o n i a as t h e etiologic f a c t o r a p p a r e n t l y was excluded by t h e x - r a y a p p e a r a n c e . AdditioneA findings on t h e f o u r t h d a y of illness included pain~ evidenced b y c r y i n g w h e n t h e t h i g h s , w h i c h were u s u a l l y flexed on t h e a b d o m e n , were p a s s i v e l y extended. A m o d e r a t e a m o u n t of s o f t p i t t i n g e d e m a o f b o t h lower e x t r e m i t i e s w a s n o t e d a t t h i s t i m e , b u t t h e r e wore no s i g n s o f redness, t e n d e r n e s s or l o c ~ i z e d swelling p r e s e n t i n these r e g i o n s a t a n y time. T h e u r i n e w a s n o r m a l on two successive e x a m i n a t i o n s . T h e blood e x a m i n a t i o n showed
Fig. l . - - P n e u m o t h o r a x in a n e w b o r n ; the a r r o w s point to t h e sites of the p n e u m o thorax.
9Ir~dicat~ a ~ c e ~ Fig. 2 . - - S c h e m a t i c d r a w i n g of findings a t autopsy. l i B . 75 per c e n t ; 1%.B.C. 4,250,000; W.B.O. 18,300, of w h i c h 75 p e r cent were p o l y m o r p h o n u c l e a r cells, 16 p e r cent s m a l l l y m p h o c y t e s a n d 8 p e r c e n t l a r g e lymphocytes. T h e leueocytosis f u r t h e r s t r e n g t h e n e d t h e belief t h a t p u s existed w i t h t h e p n e u m o t h o r a x . S u b s e q u e n t films of t h e chest on t h e s i x t h d a y of illness revealed in a d d i t i o n to t h e p r e v i o u s findings evidences of a s m a l l a m o u n t o f fluid in t h e l e f t chest. D i a p h r a g m a t i c h e r n i a was excluded b y t h e x - r a y picture. Exp l o r a t o r y p u n c t u r e did n o t a p p e a r a d v i s a b l e at this time. T h e i n f a n t c o n t i n u e d to n u r s e well a n d m a d e m o d e s t gains, t h o u g h at t i m e s h a d a w a t e r y stool a n d v o m i t e d occasionally. S u p p o r t i v e m e a s u r e s i n c l u d i n g o x y g e n were r e s o r t e d to at v a r i o n s times. O n t h e e i g h t h d a y of illness, t h e findings o f t h e c h e s t included d i m i n i s h e d r e s o n a n c e to dullness, associated w i t h i n c r e a s e d vocal f r e m i t u s over t h e
446
THE JOURNAL OF PEDIATRICS
whole left side of the chest, particularly the upper anterior three-fourths. Breath sounds were trazasmitted throughout, but diminished at the left base. Tubular breathing was heard below both scapular angles posteriorly. There was marked p i t t i n g edema of the r i g h t lower extremity and anterior abdominal wall. There was no evidence of a n inflammatory process in tl~e region of the abdomen or lower extremities. Death occurred on the n i n t h day of illness. The final clinical diagnosis was acute pyopneumothorax of the left chest; terminal bronehopneumonia; compression atelectasis and phlebitis of the left femoral vein.
A~tops~.--The i n f a n t appeared full term, weighed 8 pounds. The skin was subicteric and was exfoliating over the abdomen. The scrotum and the right thigh were enlarged a n d markedly edematous. The diaphragm on the left side extended to the seventh r i b ; on the right, to the sixth rib. The thymus was not enlarged. The left pleural cavity presented an encapsulated cavity filled with 200 c.c. purulent exudate, extending largely over the lower lobe of left ]ung. The. upper lobe was atelectatic, and the pleural cavity over this lobe contained air and no exudate. (Fig. 2 0 The r i g h t pleura] cavity revealed similarly about 100 c.e. of white pus. The pleura, of left lung was covered with a fibrinous purulent exudate and showed several small subpleural abscesses 3 to 6 nml. in diameter. The lower lobe was partially collapsed. The pleura of the r i g h t lower lobe was covered with purulent exudate and revealed similar subpleural abscesses. The lower lobe was partially atelectatic; the upper and middle were distinctly emphysematous; cut section of both lobes revealed no abscesses or patches of consolidation i a the parenehyma. The bronchi were free of exudate. The esophagus was lmchanged. The peribronchial l y m p h s were enlarged and soft. The h e a r t was of normal size and the valves showed no vegetations. The foramen ovale was closed. The myocardium was soft and light brown. The pericardium was smooth, and the cavity contained no exudate. A deep abscess cavity containing 60 c.c. of white pus led into the deep fascia1 planes of the r i g h t thigh, extending to the retroperitoneal tissue. There were no connections to rectum or bladder, intestines or the bony pelvis. The iliac and femoral vessels were free of thrombi. Th~ liver was slightly enlarged, light brown and soft. Spleen was soft, swollen~ and the markings were obscure. The kidneys were similarly involved by cloudy swelling; the medulla of right adrenal was markedly congested. The pancreas, stomach, duodenal, and intestines revealed no gross changes. The testes were in normal position. The urinary bladder was filled with clear urine. The anatomic diagnosis was as follows: E m p y e m a - - b o t h pleura] cavities; left pneumothorax; multiple subpleural abscesses; bilateral acute fibrinopurulent pleuritis, atelectasis of left lung and ]'ight lower lobe, emphysema of r i g h t upper and middle lobes; deep abscess of the right t h i g h ; cloudy swelling of liver, spleen, kidneys and myocardium; edema of right leg. Cultures made of the h e a r t ' s blood, subpleural abscess and from deep abscess of the thigh all yielded pure cultures of S taphy~o~occ/uv a~'reus. COMMENT Pyopneumothorax
has been
described
more
frequently
p a s t t h r e e y e a r s o f a g e , a n d i t is r e l a t i v e l y r a r e age. 2 The size and shape of the chest in infants not
comparable
to those
coin test, succussion
elicited in older
splash and metallic
fluid and air in the chest are frequently
children
tinkle that
in children
under one year of permit of findings and
adults.
The
we associate with
not obtained
in infants.
In
Johnson's ~ series of pyopneumothorax in ten patients ranging from one month to three years, five gave a positive coin test, four a positive
I-IALPEtgN AND PILOT:
PYOPIVEUNIOTHORAX
447
succussion splash and six t h e metallic tinkle. Percussion findings, absence of diminished b r e a t h sounds t o g e t h e r w i t h a l i m i t a t i o n of expansion on the affected side were described as the i m p o r t a n t findings m o s t f r e q u e n t l y obtained. I t is significant t h a t the i n f a n t f o u r weeks old in his series, w h e r e a diagnosis of p y o p n e u m o t h o r a x w a s substant i a t e d at autopsy, p r e s e n t e d only dullness w i t h s u p p r e s s e d b r e a t h sounds of amp.boric q u a n t i t y but l a c k e d the coin test and o t h e r signs mentioned. All of his cases were t h o u g h t to h a v e p l e u r o p n e u m o n i a f r o m the onset, and b y r u p t u r e of a s u b p l e u r a l abscess p r o d u c e d tile p y o p n e u m o t h o r a x . The use of the x - r a y picture b o t h in o u r ease and in J o h n s o n ' s second case of an i n f a n t u p o n w h o m an a u t o p s y was not made, was the deciding f a c t o r t o w a r d a r r i v i n g at eorr'ect diagnosis. The value of this l a b o r a t o r y m e t h o d used early in infants w h e n physical findings of the chest are c o n f u s i n g is inestimable. I n o u r case, tile d e m o n s t r a t i o n b y this m e a n s of the p n e u m o t h o r a x combined w i t h the a f o r e m e n t i o n e d findings a n d the k n o w l e d g e t h a t e m p y e m a of the newb o r n is not i n f r e q u e n t a p o i n t e d clinically to the diagnosis of a r a r e condition in the newborn. Pus in the chest of the n e w b o r n can be eff e c t i v e l y d r a i n e d w i t h recovery, a The source of p y o p n e u m o t h o r a x in i n f a n t s is sepsis either in the n e w b o r n or in the mother. I n the f o r m e r , the most c o m m o n modes of e n t r y are r e s p i r a t o r y , cutaneous, umbilical or gastrointestinal. T h o u g h the umbilical s t u m p in our case p r e s e n t e d t h e moist m u e o p u m l e n t condition usually e n c o u n t e r e d d i r e c t l y a f t e r the cord separates, the f a c t t h a t b a c t e r i a including staphylococci are f r e q u e n t l y d e m o n s t r a t e d in the e x u d a t e leads us to believe t h a t this m a y h a v e been the source of e n t r y in our' patient, p a r t i c u l a r l y in the absence of o t h e r d e m o n s t r a b l e foei. The m e t a s t a t i c deep abscess of the thigh is a r a r e finding' a n d is i m p o r t a n t and i n t e r e s t i n g in view of the f a c t t h a t no e x t e r n a l i n f l a m m a t o r y signs were present. N e w b o r n infants, are especially susceptible to staphylococcus infection, and in out" case a s e p t i c o p y e m i a developed w i t h localization of a deep abscess in the t h i g h a n d in the pleura. F r o m the p l e u r a l lesions p y o p n e u m o t h o r a x r e s u l t e d f r o m r u p t u r e of the a d j a c e n t p u l m o n a r y tissue. SUMMAI~Y
A case of p y o p n e u m o t h o r a x diagnosed d u r i n g life a n d confirmed by a u t o p s y is r e p o r t e d in an i n f a n t six days old, the y o u n g e s t on record. The condition was a p p a r e n t l y due to s e p t i e o p y e m i a b y the S t a p h y l o coccus a.u.reus which was isolated f r o m the pus f r o m deep abscess of the thigh and the pleura] exudate. IgEFERENCES '1. J o h n s o n , F. E." Am. J. Dis. Child. 33: 740, 1927. 2. R o b a t z , J., ~nd l~osenberg, A.: Am. J. Dis. Child. 41: 1104, 1931. 3. Glaser, J., a n d E p s t e i n , 5.: Am. J. Dis. Child. 41~ 110, 1931. 185 N. WABASH AVENUE.