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Surgical treatment of pulmonary melioidosis
Surgical treatment of pulmonary melioidosis Russ Zajtchuk, Lieutenant Colonel, MC, USA, Carl R. Guiton, Lieutenant Colonel, MC, USA, Theodore R. Sadler, M.D., William H. Heydorn, Lieutenant Colonel, Me, USA, and Tracy E. Strevey, Colonel, MC, USA, Denver, Colo.
~itmore
and Krishnaswami,' in 1912, reported the discovery of a gram-negative bacterium which caused an infectious disease that had not previously been described. It was later named melioidosis by Stanton and Fletcher." There are multiple pulmonary manifestations of this disease, such as cystic cavitary disease, pulmonary infiltration, pleural effusion, empyema, and tracheobronchitis." Review of our experience with pulmonary melioidosis revealed that 5 patients required pulmonary resections. Their postoperative course and follow-up form the basis of this report. Clinical material
Thirty patients with pulmonary melioidosis have been seen at Fitzsimons Army Medical Center since 1965. Their presenting complaints were fever, chest pain, productive cough, and weight loss. Twenty per cent of the patients were aware of hemoptysis. On chest roentgenography, 24 of the 30 patients had cavitary disease in the upper lobes. All of the patients had positive cultures as well as high hemagglutination and complement fixation titers. The patients were treated with chloramphenicol and tetracycline at a dose of 2 From Fitzsimons Army
Medical Center, Denver, Colo.
80240.
Received for publication June 25, 1973.
838
Gm. per day. The therapy with the two drugs was continued for 30 days, after which tetracycline was given for at least another 30 days. If the culture had not reverted to normal, treatment with one drug was continued and other drugs were added, such as kanamycin, novobiocin, and Gantrisin. Despite the intensive medical therapy, 5 patients were referred for operation. Case reports of these patients are presented. Case reports CASE 1. A 23-year-old Negro man presenled with fever, cough, and myalgia. Chest roentgenography in October, 1968, revealed a left upper lobe infiltrate with a 4 cm., fluid-filled cavity. Sputum culture was positive for Pseudomonas pseudomallei, and the melioidosis titer was 1: 1,280. The patient was treated with large doses of antibiotics including Chloromycetin, tetracycline, novobiocin, kanamycin, and Gantrisin for 1 year. Despite the massive antibiotic therapy he remained ill, culture of sputum remained positive for Pseudomonas pseudomallei, melioidosis titers ranged between 1: 1,280 and 1: 20,480 during the course of treatment, and the cavity in the left upper lobe persisted (Fig. 1). On Oct. 15, 1969, a left upper lobectomy was performed. There were no complications postoperatively. One month after the operation, sputum cultures became negative and the hemagglutination titer had fallen to 1: 640. CASE 2. A 22-year-old man was admitted in September, 1968, with fever, productive cough, hemoptysis, and weight loss. Chest roentgenography revealed a large left upper lobe infiltrate with a cavity and a smaller right upper lobe infiltrate. Sputum culture was positive for Pseu-
Volume 66 Number 5
Pulmonary melioidosis
839
November, 1973
Fig. 1. Chest roentgenogram showing cavity in the left upper lobe. The patient had been treated for 12 months with antibiotics.
Fig. 2. Chest roentgenogram showing persistent right upper lobe infiltrate. The patient had been treated for tuberculosis without any change in the infiltrate.
domonas pseudomallei, and the melioidosis titer was 1: 10,240. He was treated with large doses of Chloromycetin and tetracycline for 13 months. During the course of the therapy he developed parasthesias of both feet thought to be due to the Chloromycetin therapy. The patient continued to be ill, with persistence of the left upper lobe cavity, positive cultures, and high melioidosis titers. On Nov . 26, 1969, an apicoposterior segment of the upper lobe was removed . Postoperatively, there was a persistent air leak for 2 weeks. Two months following the operation, the sputum cultures were negative and the melioidosis titer was 1: 80. Three years postoperatively he has no pulmonary problems but continues to have severe parasthesias of his feet, probably as a consequence of prolonged antibiotic therapy. CAS E 3. A 31-year-old Caucasian man was admitted in October, 1968, with fever and pro ductive cough . Chest roentgenograms revealed a left upper lobe cavity. Sputum culture was positive for Pseudomonas pseudomallei, and the melioidosis titer was 1:5,120. He was treated with large doses of Chlorornycetin and tetracycline. During the course of therapy the cultures remained positive and melioidosis titers were as high as 1:40,960. On Nov . 18, 1969, after 13 months of antibiotic therapy, an apicoposterior segment of the left upper lobe was removed. Postoperatively, he developed a bronchopleural cutaneous fistula and empyema requiring an additional 4 months of
hospitalization. The most recent melioidosis titer, measured in April, 1970, was 1:2,560. Sputum became negative for Pseudomonas pseudomallei in May of 1970. The patient was doing very well when last seen in June, 1970. CASE 4. A 38-year-old Negro man was admitted on May 5, 1965, with fever, chest pain , and cough. Chest roentgenograms revealed an infiltrate in the right upper lobe. Because of recent exposure to active pulmonary tuberculosis plus a positive skin test, he was placed on isoniazid, para-arninosalicyclic acid, and pyridoxine. After 4 months of antituberculosis therapy the infiltrate did not change (Fig. 2). Bronchograms revealed obstruction of the anterior segmental bronchus, and the patient was referred for operation. On Oct. 14, 1965, a right upper lobectomy was performed. Specimen cultures grew Pseudomonas pseudomallei. Postoperative melioidosis titers were negative. The patient had no complications after the operation and was doing well 1 year later but subsequently has been lost to follow-up. CASE 5. A 45-year-old Negro man was admitted in June, 1965, with cough , malai se, evening sweats , anorexia, and chest pain . Che st roentgenograms revealed an infiltrate in the left upper lobe. The patient was treated with penicillin, but the infiltrate in the anterior segment of the left upper lobe persisted. Two months following admission, because of suspicion of malignancy, a left thoracotomy was performed and an anterior segment of the left upper lobe was resected . Postoperatively, the patient developed a bronchopleural fistula and an empyema resulting in a
The Journal of
840
Zaitchuk et at.
Thoracic and Cardiovascular Surgery
prolonged hospitalization. Purulent drainage from the chest grew Pseudomonas pseudomallei, and he was treated with large doses of Chloromycetin and kanamycin. He was discharged 4 months after the operation and was doing well 5 years later. The Melioidosis titer in 1970 was 1: 10.
Comments and summary Of the 30 patients with pulmonary melioidosis, 5 have had pulmonary resection. Three of the 5 patients were operated upon because of resistance to medical therapy, whereas the other 2 were operated upon for purposes of diagnosis. The 2 patients who had lobectomies had no postoperative complications. By comparison, 2 of the 3 patients who had segmental resections had significant postoperative complications. Postoperatively, in all cases, the cultures became negative for Pseudomonas pseudomallei and the hemagglutination and complement fixation titers dropped markedly.
In patients who had segmental resections, it took longer for the titers to drop and for the cultures to become negative. It appears that there may be a few patients with melioidosis who, after prolonged medical therapy, may need operative intervention. In such cases the procedure of choice should be lobectomy so as to minimize postoperative complications. REFERENCES Whitmore, A, and Krishnaswami, C.! An Account of the Discovery of a Hitherto Undescribed Infective Disease Occurring Among the Population of Rangoon, Indian Med. Gaz. 47: 262, 1912. 2 Stanton, A T., and Fletcher, W.: Melioidosis: Studies From the Institute of Medical Research, Federated Malay States, No. 21, London, 1932, John Bale, Sons and Curnow, Ltd. 3 Flemma, R. J., DiVincenti, F. C., Dotin, L. N., and Pruitt, B. A: Pulmonary Melioidosis: A Diagnostic Dilemma and Increasing Threat, Ann. Thorac. Surg. 7: 491, 1969.
Introductory abstracts Beginning in January, 1974, it is requested that each article begin with a brief abstract. Authors submitting articles on or after September 1, 1973, should supply an abstract of 150 words or less.
~itmore
and Krishnaswami,' in 1912, reported the discovery of a gram-negative bacterium which caused an infectious disease that had not previously been described. It was later named melioidosis by Stanton and Fletcher." There are multiple pulmonary manifestations of this disease, such as cystic cavitary disease, pulmonary infiltration, pleural effusion, empyema, and tracheobronchitis." Review of our experience with pulmonary melioidosis revealed that 5 patients required pulmonary resections. Their postoperative course and follow-up form the basis of this report. Clinical material
Thirty patients with pulmonary melioidosis have been seen at Fitzsimons Army Medical Center since 1965. Their presenting complaints were fever, chest pain, productive cough, and weight loss. Twenty per cent of the patients were aware of hemoptysis. On chest roentgenography, 24 of the 30 patients had cavitary disease in the upper lobes. All of the patients had positive cultures as well as high hemagglutination and complement fixation titers. The patients were treated with chloramphenicol and tetracycline at a dose of 2 From Fitzsimons Army
Medical Center, Denver, Colo.
80240.
Received for publication June 25, 1973.
838
Gm. per day. The therapy with the two drugs was continued for 30 days, after which tetracycline was given for at least another 30 days. If the culture had not reverted to normal, treatment with one drug was continued and other drugs were added, such as kanamycin, novobiocin, and Gantrisin. Despite the intensive medical therapy, 5 patients were referred for operation. Case reports of these patients are presented. Case reports CASE 1. A 23-year-old Negro man presenled with fever, cough, and myalgia. Chest roentgenography in October, 1968, revealed a left upper lobe infiltrate with a 4 cm., fluid-filled cavity. Sputum culture was positive for Pseudomonas pseudomallei, and the melioidosis titer was 1: 1,280. The patient was treated with large doses of antibiotics including Chloromycetin, tetracycline, novobiocin, kanamycin, and Gantrisin for 1 year. Despite the massive antibiotic therapy he remained ill, culture of sputum remained positive for Pseudomonas pseudomallei, melioidosis titers ranged between 1: 1,280 and 1: 20,480 during the course of treatment, and the cavity in the left upper lobe persisted (Fig. 1). On Oct. 15, 1969, a left upper lobectomy was performed. There were no complications postoperatively. One month after the operation, sputum cultures became negative and the hemagglutination titer had fallen to 1: 640. CASE 2. A 22-year-old man was admitted in September, 1968, with fever, productive cough, hemoptysis, and weight loss. Chest roentgenography revealed a large left upper lobe infiltrate with a cavity and a smaller right upper lobe infiltrate. Sputum culture was positive for Pseu-
Volume 66 Number 5
Pulmonary melioidosis
839
November, 1973
Fig. 1. Chest roentgenogram showing cavity in the left upper lobe. The patient had been treated for 12 months with antibiotics.
Fig. 2. Chest roentgenogram showing persistent right upper lobe infiltrate. The patient had been treated for tuberculosis without any change in the infiltrate.
domonas pseudomallei, and the melioidosis titer was 1: 10,240. He was treated with large doses of Chloromycetin and tetracycline for 13 months. During the course of the therapy he developed parasthesias of both feet thought to be due to the Chloromycetin therapy. The patient continued to be ill, with persistence of the left upper lobe cavity, positive cultures, and high melioidosis titers. On Nov . 26, 1969, an apicoposterior segment of the upper lobe was removed . Postoperatively, there was a persistent air leak for 2 weeks. Two months following the operation, the sputum cultures were negative and the melioidosis titer was 1: 80. Three years postoperatively he has no pulmonary problems but continues to have severe parasthesias of his feet, probably as a consequence of prolonged antibiotic therapy. CAS E 3. A 31-year-old Caucasian man was admitted in October, 1968, with fever and pro ductive cough . Chest roentgenograms revealed a left upper lobe cavity. Sputum culture was positive for Pseudomonas pseudomallei, and the melioidosis titer was 1:5,120. He was treated with large doses of Chlorornycetin and tetracycline. During the course of therapy the cultures remained positive and melioidosis titers were as high as 1:40,960. On Nov . 18, 1969, after 13 months of antibiotic therapy, an apicoposterior segment of the left upper lobe was removed. Postoperatively, he developed a bronchopleural cutaneous fistula and empyema requiring an additional 4 months of
hospitalization. The most recent melioidosis titer, measured in April, 1970, was 1:2,560. Sputum became negative for Pseudomonas pseudomallei in May of 1970. The patient was doing very well when last seen in June, 1970. CASE 4. A 38-year-old Negro man was admitted on May 5, 1965, with fever, chest pain , and cough. Chest roentgenograms revealed an infiltrate in the right upper lobe. Because of recent exposure to active pulmonary tuberculosis plus a positive skin test, he was placed on isoniazid, para-arninosalicyclic acid, and pyridoxine. After 4 months of antituberculosis therapy the infiltrate did not change (Fig. 2). Bronchograms revealed obstruction of the anterior segmental bronchus, and the patient was referred for operation. On Oct. 14, 1965, a right upper lobectomy was performed. Specimen cultures grew Pseudomonas pseudomallei. Postoperative melioidosis titers were negative. The patient had no complications after the operation and was doing well 1 year later but subsequently has been lost to follow-up. CASE 5. A 45-year-old Negro man was admitted in June, 1965, with cough , malai se, evening sweats , anorexia, and chest pain . Che st roentgenograms revealed an infiltrate in the left upper lobe. The patient was treated with penicillin, but the infiltrate in the anterior segment of the left upper lobe persisted. Two months following admission, because of suspicion of malignancy, a left thoracotomy was performed and an anterior segment of the left upper lobe was resected . Postoperatively, the patient developed a bronchopleural fistula and an empyema resulting in a
The Journal of
840
Zaitchuk et at.
Thoracic and Cardiovascular Surgery
prolonged hospitalization. Purulent drainage from the chest grew Pseudomonas pseudomallei, and he was treated with large doses of Chloromycetin and kanamycin. He was discharged 4 months after the operation and was doing well 5 years later. The Melioidosis titer in 1970 was 1: 10.
Comments and summary Of the 30 patients with pulmonary melioidosis, 5 have had pulmonary resection. Three of the 5 patients were operated upon because of resistance to medical therapy, whereas the other 2 were operated upon for purposes of diagnosis. The 2 patients who had lobectomies had no postoperative complications. By comparison, 2 of the 3 patients who had segmental resections had significant postoperative complications. Postoperatively, in all cases, the cultures became negative for Pseudomonas pseudomallei and the hemagglutination and complement fixation titers dropped markedly.
In patients who had segmental resections, it took longer for the titers to drop and for the cultures to become negative. It appears that there may be a few patients with melioidosis who, after prolonged medical therapy, may need operative intervention. In such cases the procedure of choice should be lobectomy so as to minimize postoperative complications. REFERENCES Whitmore, A, and Krishnaswami, C.! An Account of the Discovery of a Hitherto Undescribed Infective Disease Occurring Among the Population of Rangoon, Indian Med. Gaz. 47: 262, 1912. 2 Stanton, A T., and Fletcher, W.: Melioidosis: Studies From the Institute of Medical Research, Federated Malay States, No. 21, London, 1932, John Bale, Sons and Curnow, Ltd. 3 Flemma, R. J., DiVincenti, F. C., Dotin, L. N., and Pruitt, B. A: Pulmonary Melioidosis: A Diagnostic Dilemma and Increasing Threat, Ann. Thorac. Surg. 7: 491, 1969.
Introductory abstracts Beginning in January, 1974, it is requested that each article begin with a brief abstract. Authors submitting articles on or after September 1, 1973, should supply an abstract of 150 words or less.