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Tuberculous pyopneumothorax
TUBERCULOUS
PYOPNEUMOTHORAX
UNUSUAL CASE REPORT LOUIS F. KNOEPP, M.D. ThoracicSurgeon,
Jefferson County Tubercdosis BEAUMONT,
T
HE serious nature of mixed tubercuIous empyema complicating puImonarv tubercuIosis is we11 known. Its presence is usuaIIy secondary to an induced or spontaneous pneumothorax and in this regard is often spoken of as tuberculous pyopneumothorax. In 1931, the Committee on the Treatment of TubercuIous Empyema reported that without adequate surgica1 coIIapse 61 or 75 per cent are dead, or the figures may be worse, depending on whether cIosed or open drainage is used. With adequate coIIapse in experienced hands 55 per cent wiI1 be cured and onIy 43 per cent wiI1 die. Operation must be done with consideration for the underIying puImonary pathoIogy, and any operation attempted to contro1 the empyema alone will have disastrous consehas effectiveIy quences. Thus, ArchibaId cIassified the mode of attack on tubercuIous empyemata into two principa1 groups; those with gross or cavernous puImonary findings, and those without. The former group constitute the majority by far, and require surgica1 coIIapse for the puImonary as we11 as the pIeura1 disease. Such coIIapse must be radica1 and compIete, and is better borne in muItipIe stages. A few tubercuIous empyemata without mixed infection will tolerate oIeothorax with gratifying success, but it cannot be used in the mixed type which have origin in broncho-pIeura1 IistuIa. The foIIowing case is reported, not as an unusua1 entity, but as an exampIe where both surgery and oIeothorax were utiIized with success. A negro maIe, A. K., aged rg, was first admitted to the Jefferson County Tuberculosis Hospital Sept. rg, 1934 with a diagnosis of far
HospitaI
TEXAS
advanced puImonary tuberculosis. His disease was not suspected or diagnosed until July, 1934, when he was being examined for life insurance. There were no symptoms except a sIight cough with occasional thick yellowishgrey sputum. There was no history of fever, chest pain, or Ioss of weight. Examination on admission was essentiaIIy negative except for the pulmonary findings which were Iimited to the Ieft lung. Roentgenograms showed a 5 cm. cavity in the left infracIavicuIar area and a 2 cm. cavity in the Iower pole of the Ieft upper lobe. In addition, there was moderate exudative inff ammation throughout the whoIe Ieft Iung. The right Iung was norma except for some enIargement of hiIar gIands. (Fig. I.) Laboratory studies revealed nothing of importance except a positive sputum, Gaffky IV, ranging in amount from 3 to 4 ounces daily. Serology was 4+ by various methods (Kahn, Lewis, KIine, Wassermann). He was placed on conservative regimen incIuding Mapharsen and bismuth saIicyIate in bIock doses for Iues, and his course was uneventfu1 unti1 March 7, 1935, when he suddenIy deveIoped a sharp pain in his Ieft lung and marked dyspnea. Temperature rose from normaI to 103’~. At this time I was caIIed as a cons&ant, and there was evidence of a marked tension pneumothorax on the Ieft. The heart was pushed far into the right thorax, the Ieft intercosta1 spaces were buIging and there was a conspicious distention of the left epigastrium. A needIe was thrust into the Ieft pIeura1 space and gradual decompression effected. Roentgenograms showed a fIuid level to the seventh rib posteriorly, and on culture a mixed growth of organisms was obtained including tubercIe baciIIi (smear.) It was apparent that drainage was imminent to aIIay absorption of the mixed infection, with proposa1 for surgical collapse to the underIying puImonary and pIeura1 cavities as soon as his condition justified it. Therefore the foIIowing
145
146 American JournalofsurgeryKnoepp-Tubercdous day, a closed thoracostomy was performed under IocaI anesthesia pIacing a tube in the interspace postero-IateraIIy. Large tenth
FIG. I. Roentgenogram of chest, Sept. 20, 1934, showing Iarge cavity Ieft upper Iobe, and smaller cavity beneath.
amounts of fou1, yeIIowish-green pus varying from 600 C.C. to 700 C.C. daiIy were obtained at the onset; by the eIeventh day it had reduced to I 50 C.C. A Ieft permanent phrenicectomy was performed March 28th, but fever continued high (102“--Io~“F.). First stage thoracopIasty was performed under nitrous oxid-oxygen using a WiImsSauerbruch technique and removing short segments of the first five ribs posteriorIy. Temperature receded sIightIy but stiI1 varied IOO’102’~. with p&e rate of 130. By June I Ith, the second stage was compIeted and we were gratified to find a gradua1 improvement in the patient’s condition in the succeeding days in spite of a surgica1 coIIapse which we wouId consider inadequate today. By May 23rd, temperature and puIse were within norma Iimits and there was no cough or sputum. There was however, a pIeuro-cutaneous fistuIa from the thoracostomy wound which Ied to a pleura1 sinus of a capacity of 150 C.C. The drainage from this sinus, however, remained constant at 20 C.C. and was composed of a mixed flora. Figure 2 shows the Roentgen findings.
Pyopneumothorax
JANUARY. 1938
After three months of asymptomatic response, it was thought that a Schede operation wouId eventually be necessary to cIose the
2. Roentgenogram of chest foIlowing thoracopIasty, ApriI 21, 1936. Safety pin in Lower Ieft represents Iocation of cork pIug withhoIding oleothorax.
FIG.
pleura1 sinus. After some deIiberation, oIeothorax was given a tria1, consisting of 150 C.C. of steriIe cottonseed oi1 with 5 per cent gomeno1, pIacing a small cork pIug tightIy into the outIet of the sinus, so as to retain the oiI. This, it was thought, might give the interna portion of the sinus a chance to cIose. After three days, the reaccumulated pus was drawn off with a needIe (40 CC.) and the same amount of steri1 oi1 reintroduced. There was no leakage around the cork, and on the eIeventh day foIIowing original introduction, the cork was removed. The sinus had cIosed as was hoped for, and the patient suffered no return of untoward symptoms regarding either the puImonary or pIeura1 entities. This patient was cIassified as arrested tubercuIosis Dec. 15, 1935, and has been doing Iight Iabor every since. He was re-examined Nov. 30, 1936 and has had no recurrence of tubercuIosis. It is interesting to note that his seroIogy became entireIy negative after approximateIy one year of anti-Iuetic therapy. There mistakes
is much to be Iearned by one’s and we came upon the idea of
NEWSERIESVOL. XXXIX,
No. I KnoeppTubercuIous
accompIishing this treatment through one of the common errors in the treatment of empyema; i.e., the use of too short a
FIG. 3. Showing mixed empyema witht horacostomy sinus.
drainage tube wiII frequentIy cause obstruction to the outIet in the chest waI1. The cork was utiIized with this common error of technique in mind, that if the interna portion of the sinus were Ieft to cIose, it wouId eventuaIIy serve to retain the oil in the pIeura1 cavity. Any re-formed pus couId be easiIy controIIed by aspiration with a needIe and syringe unti1 it was cIeared up. This case aIso exempIifies a mistake that, if obviated, may have effected a cure without oleothorax. That is, the WiIms-Sauerbruch operation is not suffIcientIy radica1 to cIose a tubercuIous emovema. Iet aIone any_ form of cavernous puImonary tubercuIosis. It is too uncertain, and we now remove Iarger portions of ribs as advocated by AIexander and others. I”
,
”
CONCLUSION
I. A case of tubercuIous empyema with cavernous puImonary tuberculosis is pre-
Pyopneumothorax
A me&an Journaf of Surgery
147
sented exemphfying tension pneumothorax and mixed infection. 2. This case was arrested by use of
FIG. 4.
Illustrating method of pIacing retain sterile 0iI in pleural cavity.
cork
to
severa modes of surgica1 attack: Thoracostomy, phrenicectomy, and thoracopIasty. 3. OIeothorax was attempted to correct a remaining empyema sinus, in preference to the more radica1 Schede operation. This oIeothorax was effected by inserting a cork into the externa1 opening of the fistuIa, so as the interna portion might cIose first. This procedure was successfu1. 4. Cognizance is given to the fact that under present-day regimen of surgica1 coIlapse, a more radica1 type of thoracopIasty wiI1 give more satisfactory resuIts in tubercuIous empyema. REFERENCES ALEXANDER, JOHN. Persona1 communication. ARCHIBALD, E. “Surgical Treatment of TubercuIous Empyema.” Cunad. M. A. J., 23: 160, 1930. Committee Report of Treatment of TubercuIous Empyema. Am. Rev. Tuberc., 24: 757, 1931. ELOESSER. L. “An Ooeration for Tuberculous Emovema.” Diseases of Chest. I : 8; p. 8. (October) 163;. GRAHAM, E. A. “SurgicaI Diseases of Chest,” 1933. Lea and Febiger. HEDBLOM, CARL A. SurgicaI Treatment of TubercuIous Empyema.” J. Tbor. Surg., 2: 115, 1932.
PYOPNEUMOTHORAX
UNUSUAL CASE REPORT LOUIS F. KNOEPP, M.D. ThoracicSurgeon,
Jefferson County Tubercdosis BEAUMONT,
T
HE serious nature of mixed tubercuIous empyema complicating puImonarv tubercuIosis is we11 known. Its presence is usuaIIy secondary to an induced or spontaneous pneumothorax and in this regard is often spoken of as tuberculous pyopneumothorax. In 1931, the Committee on the Treatment of TubercuIous Empyema reported that without adequate surgica1 coIIapse 61 or 75 per cent are dead, or the figures may be worse, depending on whether cIosed or open drainage is used. With adequate coIIapse in experienced hands 55 per cent wiI1 be cured and onIy 43 per cent wiI1 die. Operation must be done with consideration for the underIying puImonary pathoIogy, and any operation attempted to contro1 the empyema alone will have disastrous consehas effectiveIy quences. Thus, ArchibaId cIassified the mode of attack on tubercuIous empyemata into two principa1 groups; those with gross or cavernous puImonary findings, and those without. The former group constitute the majority by far, and require surgica1 coIIapse for the puImonary as we11 as the pIeura1 disease. Such coIIapse must be radica1 and compIete, and is better borne in muItipIe stages. A few tubercuIous empyemata without mixed infection will tolerate oIeothorax with gratifying success, but it cannot be used in the mixed type which have origin in broncho-pIeura1 IistuIa. The foIIowing case is reported, not as an unusua1 entity, but as an exampIe where both surgery and oIeothorax were utiIized with success. A negro maIe, A. K., aged rg, was first admitted to the Jefferson County Tuberculosis Hospital Sept. rg, 1934 with a diagnosis of far
HospitaI
TEXAS
advanced puImonary tuberculosis. His disease was not suspected or diagnosed until July, 1934, when he was being examined for life insurance. There were no symptoms except a sIight cough with occasional thick yellowishgrey sputum. There was no history of fever, chest pain, or Ioss of weight. Examination on admission was essentiaIIy negative except for the pulmonary findings which were Iimited to the Ieft lung. Roentgenograms showed a 5 cm. cavity in the left infracIavicuIar area and a 2 cm. cavity in the Iower pole of the Ieft upper lobe. In addition, there was moderate exudative inff ammation throughout the whoIe Ieft Iung. The right Iung was norma except for some enIargement of hiIar gIands. (Fig. I.) Laboratory studies revealed nothing of importance except a positive sputum, Gaffky IV, ranging in amount from 3 to 4 ounces daily. Serology was 4+ by various methods (Kahn, Lewis, KIine, Wassermann). He was placed on conservative regimen incIuding Mapharsen and bismuth saIicyIate in bIock doses for Iues, and his course was uneventfu1 unti1 March 7, 1935, when he suddenIy deveIoped a sharp pain in his Ieft lung and marked dyspnea. Temperature rose from normaI to 103’~. At this time I was caIIed as a cons&ant, and there was evidence of a marked tension pneumothorax on the Ieft. The heart was pushed far into the right thorax, the Ieft intercosta1 spaces were buIging and there was a conspicious distention of the left epigastrium. A needIe was thrust into the Ieft pIeura1 space and gradual decompression effected. Roentgenograms showed a fIuid level to the seventh rib posteriorly, and on culture a mixed growth of organisms was obtained including tubercIe baciIIi (smear.) It was apparent that drainage was imminent to aIIay absorption of the mixed infection, with proposa1 for surgical collapse to the underIying puImonary and pIeura1 cavities as soon as his condition justified it. Therefore the foIIowing
145
146 American JournalofsurgeryKnoepp-Tubercdous day, a closed thoracostomy was performed under IocaI anesthesia pIacing a tube in the interspace postero-IateraIIy. Large tenth
FIG. I. Roentgenogram of chest, Sept. 20, 1934, showing Iarge cavity Ieft upper Iobe, and smaller cavity beneath.
amounts of fou1, yeIIowish-green pus varying from 600 C.C. to 700 C.C. daiIy were obtained at the onset; by the eIeventh day it had reduced to I 50 C.C. A Ieft permanent phrenicectomy was performed March 28th, but fever continued high (102“--Io~“F.). First stage thoracopIasty was performed under nitrous oxid-oxygen using a WiImsSauerbruch technique and removing short segments of the first five ribs posteriorIy. Temperature receded sIightIy but stiI1 varied IOO’102’~. with p&e rate of 130. By June I Ith, the second stage was compIeted and we were gratified to find a gradua1 improvement in the patient’s condition in the succeeding days in spite of a surgica1 coIIapse which we wouId consider inadequate today. By May 23rd, temperature and puIse were within norma Iimits and there was no cough or sputum. There was however, a pIeuro-cutaneous fistuIa from the thoracostomy wound which Ied to a pleura1 sinus of a capacity of 150 C.C. The drainage from this sinus, however, remained constant at 20 C.C. and was composed of a mixed flora. Figure 2 shows the Roentgen findings.
Pyopneumothorax
JANUARY. 1938
After three months of asymptomatic response, it was thought that a Schede operation wouId eventually be necessary to cIose the
2. Roentgenogram of chest foIlowing thoracopIasty, ApriI 21, 1936. Safety pin in Lower Ieft represents Iocation of cork pIug withhoIding oleothorax.
FIG.
pleura1 sinus. After some deIiberation, oIeothorax was given a tria1, consisting of 150 C.C. of steriIe cottonseed oi1 with 5 per cent gomeno1, pIacing a small cork pIug tightIy into the outIet of the sinus, so as to retain the oiI. This, it was thought, might give the interna portion of the sinus a chance to cIose. After three days, the reaccumulated pus was drawn off with a needIe (40 CC.) and the same amount of steri1 oi1 reintroduced. There was no leakage around the cork, and on the eIeventh day foIIowing original introduction, the cork was removed. The sinus had cIosed as was hoped for, and the patient suffered no return of untoward symptoms regarding either the puImonary or pIeura1 entities. This patient was cIassified as arrested tubercuIosis Dec. 15, 1935, and has been doing Iight Iabor every since. He was re-examined Nov. 30, 1936 and has had no recurrence of tubercuIosis. It is interesting to note that his seroIogy became entireIy negative after approximateIy one year of anti-Iuetic therapy. There mistakes
is much to be Iearned by one’s and we came upon the idea of
NEWSERIESVOL. XXXIX,
No. I KnoeppTubercuIous
accompIishing this treatment through one of the common errors in the treatment of empyema; i.e., the use of too short a
FIG. 3. Showing mixed empyema witht horacostomy sinus.
drainage tube wiII frequentIy cause obstruction to the outIet in the chest waI1. The cork was utiIized with this common error of technique in mind, that if the interna portion of the sinus were Ieft to cIose, it wouId eventuaIIy serve to retain the oil in the pIeura1 cavity. Any re-formed pus couId be easiIy controIIed by aspiration with a needIe and syringe unti1 it was cIeared up. This case aIso exempIifies a mistake that, if obviated, may have effected a cure without oleothorax. That is, the WiIms-Sauerbruch operation is not suffIcientIy radica1 to cIose a tubercuIous emovema. Iet aIone any_ form of cavernous puImonary tubercuIosis. It is too uncertain, and we now remove Iarger portions of ribs as advocated by AIexander and others. I”
,
”
CONCLUSION
I. A case of tubercuIous empyema with cavernous puImonary tuberculosis is pre-
Pyopneumothorax
A me&an Journaf of Surgery
147
sented exemphfying tension pneumothorax and mixed infection. 2. This case was arrested by use of
FIG. 4.
Illustrating method of pIacing retain sterile 0iI in pleural cavity.
cork
to
severa modes of surgica1 attack: Thoracostomy, phrenicectomy, and thoracopIasty. 3. OIeothorax was attempted to correct a remaining empyema sinus, in preference to the more radica1 Schede operation. This oIeothorax was effected by inserting a cork into the externa1 opening of the fistuIa, so as the interna portion might cIose first. This procedure was successfu1. 4. Cognizance is given to the fact that under present-day regimen of surgica1 coIlapse, a more radica1 type of thoracopIasty wiI1 give more satisfactory resuIts in tubercuIous empyema. REFERENCES ALEXANDER, JOHN. Persona1 communication. ARCHIBALD, E. “Surgical Treatment of TubercuIous Empyema.” Cunad. M. A. J., 23: 160, 1930. Committee Report of Treatment of TubercuIous Empyema. Am. Rev. Tuberc., 24: 757, 1931. ELOESSER. L. “An Ooeration for Tuberculous Emovema.” Diseases of Chest. I : 8; p. 8. (October) 163;. GRAHAM, E. A. “SurgicaI Diseases of Chest,” 1933. Lea and Febiger. HEDBLOM, CARL A. SurgicaI Treatment of TubercuIous Empyema.” J. Tbor. Surg., 2: 115, 1932.