A case of empyema necessitans in an adolescent with mycobacterium tuberculosis

Abstract

Introduction and importance

An empyema is a buildup of pus in the pleural space and is most commonly associated with pneumonia. Streptococcus pneumonia is the most common cause of pneumonia, although staphylococcus aureus is common in developing countries. empyema necsitans is An extravasation of purulent material outside the pleural space involving the chest wall.

Case presentation

Here we present a 15-year-old girl presented with swelling on the right thorax wall. I was told that the swelling had been there for 1 year with moderate discomfort upon lifting objects, with no other complaints. Her medical history was unremarkable until the mass appeared. There was no history of fever, cough, or weight loss, and there was no family history of tuberculosis.

Clinical discussion

Empyema necessitatis can be quite harmful. It has the potential to cause bone and soft tissue erosion. This may be asymptomatic at first and proceed at a slow and steady pace. Tuberculous EN can be treated with both surgical and medical treatments. This case applies to both surgical intervention and medical treatment with antituberculosis.

Conclusion

Empyema necessitans is uncommon consequence of pleural space infection. pulmonary mycobacterium tuberculosis, Actinomyces, and nontuberculous organisms such Staphylococcus aureus are the most prevalent causes.

Highlights

• •When pus in the pleural cavity finds its way through the parietal pleura into the subcutaneous tissue. It is called an empyema necesitans.
• •In tuberculosis-endemic areas, a painless chest wall mass can be a key sign of tuberculosis empyema necesitans.
• •Early identification and management of empyema necesitans can reduce morbidity and mortality.

1. Introduction

An empyema is a buildup of pus in the pleural space, most commonly associated with pneumonia. Although staphylococcus aureus is common in developing countries, pneumonia is the common cause of pneumonia. [1]. Pleural TB is the most frequent extrapulmonary tuberculosis presentation and the leading cause of pleural effusion in the world. [2].empyema necsitans is An extravasation of purulent material outside the pleural space involving the chest wall [3].An exudative fluid in the pleural cavity collects and forms a fistula, resulting in a subcutaneous accumulation where the patient might be present with a chest wall lump and that lump could go unnoticed since it does not cause significant symptoms Antibiotics, tube drainage, and decortication to obliterate the cavity and restore pulmonary function are all possible treatments for this illness. [4]. He we report a pediatric case of tubeculos empyema necesitans presenting with chest wall mass treated with open drainage, tube thoracotomy, and tuberculosis treatment.

2. Case report

A 15- years -old girl presented with swelling on the right thorax wall. and told that swelling was there for 1 year with moderate discomfort upon lifting object no other complaint.her medical history is unremarkable until the mass appeared . No history of fever cough and weight loss,and no family history of TB.lab tests showed a WBC 8.32x¹⁰⁹/l, CRP of 2.22mg/dl,serologic tests of HBV,HCV and HIV were all negative. superficial ultrasound revealed 7cm collection of dense content in the in the right pleura extending under the skin.thorax CT scan showed in the right chest wall 8 × 5cm sized peripheral enhancing cystic lesion that enveloped the right 5th and 6th rib and radiologically diagnosed as empyema necessitates (Fig. 1).

Fig. 1.

Preoperative CT scan 8 × 5cm sized peripheral enhancing cystic lesion that enveloped the right 5th and 6th rib.

Under sedation we made 4cm incision over the mass and deepened the incision through fascia and thorax muscles to mass then punctured the mass and took fluid sample from the mass content and sent to TB center for gene expert analysis,culture and sensitivity. then emptied whole content which was yellow purulent material and pus was also coming from thorax cavity through intercostals space which confirms connection between mass in thoracic wall and pleural cavity and excludes subcutaneous empyema from empyema necesitans, then washed with normal saline and trimmed the cystic wall then placed drain in the space and pleurocan in thorax then closed wound.(Fig. 2). sample result was positive of mycobacterium tuberculosis sensitive to rifampicin and started TB treatment.chest x-ray of day 1 post op was normal,thorax CT scan of post op day 5 showed minimal pleural effusion in the right hemithorax (Fig. 3). post op day 6 removed drain and pleurocan day 7 and discharged with medications. At 3 months' follow-up, the patient has no symptoms and the incion site is fully healed and under TB treatment. This study was reported in accordance with the SCARE 2020 guidelines[5].

Fig. 2.

Intra-operative sample collection, drainage and capsule trimming.

Fig. 3.

Thorax CT scan of post op day 5.

3. Discussion

Tuberculosis (TB) is a highly contagious infection that causes major morbidity and mortality. It is the tenth greatest cause of death among HIV-positive and immune-compromised patients worldwide, accounting for more than 90% of deaths in developing countries [6].for current case study is HIV negative and has no immune compromising diseases and immune suppressing medication as well.Empyema necessitatis can be quite harmful. It has the potential to cause bone and soft tissue erosion. This may be asymptomatic at first and proceed at a slow and steady pace. Tuberculous EN can be treated with both surgical and medical treatments. This case applies to both surgical intervention and medical treatment with antituberculosis. Because of its paucibacillary form and frequently hidden location, extrapulmonary tuberculosis (EPTB) is difficult to diagnose. The diagnosis is frequently overlooked or discovered too late in the disease's progression, when consequences have already developed and Direct isolation of tuberculous bacteria requires collecting the appropriate sample, mostly with invasive procedures [6].our case underwent surgical intervention to collect sample for isolation of tuberculosis bacteria. Potts KJ et al. described a 33-year-old female diabetic and hypertensive patient who developed pulmonary TB with empyema necesisats and was treated with only TB medication [7].The current case has no chronic disease and is being treated with surgical intervention and a combination of medical treatments.

Adolescence is marked by a significant increase in the incidence of TB, which has been known since the early twentieth century. The majority of the world's adolescents reside in low and middle-income nations, where TB is still prevalent and they make up a quarter of the population. Despite this, teenagers have yet to be recognized as a unique demographic in TB policy or treatment programs, and new data reveals that current care models may not satisfy their requirements [8]. Finally, pediatric EN is quite rare. This may result in underdiagnosis in the early stages of pediatric cases [4]. If not detected early and treated appropriately, the morbidity and death can be substantial. This case serves as a reminder that extrapulmonary tuberculosis can manifest without the classic symptoms of pulmonary tuberculosis, such as cough, night sweats, and weight loss. The presence of a chest wall mass in a patient from a TB pandemic area should raise clinical suspicion for empyema necessitatis.

4. Conclusion

Empyema necessitans is uncommon consequence of pleural space infection. pulmonary mycobacterium tuberculosis, Actinomyces, and nontuberculous organisms such Staphylococcus aureus are the most prevalent causes. Gram-negative bacterial infections, such as those caused by Proteus spp., should also be evaluated as a cause of pleural effusion in empyema necessitans. The diagnosis of this case was challenging since it was difficult to differentiate between tuberculous and nontuberculous effusion before effusion drainage culture result.

Provence and peer review

Not commissioned, externally peer reviewed.

Sources of funding

No funding for this research.

Ethics approval

No need ethical approval for case report study in our Hospital.

Consent

A written informed consent was obtained from her father for publication in this case study.

A copy of written consent is available for review by the editor-in chief of this journal on request.

Author contributories

Abdishakur Mohamed Abdi wrote the manuscript and corrected the manuscript for its scientific basis.

Abdullah Yusuf Ali collected the data for the study.

Ervin Mambet director of the Department of Surgery and the consultant surgeon who provided the case.

All authors have read and approved the final manuscript.

Guarantor

DR.Abdishakur Mohamed Abdi corrected the manuscript for its scientific basis.

Declaration of competing interest

The authors have no conflicts of interests.