Transcript Tuberculous and fungal infection of the pleura

Tuberculous and Fungal Infection
of the Pleura
GENERAL THORACIC SURGERY
CHAPTER 60
Tuberculous and fungal infection of the pleura
• Pleural tuberculosis– Most often a side
phenomenon of primary infection.
• Fungle empyema– Occurred in residule
pleural space.
Tuberculous and fungal infection of the pleura
• General guide line:
First: Clean gross contamination
(1). Tube thoracostomy.
(2). Open window thoracostomy.
Second: Obliteration the space.
Tuberculous and fungal infection of the pleura
• The common feature of chronic
mycobacterial and fungal infection–
Underlying lung cannot be expanded to fill
the pleural space because the partial
resection or diffuse fibrosis.
Tuberculous and fungal infection of the pleura
• Tuberculous empyema.
• Aspergilus empyema.
• Miscellaneous condition.
Pleural tuberculosis
• Subdivided into three groups:
1. Primary TB, pleural effusion– 8%,
serofibrinous, called tuberculous pleuritis.
2. Reaction TB, pleural infection turn to
true empyema, opaque purulent effusion,
pure or mixed.
3. Late complication of collapse therapy for
TB.
Tuberculous pleuritis
• Pleural space– The second most common
site of extrapulmonary TB（The first is
lymphatic system.）.
• Originate– Subpleural pulmonary lesion.
Tuberculous pleuritis
• Symptom/Sign:
Lower grade fever, Weakness, Weight
loss, Night sweat, Nonproductive cough,
Pleuritic chest pain, Dyspnea.
Tuberculous pleuritis
• Dignosis—
• Chest x-ray—pleural effusion, 1/3 with concomitant
parenchymal disease.
• Tuberculin test– Early stage positive: 75%.
• Pleural fluid– Exudates, protein excess 40 g/L, WBC 1-6
g/L with predominant lymphocyte, absence desquamated
mesothelial cell.
• Culture– 3-6 weeks.
• IgG to mycobacterial antigen: 60, with cut-off value 150
u/ml.
• Pleural biopsy: Most reliable. VATS. Histology–
Caseating epithelioid granulomas is indicative of TB.
Tuberculous pleuritis
• Treatment—
• Antituberculous treatment, repeat thoracentesis,
close observation.
• Excessive production of exudative material– May
start diffuse thickening the visceral pleura leading
entrapment of the lung, regardless adequate
antituberculous treatment.
• Decortication should be considered.
Tuberculous pleuritis
• PA view– are seen with pleural disease but
not lateral view, the disease may
progressive clear.
• PA with lateral view were both seen pleural
disease– The decortication should be
considered.
Tuberculous pleuritis
• Chest CT– Determination of appropriate timing
of surgical intervention—Langston criteria—for
DECORTICATION.
1. Thoracentesis fail to yield fluid or fail to alter
radiographic apperance.
2. Pleural involvement 1/3 or 1/4 of hemithorax.
3. As early as is consistent with good judgement.
（After 2-4 months of drug therapy）.
● Generous Thoracotomy.
● VATS.
Tuberculous empyema
• Patient didn’t receive major antituberculous
drug therapy, chronic empyema by
bronchopleural fistula, leading so-called
mixed empyema.
Tuberculous empyema
• Diagnosis—Lower grade fever, dyspnea,
chest pain, abundant sputum.
• Chest x ray—Increase extent of pleural
involvement, air-fluid level.
• Thoracentesis.
Tuberculous empyema
• Treatment—Adequate drainage by tube
thoracostomy, table 60-1.
• First– Determine the underlying lung is reexpandable.
• Second– Determine whether the
parenchymal resection is required.
Table 60-1.
Tuberculous empyema
• Indication of parenchymal resection:
1. Multiple drug resistant.
2. Threat hemoptysis.
3. Infection complication（Bronchiectasis or
Aspergilloma）.
• Criteria for drug resistant:
1. Clinical or radiologic evidence of progressive
disease.
2. Persistent mycobacteria on sputum
examination after 3 months of a four-drug
treatment.
• The remaining lung is extensively destroy– Extrapleural
pneumonectomy is considered.
Late pleural and extrapleural complications of
Collapse therapy
• Collapse therapy—Before early 1960. Only active
treatment of TB. Collapse cavitated lung tissue, to obtain
progressively scarring of the tuberculous area.
• Fist stage– Creation artificial intrapleural pneumothorax:
Injection air into pleural cavity q2 weeks, continue 2-3
years, the space progressively filled with serous fluid and
retracted to a small and permanent residule space.
• Second stage– Extramusculoperiosteal plombage called
birdcage operation– The periosteum and intercostals
muscle were stripped off the ribs, pushed inside the chest
cavity.
• Maintained with methyl mathacrylate ball.
Late pleural and extrapleural complications of
collapse therapy
• Side effect of collapse therapy—Many infectious
complication, migrations of material.
• All the procedure vanished with antibtuberculous
chemotherapy.
• Treatment– Decortication, re-expand the
underlying lung, triple drainage connect to strong
suction（100-150 mmhg）, antituberculous
therapy.
Aspergillous empyema
• Aspergillous fumigatus.
• Infrequent.
• Fungal growth required persistent pleural
space, temperature 370c, moisture 100%,
abundant protein.
• Acute and chronic.
Acute aspergillous empyema
• Immediate postoperative course.
• Most common is partial lung resection–
Lobectomy or Segmentectomy.
Acute aspergillous empyema
• Symptom /Sign—
Prolonged air leak.
Persistent drainage of fluid.
Fever.
Weight loss.
Acute aspergillous empyema
• Diagosis–
• Chest x ray: Residule space, rapid increase
pleural air-fluid level, mediastinum shift.
• CT.
• WBC increase, CRP.
• Analysis of pleural fluid.
• Serodiagnosis.
Acute aspergillous empyema
• Treatment—
• Sterilization and complete obliteration of
pleural space.
• Antifungal therapy（itraconazole,
amphotericin B, ）.
• Thoracoplasty.
Chronic aspergillous empyema
• Residual pleural space with communicating
with bronchial tree.
• Most frequent in partial lung resection for
TB or lung cancer.
• Medical treatment with Itraconazole fail:
Fibrotic scar tissue– Drug penetrating low,
infection persistent as the residual space
exist.
Chronic aspergillous empyema
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Symptom /Sign—
Hemoptysis.
Bronchorrhea.
Dyspnea.
Chest pain.
Chronic aspergillous empyema
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Diagosis—
Chest x-ray: Hydropneumothorax.
Direct identification of aspergillus species.
Serodiagnosis– Most reliable.
Chronic aspergillous empyema
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Treatment—
Decortication– Easy fail.
Muscle transfer.
Curettage of all fungal material.
Thoracoplasty– Retailoring chest wall.
Mortality: 7%-- Infection, perioperative
bleeding because of hypervascularization.
Miscellaneous conditions
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Blastomycosis.
Histoplasmosis.
Cryptococcosis.
Sporotrichosis.
Treatment– Adequate antifungal therapy.
Coccidioidomycosis
• Diffuse lung destruction.
• 40%-- Acute infection as influenza-like.
• 5%-- Irreversible pulmonary lesion as cavitation
or bronchiectasis,
• Treatment— Amphotericin B.
• Surgical intervention– Bronchopleural fistula,
chronic empyema, hemoptysis– Completion
pmeumonectomy and mass closure of hilar vessel.
Candida empyema
• Esophageal fistula.
• Pneumonectomy: 0.5% with esophageal fistula.
• Intraoperative injury, devascularization with
subsequent necrosis.
• Diagnosis—Contrast study.
• Treatment—Chest tube, direct repair the
esophagus with reinforced with myoplasty and
omentoplasty, thoracoplasty or muscle flap
transfer.