Successful treatment of late onset empyema after extrapleural pneumonectomy: A case report

Our plain-English summary of Successful treatment of late onset empyema after extrapleural pneumonectomy: A case report, by S. Nishikawa, S. Tamari, K. Okita, et al (Respiratory Medicine Case Reports, 2019).

The study

• Authors: S. Nishikawa, S. Tamari, K. Okita, K. Chihara
• Journal: Respiratory Medicine Case Reports
• Published: 2019;26:174-175
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Treatment of post-extrapleural pneumonectomy empyema (PEPPE) is more difficult than that for post-pneumonectomy empyema for two reasons: first, a large infectious dead space remains after extrapleural pneumonectomy (EPP); and second, defects of the pericardium and diaphragm are reconstructed with artificial materials, which ideally should be removed for treatment of infection. Here, we report the case of a 56-year-old male with PEPPE that occurred long after EPP for mesothelioma. The patient was treated successfully by minimally invasive procedures of irrigation, instillation of urokinase and antibiotics, and surgical debridement without peeling off artificial materials.

In plain English

This case report from Shizuoka, Japan described one 56-year-old man. He had worked at a construction company and had been exposed to asbestos for 3–4 years in his twenties during building or demolition of foundations. The article did not name a fiber type. A right mesothelioma was diagnosed from a pleural specimen. He received chemotherapy with cisplatin plus pemetrexed, then extrapleural pneumonectomy (EPP), then radiation. Eighteen months after EPP he developed empyema, an infection filling the right chest cavity. Treatment included drainage, antibiotics, daily saline washing, instillation of urokinase, and keyhole surgery to scrape out pus without removing the artificial mesh. No bacteria were found on day 48; the chest tube was removed on day 58 and he was discharged the next day. About four months after treatment he died of acute respiratory distress syndrome caused by viral pneumonia. Autopsy found the right chest cavity aseptic, and found a left-sided mesothelioma that had not been apparent on chest CT. The authors believed the gradual, step-by-step procedures cured the empyema. They noted they could not examine the outcome over a longer period.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (a single patient)
• Who was studied: one 56-year-old man in Japan who worked at a construction company, treated at Shizuoka City Shizuoka Hospital
• Exposure: asbestos exposure for 3–4 years in his twenties during building or demolition of foundations; fiber type not stated
• Main results:
  • A right mesothelioma was diagnosed from a pleural specimen taken during a bullectomy
  • The patient received trimodal therapy: chemotherapy with cisplatin plus pemetrexed, followed by EPP and radiation
  • Empyema after EPP was found on admission, 18 months after EPP
  • Coagulase negative staphylococcus was cultured from the pleural fluid
  • A total of 60,000 units of urokinase were instilled into the thoracic cavity on days 17 and 22, and urokinase instillation was repeated on days 26 and 29
  • Thoracoscopic debridement on day 37 scraped off residual pus without peeling off the artificial mesh
  • No residual bacteria were found on day 48
  • The chest tube was removed on day 58 and the patient was discharged the next day
  • About four months after treatment the patient died of acute respiratory distress syndrome caused by viral pneumonia
  • Autopsy showed the right thoracic cavity was aseptic
  • Autopsy found no recurrence of right-sided mesothelioma, but found a left-sided mesothelioma not apparent on chest CT
• The authors' conclusion: The authors believed that a gradual decrease in the amount of bacteria through sequential procedures led to a cure of the late onset empyema. They stated that reinforcing the bronchial stump with intercostal muscle during EPP prevents bronchial fistula and enables non-invasive treatment in such cases.
• Limitations the authors state:
  • The authors could not examine the outcome of the conservative treatment over a longer period

Topics

Medical terms in this study, explained in our Lexicon: Empyema, Extrapleural Pneumonectomy (EPP), Pneumonectomy, Pericardium, Diaphragm, Mesothelioma.

Related studies

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• Late-onset damage from occupational asbestos exposure: case report — C. Zeroual, M. Benzakour, et al. (2025)
• Extrapleural pneumonectomy in the treatment of epithelioid malignant pleural mesothelioma: novel prognostic implications of combined N1 and N2 nodal involvement based on experience in 529 patients — D.J. Sugarbaker, W.G. Richards, et al. (2014)
• Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors — T.D. Yan, M. Boyer, et al. (2009)
• Extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma — D.J. Sugarbaker, S.J. Mentzer, et al. (1992)
• Intensity-modulated radiotherapy after extrapleural pneumonectomy in the combined-modality treatment of malignant pleural mesothelioma — A. Chi, Z. Liao, et al. (2011)

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