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Fungal Empyema

Fungal Empyema. History. 57 Male X smoker (20 pack) Admitted D6 with 1 week H/O: SOBE , Cough , minimal sputum ? Fever & night sweating Being treated as CAP as outpatient with amoxicillin for 5 days No response to RX. History. PMH : MDS April /02 AML Aug/02

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Fungal Empyema

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  1. Fungal Empyema

  2. History • 57 Male X smoker (20 pack) • Admitted D6 with 1 week H/O: SOBE , Cough , minimal sputum ? Fever & night sweating • Being treated as CAP as outpatient with amoxicillin for 5 days • No response to RX

  3. History • PMH : MDS April /02 AML Aug/02 • Treated with {Cytarabine & Doxorubicin} • Back to MDS oct/02AML Aug /03 • Treated with {Ara-c & Mixotracine} Sep/03

  4. History • No symptoms Of COPD • NO IHD risk factor • NO previous pneumonias • No VTE • No contact with TB • No travel , occupational exposure ,pets • Systemic review unremarkable

  5. History • Medications: gatifluxacine Hydrxyurea allopurinol • Palliative case {transfusion dependent} No plans for further Chemo Nor BMT

  6. Examination • Afebrile BP 120/70 HR 90 • RR 18 Sat 86% RA 93% 5L O2 • Chest :absent breath sounds Rt 2/3 Post dull percussion • CVS: S1+S2 +0 • Abdomen : Hepatosplenomegaly • LL: no edema or size difference

  7. Investigations • CBC : WBC 32000 {premature cells } Blasts 10000 Poly 550 Hb 77 Plt 22 PTT & INR N • BUN & Creat & Lytes N • Alk Phos 162 LDH 420 • Albumen 26 TP 86 • ABG PH 7.45 PCO2 38 PO2 51 HCO3 27 Sat 86% RA • CXR & CT

  8. Investigations • Pleural Fluid Bloody Protein 68 LDH 1958 Glucose 1.4 WBC 9500 24% Poly 40% Blast RBC 2000 GS +2 Poly & no organism C/S –ve Cytology AML with YEAST

  9. Investigations • Cytology finding similar (Fungal element) Both on Oct 8th {diagnostic} & Oct 10th {therapeutic} • -ve Fungal stain & C/S • Being treated with Ampho B since Oct 8th • 3rd tapping Oct 16th -ve C/S

  10. Fungal Empyema • Limited data • Increasing incidence of fungal infections • CDC report 19801990 Candida emerged as the 6th most common nosocomial pathogen 7.2% • More immunocompromised patients • Increased use of broad spectrum Abx • Increased Central Venous Catheters

  11. Fungal Empyema • Retrospective study • Jan 1990 Dec1997 University Hospital Taiwan • To analyze clinical spectrum , pathogenesis , treatment ,outcomes & prognostic factors Shian-Chin Ko et al Chest June 2000

  12. Fungal Empyema • Fungal empyema Diagnosed by: * Isolation of Fungus from pleural fluid (minimum 2 occasions) * Signs of infection fever ,leucocytosis * Isolation of the same fungus from other specimens {blood , sputum , surgical wound} or more than once from the pleural fluid Shian-Chin Ko et al Chest June 2000

  13. Fungal Empyema • Considered Hospital acquired if developed 48 hours after admission • Coexisting pneumonia if symptoms or CXR finding +ve • Most patients were treated with standard chest tubes or pigtail • Fibrinolytics , open drainage or decortication  loculated effusion or clinical worsening Shian-Chin Ko et al Chest June 2000

  14. Fungal Empyema • 111 cases identified • 44 excluded because of: Fluid was transudate Patients were asymptomatic Single isolated fungal growth in the pleural fluid Isolation through prior chest tube Shian-Chin Ko et al Chest June 2000

  15. Fungal Empyema • 60% received Abx 1 week before empyema • 41% loculated effusion • Mean Protein 3.5 LDH 3198 Glucose 27 • 69% Poly predominance

  16. Fungal Empyema • 28% Fungemia Candida 60% Vs Torulopsis 30% • 24% bacterial empyema G-ve bacilli (45%) Pesudomonas G+ve Enterococci & Staph 28% bacteremia No significant correlation with increased mortality

  17. Fungal Empyema • 49/67 died (73%) • 43/49 (88%) immunocompromised • All Torulopsis & more than one fungal isolate patients died • Antifungal Rx : Fluconazole (33%) Ampho B (12%) Combined (28%)

  18. Fungal Empyema • 29/44 who had chest drainage died (66%) • 20/23 who didn’t have drainage died (87%) • All surgical intervention Pt 6 survived 4/6 Aspergillous lung abscess 2/6 Candida with poor response to antifungal • Multivariate analysis  Immunosuppression , Lack of antifungal Rx & respiratory failure were independent risk factor for death

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