Fungal EmpyemaFungal Empyema

HistoryHistory 57 57 Male X smoker (20 pack)Male X smoker (20 pack) Admitted D6 with 1 week H/O:Admitted D6 with 1 week H/O:

SOBE , Cough , minimal sputumSOBE , Cough , minimal sputum

? Fever & night sweating? Fever & night sweating Being treated as CAP as outpatient with Being treated as CAP as outpatient with

amoxicillin for 5 daysamoxicillin for 5 days No response to RX No response to RX

HistoryHistory PMH : MDS April /02 PMH : MDS April /02 AML Aug/02AML Aug/02

Treated with {Cytarabine & Doxorubicin}Treated with {Cytarabine & Doxorubicin}

Back to MDS oct/02Back to MDS oct/02AML Aug /03AML Aug /03

Treated with {Ara-c & Mixotracine} Sep/03Treated with {Ara-c & Mixotracine} Sep/03

HistoryHistory No symptoms Of COPDNo symptoms Of COPD NO IHD risk factorNO IHD risk factor NO previous pneumonias NO previous pneumonias No VTENo VTE No contact with TBNo contact with TB No travel , occupational exposure ,petsNo travel , occupational exposure ,pets Systemic review unremarkableSystemic review unremarkable

HistoryHistory Medications: gatifluxacineMedications: gatifluxacine

HydrxyureaHydrxyurea

allopurinolallopurinol

Palliative case {transfusion dependent}Palliative case {transfusion dependent}

No plans for further Chemo Nor BMTNo plans for further Chemo Nor BMT

ExaminationExamination Afebrile BP 120/70 HR 90Afebrile BP 120/70 HR 90 RR 18 Sat 86% RA 93% 5L O2RR 18 Sat 86% RA 93% 5L O2 Chest :absent breath sounds Rt 2/3 PostChest :absent breath sounds Rt 2/3 Post

dull percussion dull percussion CVS: S1+S2 +0CVS: S1+S2 +0 Abdomen : HepatosplenomegalyAbdomen : Hepatosplenomegaly LL: no edema or size differenceLL: no edema or size difference

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

InvestigationsInvestigations Pleural Fluid BloodyPleural Fluid Bloody

Protein 68 LDH 1958 Glucose 1.4Protein 68 LDH 1958 Glucose 1.4

WBC 9500 24% Poly 40% BlastWBC 9500 24% Poly 40% Blast

RBC 2000 RBC 2000

GS +2 Poly & no organismGS +2 Poly & no organism

C/S –veC/S –ve

Cytology AML with YEAST Cytology AML with YEAST

InvestigationsInvestigations

Cytology finding similar (Fungal element)Cytology finding similar (Fungal element)

Both on Oct 8Both on Oct 8thth {diagnostic} {diagnostic}

& Oct 10& Oct 10thth {therapeutic} {therapeutic} -ve Fungal stain & C/S-ve Fungal stain & C/S Being treated with Ampho B since Oct 8Being treated with Ampho B since Oct 8 thth

33rdrd tapping Oct 16 tapping Oct 16thth

-ve C/S-ve C/S

Fungal EmpyemaFungal Empyema Limited dataLimited data Increasing incidence of fungal infectionsIncreasing incidence of fungal infections CDC report 1980CDC report 19801990 1990

Candida emerged as the 6Candida emerged as the 6thth most common most common nosocomial pathogen 7.2%nosocomial pathogen 7.2%

More immunocompromised patientsMore immunocompromised patients Increased use of broad spectrum AbxIncreased use of broad spectrum Abx Increased Central Venous Catheters Increased Central Venous Catheters

Fungal EmpyemaFungal Empyema Retrospective study Retrospective study

Jan 1990Jan 1990 Dec1997 University Hospital Taiwan Dec1997 University Hospital Taiwan

To analyze clinical spectrum , pathogenesis , To analyze clinical spectrum , pathogenesis , treatment ,outcomes & prognostic factors treatment ,outcomes & prognostic factors

Shian-Chin Ko et al Shian-Chin Ko et al

Chest June 2000Chest June 2000

Fungal EmpyemaFungal Empyema Fungal empyema Diagnosed by:Fungal empyema Diagnosed by:

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

Fungal EmpyemaFungal Empyema Considered Hospital acquired if developed 48 hours Considered Hospital acquired if developed 48 hours

after admissionafter admission Coexisting pneumonia if symptoms or CXR finding Coexisting pneumonia if symptoms or CXR finding

+ve +ve Most patients were treated with standard chest tubes Most patients were treated with standard chest tubes

or pigtail or pigtail Fibrinolytics , open drainage or decortication Fibrinolytics , open drainage or decortication

loculated effusion or clinical worsening loculated effusion or clinical worsening

Shian-Chin Ko et al Shian-Chin Ko et al

Chest June 2000Chest June 2000

Fungal EmpyemaFungal Empyema 111 cases identified 111 cases identified 44 excluded because of:44 excluded because of:

Fluid was transudate Fluid was transudate

Patients were asymptomaticPatients were asymptomatic

Single isolated fungal growth in the Single isolated fungal growth in the

pleural fluidpleural fluid

Isolation through prior chest tube Isolation through prior chest tube

Shian-Chin Ko et al Shian-Chin Ko et al

Chest June 2000Chest June 2000

Fungal EmpyemaFungal Empyema 60% received Abx 1 week before empyema60% received Abx 1 week before empyema 41% loculated effusion41% loculated effusion Mean Protein 3.5 Mean Protein 3.5

LDH 3198LDH 3198

Glucose 27Glucose 27 69% Poly predominance69% Poly predominance

Fungal EmpyemaFungal Empyema 28% Fungemia 28% Fungemia

Candida 60% Vs Torulopsis 30% Candida 60% Vs Torulopsis 30%

24% bacterial empyema24% bacterial empyema

G-ve bacilli (45%) Pesudomonas G-ve bacilli (45%) Pesudomonas

G+ve Enterococci & Staph G+ve Enterococci & Staph

28% bacteremia No significant correlation with 28% bacteremia No significant correlation with increased mortalityincreased mortality

Fungal EmpyemaFungal Empyema 49/67 died (73%)49/67 died (73%) 43/49 (88%) immunocompromised 43/49 (88%) immunocompromised All Torulopsis & more than one fungal isolate All Torulopsis & more than one fungal isolate

patients died patients died Antifungal Rx :Antifungal Rx :

Fluconazole (33%) Fluconazole (33%)

Ampho B (12%) Ampho B (12%)

Combined (28%) Combined (28%)

Fungal EmpyemaFungal Empyema 29/44 who had chest drainage died (66%)29/44 who had chest drainage died (66%) 20/23 who didn’t have drainage died (87%)20/23 who didn’t have drainage died (87%) All surgical intervention Pt 6 survived All surgical intervention Pt 6 survived 4/6 Aspergillous lung abscess 4/6 Aspergillous lung abscess 2/6 Candida with poor response to antifungal 2/6 Candida with poor response to antifungal Multivariate analysisMultivariate analysis Immunosuppression , Lack of antifungal Rx Immunosuppression , Lack of antifungal Rx

& respiratory failure were independent risk & respiratory failure were independent risk factor for deathfactor for death