Clinical Brief Indian J Pediatr 1996; 63:704-706 I

Neonatal Empyema Thoracis

Raju Gupta, MMA Faridi, and Piyush Gupta

Division of Neonatology, Department of Pediatrics, University College of Medical Sciences and G.T.B Hospital, Delhi

Abstract . Empyema thoracis, a serious complication of pneumonia, fortunately remains a less common cause of respiratory distress in neonates. Only 14 cases of neonatal empyema thoracis have been described in the world literature. The condition is characterized by its rarity, inability to identify any consistent predisposing factors, uncertain pathogenesis, rapid course, lack of consensus on management and a high mortality. We describe here two cases of empyema aged 6 and 8 days caused by E. Coil and Klebsiella respectively. Out of them one survived. A brief review of literature follows the above account.

Key words : Empyema; Neonate

Empyema thoracis is defined as pyogenic i n f e c t i o n of the p l e u r a l c a v i t y w i th pu ru len t effusion. Majori ty of chi ldren who are affected are under two years. Though excellent reviews and studies are available regarding childhood empyema, 1 yet reports are scanty as far as the neonatal period is concerned. We are presenting two cases of neonatal empyema that occurred ira our newborn unit.

CASE REPORT

A ful l t e rm, b r ea s t fed, ma le i n f a n t weighing about 2.5 kg, born normally to a pr imigravida was admit ted in the NICU on the 4th day with refusal to feed and tachypnea for 20 hours. History suggestive of any o b s t e t r i c r isk fac tor or b i r th asphyxia was not forthcoming. A chest r a d i o g r a p h revea led r ight lou;er zone consol ida t ion with few pneumatoceles .

Reprint requests: Dr. Piyush Gupta, R-6A Dilshad (;ardeJ~, Near T~,lephone Exchange, Dethi-ll0 095.

Intravenous fluids, oxygen and antibiotics (Penicillin and amikacin) were instituted. The baby failed to show any improvement even after 48 hours of admission. A clinical e x a m i n a t i o n at th is s t a g e s u g g e s t e d presence of fluid in the right pleural cavity which was subsequently conf i rmed by an erect chest skiagram. Pleural tap revealed thick pus which showed gram-negat ive baci l l i . T h o r a c o s t o m y w a s d o n e and pediatric size 10 FG Portex radio opaque thorac ic c a n n u l a was i n s e r t e d in 6th intercostal space. About 150 cc of pus was d r a i n e d in the f o l l o w i n g 24 h o u r s . P e r i p h e r a l s m e a r r e v e a l e d toxic granulat ions and bandemia . WBC count was 18,500 per cu m m w i t h 80% polymorphs . Blood cul ture was sterile. Pure g r o w t h of E. Coli s e n s i t i v e to cefotaxime and amikacin was obtained on culturing the pus. Child was treated with appropriate antibiotics for three weeks. He responded well to the t reatment and chest tube was r e m o v e d a f te r 10 days . On

1996; Vol. 63: No. 5

s u b s e q u e n t fo l low up, the ch i ld w a s f o u n d to h a v e a g o o d e x p a n d i n g l u n g w i t h n o r m a l phys ica l a n d m e n t a l g r o w t h .

The second case, a h o m e d e l i v e r e d t e r m (AGA) infant , w e i g h i n g 2.6 kg, p r e s e n t e d at 8 d a y s of age wi th r e s p i r a t o r y d is t ress , cyanos i s and clinical s igns of r igh t s ided p l e u r a l e f f u s i o n w h i c h w a s c o n f i r m e d rad io log ica l ly . T h o r a c o c e n t e s i s r e v e a l e d thick p u s wh ich g r e w k lebs ie l la sens i t ive to c e f o t a x i m e a n d a m i k a c i n . D e s p i t e c o n t i n u o u s i n t e r c o s t a l d r a i n a g e , a d m i n i s t r a t i o n of a p p r o p r i a t e an t ib io t ics a n d ar t i f ic ia l v e n t i l a t i o n , ch i ld d i e d of r e s p i r a t o r y f a i l u r e w i t h i n 72 h o u r s of a d m i s s i o n .

THE INDIAN JOURNAL OF PEDIATRICS 705

DISCUSSION

E m p y e m a t h o r a c i s r e m a i n s r e l a t i v e l y c o m m o n in c h i l d r e n b u t a r a r i t y in the n e o n a t a l p e r i o d as e v i d e n c e d b y a v e r y s m a l l n u m b e r of cases r e p o r t e d till da te (Table 1). P o o r i m m u n e s ta tus in ea r ly days o f l i f e p r o b a b l y a c c o u n t s f o r n o n - l oca l i z a t i on of in fec t ion to the p l e u r a and t h u s r e s u l t s in a v e r y l ow i n c i d e n c e of e m p y e m a . The c a p a c i t y of n e o n a t a l p l eu ra to f o r m e x u d a t e is also l imi ted and one can on ly s p e c u l a t e r e g a r d i n g the p a t h o g e n e s i s a n d e v o l u t i o n of e m p y e m a in n e w b o r n s .

The m a i n e t io log ica l agen t in n e o n a t e s r e m a i n s S t a p h . a u r e u s . E. co l i e m p y e a n a ,

TABLE 1 : Neonatal empyema

S. Study No. of Age at Etiological Management Outcome no. cases diagnosis organism

1. Henderen and 2 2 wk Staph. aureus Haggerty (2)

2. Irene and 6 < 4 wk Staph. aureus-5 Rickham (3) E.coli-1

3. Howard and 1 McCracken (4)

4. Peterson and 1 Astvad (5)

5. Sokal et al (6) 1

6. Mclaughlin et al (7) 1

7. Gustavson (8) 1

8. Chellani et al (9) 1

9. Present s tudy 2

8 hr Group B 13 hemolytic Streptococci

2 day Group A 13 hemolytic Streptococci

20 hr Group B 13 hemolytic Streptococci

< 4 wk Staph.aureus

4 hr E. coli

48 hr Staph. aureus

6 day E, coli 8 day Klebsiella

lst-Antibiotics only Died at day 1 2nd-Antibiotics + ICD Died at day 6

No treatment--2 Five neonates Repeated aspiration--3 died

Antibiotics+ICD-1

Antibiotics+ICD Died within 24 hrs

Antibiotics+ICD Survived

Antibiotics+ICD Survived

Antibiotics+ICD Survived

Antibiotics+ICD Survived

Antibiotics+ICD Survived

Antibiotics+ICD 1 Died

ICD = Intercostal drainage

706 THE INDIAN JOURNAL OF PEDIATRICS 1996; Vol. 63 ~. No, 5

r e p o r t e d in 1 8 . 7 % ( 3 / 1 6 ) n e o n a t e s , i n c l u d i n g this s t udy , a c c o u n t s fo r a b o u t 14% o f t o t a l c a s e s in c h i l d r e n . P n e u m a t o c e l e s a r e a l s o k n o w n to o c c u r w i t h E. col i p n e u m o n i a . In W e s t e r n l i terature, G r o u p B-hemoly t i c s t rep tococc i , also r e m a i n i m p o r t a n t e t io logica l a g e n t for e r a p y e m a in n e o n a t e s .

It w a s d i f f i cu l t to i d e n t i f y a s i ng l e or m o r e r i s k / p r e d i s p o s i n g f a c t o r s f o r n e o n a t a l e m p y e m a , as the r e p o r t e d cases h a v e o c c u r r e d i n d e p e n d e n t o f w e i g h t , ges ta t ion , p e r i n a t a l r isks , b i r t h a s p h y x i a , leaking p e r v a g i n u m , m e c o n i u m a s p i r a t i o n and p r e c e d i n g in fec t ions . E m p y e m a h a s been n o t i c e d as e a r l y as 4 h o u r s of b i r th . 6 -{1~e s o u r c e of in fec t ion in this case c o u l d have b e e n f r o m the b i r t h cana l r e s u l t i n g in late i n t r a u t e r i n e infec t ion .

M o r t a l i t y in c h i l d h o o d e m p y e m a h a s been r e d u c e d to 2 .5% 1 b u t in n e o n a t e s , e m p y e m a is s t i l l a p o t e n t i a l l y f a t a l cond i t i on and m o r e t h a n 50% of r e p o r t e d cases h a v e s u c c u m b e d to t h e i r i l l nes s . E n o u g h e x p e r t i s e a n d e x p e r i e n c e is n o t ava i l ab l e for the m a n a g e m e n t of n e o n a t a l e m p y e m a a n d n o s t a n d a r d p r o t o c o l is c u r r e n t l y in use. T h e r a p y r e g a r d i n g p u s d r a i n a g e is l a r g e l y b a s e d on i n d i v i d u a l choice a n d bias . M o s t of the cases h a v e been t r ea t ed wi th ches t tube d r a i n a g e only. D e c o r t i c a t i o n , t h e f a v o u r e d m o d e o f the rapy , a c c o r d i n g to recen t r epo r t s , h a s not been a t t e m p t e d in n e o n a t e s so far.

H o w e v e r , w e l l t i m e d s u r g i c a l

i n t e r v e n t i o n d o e s m i n i m i s e t h e m o r b i d i t y of n e o n a t a l e m p y e m a . Str ic ter gu ide l i ne s n e e d to b e l a id d o w n for be t t e r o u t c o m e in t he se cases . A l o n g t i m e fo l low u p of t hese p a t i e n t s is a l so de s i r ed in o rde r to assess the i m p a c t of f ibrot ic changes , if any, on s u b s e q u e n t p u l m o n a r y funct ions .

REFERENCES

1. Padmini R, Srinivasan S, Puri RK, Nalini P. Empyema in infancy and childhood. Ind Pediatr 1990; 27: 447-452.

2. Hendren WH, Haggerty RJ. Staphylococcic pneumonia in infancy and childhood. JAMA 1958; 168: 6-14.

3. Irene M, Rickham PP. Malformation and other af fec t ions of lungs, pleura and medias t inum. In : Neonatal Surgery. Eds Rickham PP, Irene M.(eds.), London: Lrving Butterworth, 1978: 215.

4. Howard JB, McCracken GH. The spectrum of group B streptococcal infections in infancy. Am ] Dis Child 1974; 128: 815-818.

5. Peterson S, Astvad K. Pleural empyema in a newborn infant. Acta Pediatr Scand 1976; 65 : 527-528.

6. Sokal MM, Nagraj A, Fisher BJ, Vijayan S. Neonatal empyema caused by grot.p B Beta hemolytic streptococcus. Chest 1982; 81: 390.

7. Mclaughlin FJ, Goldmann BA, Rosenbaum DM, Harris GBC, Schuster SR, Streider DJ. Empyerna in children. Clinical course and long term follow up. Pediatrics 1984 i 73: 587-592.

8. Gus tavson EE. E. coli e m p y e m a in the newborn. Am J Dis Child 1986; 140: 408.

9. Chellani HK, Antony JJ, Chatterjee PP et al. Neonatal empyema. Indian Pediatr 1989; 26: 189-191.