A 5-Year-Old Girl With Fever and Cough

Nicholas J. Bennett, MB BChir, PhD

Disclosures

October 11, 2016

For the treatment of empyemas, especially those with loculations, VATS with decortication if necessary has become the standard of care. It has been associated with more rapid resolution of fever, shorter hospital stay, and reduced hospital costs compared with chest-tube management with or without fibrinolytic therapy.[5,6] Surgical consultation should be obtained as part of the management of all patients with clinically significant pleural effusions, empyemas, and lung abscesses.

The American Thoracic Society describes three phases in the natural course of empyemas: exudative, fibrinopurulent, and organizing.[7] In the exudative (or parapneumonic effusion) phase, the fluid is free-flowing; it can often be treated with a combination of antibiotics and some sort of minimally invasive drainage (thoracentesis or tube thoracostomy).

During the fibrinopurulent phase, adhesions, loculations, and thick pus form that make simple drainage ineffective.[8] These patients may occasionally be drained with tube thoracostomy in the early phase, but many will require surgical drainage.

In the organizing phase, thick peels form that are more difficult to remove and may require formal thoracotomy. Patients with empyemas that are at an advanced stage should undergo early definitive surgical treatment. This improves the patient's ventilatory status earlier (with complete drainage and lung reexpansion), shortens the duration of an indwelling tube, and reduces hospital stay.

At the time of the VATS, obtain appropriate cultures and stains, because bacteremia is not typical in most cases of pediatric pneumonia and this may be the only way to formally identify and type the organism. Antibiotic sensitivities can help guide therapy, as in this case, and clinical failure resulting from antibiotic resistance can be ruled out more easily.

Ideally, as much fluid or tissue as possible should be sent for aerobic and anaerobic cultures and Gram staining. Swabs of the lung, chest wall, or empyema are inappropriate specimens when several hundred milliliters of fluid may be available to sample. Anaerobic specimens should be sent in a sealed tube to minimize exposure to oxygen.

The introduction of the heptavalent conjugated polysaccharide vaccine as part of the routine childhood immunization schedule has reduced invasive pneumococcal disease (bacteremia, meningitis, and pneumonia) by approximately 80%,[9,10] although some evidence supports serotype replacement of nonvaccine strains. Severe or recurrent pneumococcal disease in immunized children should prompt testing of the bacterial serotype from cultures. Infection with a vaccine-type strain or recurrent invasive pneumococcal infections should warrant an immune evaluation and consultation with pediatric infectious disease specialists.

The patient in this case required a second surgery with decortication and multiple chest tubes to deal with persistent fever, effusion, and pneumothorax. After the procedure, she remained intubated with mechanical ventilation for 2 days. She developed a bronchopleural fistula and persistent air leak, but her chest tubes were successfully removed after 2 weeks.

The patient had a month-long hospitalization in total, including 17 days in the intensive care unit. She was discharged to home in good condition with a small, stable right pneumothorax. She was instructed to complete her 3-week course of oral linezolid that began after the second VATS procedure.

Serotyping of the pneumococcal strain at the state laboratory showed it to be serotype 19A.

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