Figure 2. Spiral chest CT scan showing a left chest wall mass contain air bubbles and thickened septa infavor of empyema.
The patient underwent a septic workup, which included aerobic and anaerobic blood cultures, polymerase chain reaction (PCR) testing for respiratory viruses, and an analysis of sputum samples for gram stain, acid-fast bacilli (AFB), and pyogenic culture, which were found to be negative. In addition, a specimen of the purulent discharge from the patient’s chest wall was collected and sent for Gram staining, AFB staining, and culture. The pyogenic culture of the patient’s discharge was positive for Staphylococcus aureus .
After confirming the diagnosis of empyema necessitans, which happened as a complicated side effect of incompletely treated parapnuemonic effusion due to the lack of fibrinolytic injection in Zahedan Medical Centre, the patient was started on a treatment plan involving intravenous (IV) administration of a broad-spectrum antibiotic regimen, video-assisted thoracic surgery (VATS), and finally a chest tube insertion. The antibiotic regimen included vancomycin at a dosage of 200 mg four times daily, metronidazole at a dosage of 200 mg three times daily, cefepime at a dosage of 1 g three times daily, and meropenem at a dosage of 400 mg three times daily. As previously mentioned, the most important part of the treatment was VATS, which was identified as a crucial aspect of the treatment plan given the prolonged duration of the patient’s EN. In the surgery performed for the patient, after making an incision along the midaxillary line, ports were inserted between the 4th and 5th intercostal spaces. Ports numbered 5 and 10 were implanted for the patient, and our surgeon entered the thoracic cavity under camera guidance. There were significant adhesions present in that area. These adhesions were meticulously dissected and thoroughly irrigated with ample amounts of saline solution. Additionally, necessary biopsies were taken from the pleural membrane and lung tissues to confirm the diagnosis by gram staining and culture. After the surgery, a chest tube was inserted to facilitate the drainage of purulent secretions. It allowed for the continuous drainage of fluids from the affected area, thereby promoting the healing process and helping the patient recover. The chest tube on the left side was successfully removed after a period of seven days. In addition, an echocardiogram was conducted to assess for endocarditis, which yielded negative results. This approach is aimed at relieving pressure and reducing the risk of further complications associated with empyema necessitans.
The patient’s recovery was notably smooth and uneventful, with no reported complications. This positive outcome is a testament to the effectiveness of the treatment approach employed, which involved a combination of broad-spectrum antibiotics, VATS, and the insertion of a chest tube for drainage. Overall, the patient responded well to the treatment plan and was able to make a full recovery without any significant issues.