Empyema necessitans

Empyema Necessitans for Radiology

1. Empyema Necessitans Dr. Manmohan Bir Shrestha For Radiology

2. Empyema Necessitans / Necessitasis Rare long term complication of empyema thoracis refers to extension of a pleural infection out of the thorax and into the neighboring chest wall and surrounding soft tissues extension of an empyema out of the pleural cavity. With the advent of antimicrobials, its incidence has decreased

3. Pathology It may either occur due the virulence of the organism or may be facilitated by previous thoracic surgery (e.g. thoracotomy) or trauma   allowing infection to track through. It occurs commonly to subcutaneous tissues of the chest wall, but can also spread to involve other sites such as esophagus breast Peritoneal & retroperitoneal region pericardial region paravertebral regions. The resultant subcutaneous abscess may eventually rupture through the skin.  Can even cause osteonecrosis of the affected rib.

4. Causative organisms Mycobacterium tuberculosis – most common Actinomyces Blastomycosis Aspergillus Nocardia Mucormycosis Fusobacterium

5. Clinical feature - varies Sign & symptoms of pulmonary tuberculosis Chest pain Erythema & swelling over chest wall.

6. Imaging modalities Chest x-ray Ultrasound CT Scan MRI

7. Plain radiograph are often non-specific and sometimes even normal may suggest soft tissue density in chest wall can resemble pleural effusion/empyema thoracis can show features of consolidation

8. CT Scan Fluid density in pleural space & extending into subcutaneous tissues in the chest wall or elsewhere in abdomen Shows bone erosions well Post contrast – rim enhancing fluid collections.

9. MRI T1WI – Iso to hypointense T2WI – hyperintense Post contrast – rim enhancing

10. Case of 40 yrs. female patient Complaints Fever, chills & sweats for one week On examination Palpable, non-tender subcutaneous mass over the right anterior chest wall.

11. Treatment Surgery for the drainage of abscess with right anterior thoracotomy Culture of drained fluid Growth of Methicillin Resistant Staphylococcus aureus

12. 25 yrs. Male with fever & chest pain for few days

13. 20 yrs. male Complaints of Mass on posterior aspect of left back for 2 months. - Low grade fever for same duration

14. Culture of drained fluid showed acid-fast bacilli confirming the diagnosis of tuberculosis

15. 56 yrs. Old male Complaints 3 weeks of progressive, localized, right-sided posterior chest wall pain and swelling. No fevers or chills, productive cough, hemoptysis, change in weight On examination hard and fixed mass on the right posterior chest wall at the level of the 11th rib with minimal tenderness to palpation.

16. Pre-operative Post-operative

17. Culture report confirmed actinomycosis. Follow up after 6 weeks

18. Presenting Case, 18 yrs. Old young male