1. A CASE OF
FUNGAL EMPYEMA
Dr. Sugata Dasgupta
MD, FNB (Critical Care Medicine)

2. Fungal Empyema
• Not largely reported or studied
• Mainly isolated case reports
• Mostly in patients with severe underlying
diseases / immunocompromised / malignancy
• Can have a fulminant course with
sepsis, organ dysfunction, respiratory
failure, persistent pleural collections & high
mortality

3. Largest data
• Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC;
Fungal empyema thoracis : An emerging
clinical entity; Chest 2000;117:1672-8
• Commonest : abdominal / thoracic
surgery, GI perforation, bronchopulmonary
infection
• Mostly in pts with severe underlying diseases
• Crude mortality rate : 73%

4. OUR PATIENT

5. Our patient
• 55 year old lady
• Admission : 5F( /HDU) : 19/6/10
ICU : 9/7/10
• Past History : GERD, Laparoscpoic Nissen’s
Fundoplication 8 years ago

6. Chief Complaints & History of present
illness on Hospital admission
• Right sided chest pain/SOB/Fever/Dysphagia
• 8.6.10 = Redo Laparoscopic Fundoplication
• Symptoms started after surgery
• 9.6.10 = Gastrograffin : Distal Oesophageal
leak (oesophageal perforation)
• 16.6.10 = Barium : leak + Right Pleural Effusion
• Cefazolin Ig 8/24 + Metronidazole 500mg 8/24
• 19.6.10 = Admission to 5F (/HDU)

7. Clinical Examination & Investigations
• Fever, tachypnoea, tachycardia, normotension
• Chest : dullness & ↓breath sounds on right
• Abdomen : slightly tender epigastrium
• Other systems : NAD
• Blood : WBC 26.9, CRP 240, ↑ AST/ALT/AP
• CXR : Rt. Pleural Effusion, small Lt.
effusion, No pneumomediastinum / diffuse
mediastinal widening / subcutaneous
emphysema
• ABG : Hypoxemia in Room Air

8. Investigations (continued)
• CECT : perforation with dye leakage at GE
junction + Large Right Hydropneumothorax
with underlying collapse / consolidation +
Small Left effusion (No mediastinal air / air-
fluid levels / diffuse mediastinal widening)
• Right Pleural Fluid (12F pigtail) :
Empyema : Yeast + viridans streptococci
• Blood / Urine / Sputum : Sterile

9. Clinical Course : first TEN days
• 19.6.10-22.6.10 = Metronidazole 500 mg 1V
12/24 + Ampicillin 1g IV 6/24 ; TPN
• Remained septic with fever + increasing
counts & CRP ; worsening SOB +↑ing O₂
requirements; worsening LFTs
• 23.6.10 = Pip-Tazo 4.5g IV 8/24
• Blood / Urine / Sputum : Sterile
• Echocardiography : Normal study

10. Clinical Course : first TEN days
• 25.6.10 = Endoscopic Oesophageal Stent + Rt.
28F ICD ↓GA
• 28.6.10 = Pleural Fluid : Candida albicans (No
sensitivity report); Pip-Tazo + Fluconazole 400
mg IV OD; Gastrograffin : No leak , oral + TPN
• 30.6.10 = CECT : ↓ Right Pleural Collection +
persistent Left pleural effusion ; No leakage
• SOB improved, but still septic with
fever, persistent leukocytosis,↑CRP; deranged
LFTs

11. Clinical Course : next TEN days
• Progressively decreasing ICD output; clinically
persistent bilateral pleural effusion + sepsis
• Blood / Sputum / Urine : always sterile
• Rt Pleural Fluid : persistently C. albicans (with
CONS once : Vanco, Doxy); Lt : sterile exudate
• 6.7.10 = CECT : Persistent Rt. Hydropneumo (not
much change from last CT) + Left effusion
• 6.7.10 = USG guided Bilateral 8F Pigtails
• Worsening sepsis, SOB with ↑WOB, AHRF

12. Clinical Course : next TEN days
• 8.7.10 : Fluconazole off, Caspofungin started
(70 mg IV on D1→ 50mg IV OD) + Pip-tazo on
• 9.7.10 = Right Thoracotomy + Pleural
debridement (2 28F + 2 15F ICDs) + Feeding
Jejunostomy ↓GA (OLV with Lt sided DLT)
• ICU (Intubated) : ventilated (4 Rt +1 Lt drains)
• 9.7.10 = Caspo 50 mg IV OD + Vancomycin 1g
IV 12/24 + Meropenem 1g IV 8/24
• Pleural tissue : C.albicans, Lt effusion: sterile

13. Clinical Course in the ICU
• 11.7.10 = Extubated, Jejunostomy feeds
• 12.7.10 = Tachypnoea,↑WOB, Hypoxemia :
Reintubated; C. albicans grown in 1 drain fluid
• 13.7.10 = CECT : Persistent Right pleural
collection as thick enhancing rind / loculated
fluid in oblique fissure + Left pleural Effusion
• Afebrile; leukocytosis + ↑CRP; deranged LFTs
• Blood / DTA / Urine / Left Pleural fluid : sterile

14. Clinical Course in the ICU
• ↓Albumin ; Fluid overload : Albumin, Filtered
• Difficult weaning ; Tracheostomy on 19.7.10
• Still growing C. albicans from 1 drain fluid
• 21.7.10 = CECT : Rt hydropneumo reduced
, but loculated collections + Lt Effusion
reduced
• Sequential drain removal, slowly weaned off
• 23.7.10 = Rt Intrapleural STK 250000 U 1dose
• 24.7.10 = Antibiotics stopped; Caspofungin on

15. Clinical Course in the ICU : Presently
• Clinically getting better; 40 days of hospital stay
• Tracheostomy / High flow / Weaned off
• Right 28F ICDs (2) still present , Left ICD out
• Afebrile, Counts, LFTs normalizing, still ↑CRP
• 24.7.10 = Pleural fluid : totally culture sterile
• C/O reflux : ? Stent (5cm above leak to 2-3cm in
stomach)
• Stent removal scheduled on 30.7.10

17. Empyema following oesophageal
perforation
• Mainly reported along with other radiological
features of acute mediastinitis
• Mainly bacterial: anaerobes / aerobes
(Staph, β/α haemolytic strep / GNB) / mixed
• Fungal : few case reports : mostly malignancy
/ immunocompromised / fungaemia
• Mostly isolated : Candida (albicans>tropicalis)

18. Nissen’s Fundoplication
• Oesophageal / gastric perforation (Open 1%,
Lap 2%; Mortality : 26% in Open, Nil in Lap)
• Empyema following perforation after Lap
Fundoplication : very few reports : bacterial
• Fungal Empyema without other radiological
features of acute mediastinitis following
Oesophageal perforation after Laparoscopic
Fundoplication in immunocompetent adult ?

19. Management issues
• Antifungals + Tube Thoracostomy +/- Surgery
• Candida Empyema without Candidemia : No
definite guideline on choice / route / duration
of Antifungals in 2009 1DSA Guidelines
• Pleural penetration : Fluconazole , Ampho :
good; Echinocandins : not largely
studied, good efficacy in invasive candidiasis
• ? Reasonable to treat like Candidemia

20. Management Issues
• Fluconazole 800mg (12 mg/kg) loading → 400
mg/ day (6mg/kg/d) (if susceptible)
• C. glabrata or krusei / severely ill / recent
azole exposure = IV Echinocandin (Caspo
70mg on D1→50mg/d / Micafungin 100mg/d
/ Anidulafungin 200 mg loading→ 100 mg/d)
• Alternatives : LFAmB (3-5mg/kg/d) qid /
AmB-d 0.5-1mg/kg/d) bid / Vori 400mg
(6mg/kg) bid 2 doses→ 200mg (3mg/kg) bid

21. Management issues
• Echinocandin: ?clinical improvement / 1-2wks
• Change to Fluconazole / Voriconazole (if
susceptible) may be appropriate
• ? Total duration of antifungals : Pleural Fluid
Culture + Drainage + Clinical improvement
• 14 days after culture sterility / drain removal
+ total resolution of pleural collection with
clinical improvement : may be appropriate

22. Controversies : in retrospect
• Interval between oesophageal perforation &
definitive treatment : predictor of outcome :
Were we late ? (Leak : 9.6.10; Stent : 25.6.10)
• Empiric Antifungals (with antibiotics) on
detection of distal oesophageal perforation ?
• Yeast : 20.6.10; C. albicans + Fluconazole :
28.6.10 ; Could have been started on 20.6.10?

23. Controversies : in retrospect
• Single dose of Intrapleural Streptokinase ?
o MIST1 Trial (NEJM 2005;352(9):865-74): No
effect on mortality / LOS / need for surgery
o Before surgical drainage ; 3 days (BTS ; ACCP)
• Persistently deranged LFT (↑AST/ALT/AP/Bi) :
sepsis / azole (off) / ↓Caspo dose ? / LFAmB ?

24. QUESTIONS