Empyema Necessitatis Caused by Prevotella melaninogenica and Dialister pneumosintes Resolved with Vacuum-Assisted Closure System: A Case Report

Abstract

Empyema necessitatis is a rare complication of an untreated or inadequately controlled empyema. We present the case of an 11-year-old female adolescent living in precarious conditions, overcrowding, incomplete vaccinations, irregular dental hygiene, and no significant family or personal medical history. The patient started with symptoms one week prior to her hospitalization, presenting a persistent sporadic dry cough, and was later diagnosed with complicated pneumonia, resulting in the placement of an endopleural tube. Vancomycin (40 mg/kg/day) and ceftriaxone (75 mg/kg/day) were administered. However, the clinical evolution was unfavorable, with fever and respiratory distress, so a right jugular catheter was placed. The CT scan showed a loculated collection that occupied the entire right lung parenchyma and pneumothorax at the right upper lobe level. After four days of treatment, the patient still presented purulent drainage with persistent right pleural effusion syndrome. P. melaninogenica and D. pneumosintes were identified from the purulent collection on the upper right lobe, so the antimicrobial treatment was adapted to a glycopeptide, Teicoplanin, at a weight-based dosing of 6 mg/kg/day and Metronidazole at a weight-based dosing of 30 mg/kg/day. In addition, VAC therapy was used for 26 days with favorable resolution.

Keywords: Dialister; Prevotella; VAC; case report; empyema necessitatis.

Figure 1

Anteroposterior thoracic X-ray taken on admission shows a right pleural tube and right pleural effusion with loss of the costophrenic angle and radiopacity in the right lung.

Figure 2

Contrasted computed tomography. Abscessified collection with hydroaeric levels, atelectasis of the parenchyma, lower zone consolidation, loculation in the base, and occlusion of the pleurostomy.

Figure 3

The patient’s laboratory results during the time she was treated in our hospital. Erythrocytes (RBC): 4.2–5.3 × 10⁶ uL; hemoglobin (Hb): 12.5–16 g/dL; hematocrit (Hct): 37.5–48%; leukocytes (WBC): 4.5–13.5 × 10³ uL; neutrophils (NEUT): 1.8–8 × 10³ uL; lymphocytes (LYMPH): 1.5–6.5 × 10³ uL; monocytes (MONO): 0–1.4 × 10³ uL; eosinophils (EOS): 0–0.9 × 10³ uL; prothrombin time (PT): 0.0 sec = 100%; C-reactive protein (CRP): 0–5 mg/L; glucose (Glu): 60–99 mg/dL; serum creatinine (SCr): 0.6–1.1 mg/dL; total cholesterol (TC): recommended less than 170 mg/dL, moderate 170–199 mg/dL, high equal to or greater than 200 mg/dL; total proteins (TPs): 6–8 g/dL; serum albumin (Alb): 3.8–5.4 g/dL; lactic dehydrogenase (LDH): 125–220 IU/L; procalcitonin (PCT): <0.1 ng/mL; medium corpuscular volume (MCV): 80–100 fL; mean corpuscular hemoglobin (MCH): 25–34 pg; red cell distribution width (RCDW): 11.5–16.6%; blood chemistry (BC): ureic nitrogen (UN): 7–16.8 mg/dL; platelets (PLTs): 130–480 × 10³ uL; liver function tests (LFTs).

Figure 4

Chest X-ray after surgery (72 h after), with the persistence of multiple alveolar consolidation zones, pleural drainage, and skin drainage.

Figure 5

Computed tomography (CT) scan shows subcutaneous emphysema due to gas in soft tissues on the rib cage, with thickening and abscessified collection.

Figure 6

A chest X-ray taken after completely stopping the negative pressure therapy showed resolution of the infectious process, observing only persistent linear atelectasis.