Novel management of pseudomonas biofilm-like structure in a post-pneumonectomy empyema

Abstract

We present a patient with a post-pneumonectomy empyema refractory to surgical debridement and systemic antibiotics. The patient initially presented with a bronchopleural fistula and pneumothorax secondary to tuberculosis (TB) destroyed lung, which required a pneumonectomy with Eloesser flap. Ongoing pleural infection delayed the closure of the Eloesser flap, and thoracoscopic inspection of his chest cavity revealed a green, mucous biofilm-like structure lining the postpneumonectomy pleural cavity. Cultures identified pan-susceptible Pseudomonas aeruginosa. Despite debriding this biofilm-like structure and administering systemic antibiotics, the patient continued to show persistent signs of infection and regrowth of the film. We employed a novel approach to dissolve the biofilm-like structure using intrapleural dornase alfa followed by intrapleural antibiotic washes. After 3 weeks of daily washes, repeat inspection demonstrated the biofilm-like structure had completely resolved. Resolving the pseudomonas biofilm-like structure allowed permanent closure of his chest without further need for systemic antibiotics. At follow up 3 months later, he showed no sequalae. This treatment option can be an important adjunct to improve likelihood of chest closure in patients with post-pneumonectomy empyema that resists standard treatment options due to biofilm formation.

Keywords: alfa; biofilm-like structure; dornase; empyema; pneumonectomy; pseudomonas; tuberculosis.

Figure 1

(A) Pre-operative computed tomography scan showing right hydropneumothorax, right lung consolidations and collapse. (B) Surgical specimen, right pneumonectomy with innumerable micro abscesses and caseating granulomas. (C) H&E stain of surgical specimen showing large necrotizing granuloma surrounded by multinucleated giant cells and epithelioid histiocytes (250µm). (D) Low power view of lung parenchyma showing diffuse involvement by granulomatous inflammation and cystic lesions (5mm).

Figure 2

(A) Eloesser flap creation. (B) Closure of Eloesser flap. (C) Final flap closure with skin reapproximated.

Figure 3

(A) VATS image showing biofilm-like structure prior to dornase alfa application. (B) VATS image showing resolution of biofilm-like structure after 21 days of dornase alfa application.

Figure 4

(A) WBC count trend throughout clinical course. (B) CRP trend from 2 months post operatively until follow up 8 months post operatively. (C) Timeline of patient clinical course. Black arrows represent time points at which patient developed symptoms and procedures revealed P. aeruginosa growth. Star represents initiation of dornase alfa and amikacin washes. Yellow arrow represents VATS showing resolution of biofilm-like structures.