A rare presentation of empyema necessitatis

A 5-year-old boy was presented, in surgical emergency of our institution, with discharge of pus from a cervical lump during inspiration. There was a history of fever, cough and respiratory distress 10 days back, followed by the appearance of a lump in the right cervical region. The parents sought medical treatment from a local dispensary. A day back the lump spontaneously bursted with cupious amount of pus came out of the cervical lump.


Letters to Editor
Sir, Empyema necessitatis is characterized by an extension of pus (empyema thoracic) from pleural cavities to the surrounding structures such as chest wall, mediastinum, pericardium, esophagus, retroperitoneum and so on. [1,2] A case of empyema necessitatis, presenting with cervical abscess, is being reported.
A 5-year-old boy was presented, in surgical emergency of our institution, with discharge of pus from a cervical lump during inspiration. There was a history of fever, cough and respiratory distress 10 days back, followed by the appearance of a lump in the right cervical region. The parents sought medical treatment from a local dispensary. A day back the lump spontaneously bursted with cupious amount of pus came out of the cervical lump.
The general physical examination revealed a temperature of 100°F, pulse 96/min, respiratory rate 33/min, and blood pressure within normal limits. The examination of the right cervical region showed an abscess cavity from which a small amount of pus was coming out during the inspiratory phase of the respiration. The respiratory system examination showed overt clinical signs of respiratory distress including nasal flaring, intercostal and subcostal retractions. The air-entry was reduced on the right side. A chest radiograph and ultrasound were requested that delineated empyema on the right side. The hemoglobin of the patient was 10g/dl with WBC count of 13000.
A tube thoracostomy with debridement of the cervical wound was performed under ketamin anesthesia. The patient was started on parenteral antibiotics including coamoxiclav and amikacin, steam nebulization, and chest A rare presentation of empyema necessitatis physiotherapy. The patient did well post-thoracostomy. The culture of the pus revealed Staphylococcus aureus which was sensitive to both of the drugs. The patient showed a commensurate amelioration of the symptoms. The chest drain was removed on tenth day of insertion and patient was discharged on oral co-amoxiclav for a week. The patient is symptom-free during a follow up of six months time.
Empyema thoracic is defined to have frank pus in the pleural cavity. Various kinds of complications can arise in untreated or partially treated patients. Empyema can extend to the surrounding structures; the reported sites are chest wall, peritoneum, pericardium, retroperitoneum, esophagus, mediastinum, abdominal wall, paravertebral space, vertebrae, bronchus, breast and diaphragm. The site in our case is very rare i.e. posterior triangle of the neck in the supraclavicular region. Empyema necessitatis usually presents with a lump in the chest along with clinical features of empyema thoracic such as fever, cough, respiratory distress etc. Rarely, the pus starts coming out from the wound, [1][2][3] but emission of pus from the lump during inspiration is a unique attribute in the index case. In our opinion, there should be a pleuro-cutaneous communication that ejects the pus from pleural cavity as the lungs expand during inspiration.
The common organisms isolated from the pus cultures in patients of empyema necessitatis are Mycobacterium tuberculosis, Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas and others. Rarely, methicillinresistant Staphylococcus aureus (MRSA) has also been isolated from the pus cultures. [1,4] In our patient, the Staphylococcus aureus was sensitive to the empirical therapy instituted and patient showed a substantial improvement in the clinical condition and general well being.
Sir, I read with interest the recent case report on ''Parotid tuberculosis'' by Garg et al, [1] and have the following comments to offer: 1. The statement made by the authors ''Since 1893, only about one hundred cases of parotid gland tuberculosis have been reported in the literature'' is incorrect. The reference cited for the statement is from an article published in 1996 which mentions the total number of cases described till that year. Ideally, the authors should have done an extensive literature search on the number of published cases of parotid gland tuberculosis till date. A search on PubMed with the keywords ''tuberculosis'' AND ''parotid gland'' revealed more than 40 cases of parotid gland tuberculosis published after 1996. 2. HIV testing was not done in the case described by the authors. HIV positive patients are more likely to present with extrapulmonary or sputum smear-negative tuberculosis as compared to HIV negative patients. [2] Extrapulmonary tuberculosis has been accepted as an AIDS-defining criterion. The WHO clinical staging of HIV/ AIDS is used in many countries to determine eligibility for antiretroviral therapy, particularly in settings in which

Extrapulmonary tuberculosis and HIV
CD4 testing is not available. Presence of extrapulmonary tuberculosis puts a patient in stage 4 which is an indication for starting ART. [3] Furthermore, HIV-infected tuberculosis patients are a priority for epidemiologic investigation because these persons are more likely to have HIV-infected contacts than are seronegative tuberculosis patients. Also, irrespective of epidemic setting, WHO recommends HIV testing for patients of all ages in whom tuberculosis is suspected or already confirmed. [4] Through this letter, I would like to re-emphasize our readers that HIV testing should be done in cases of tuberculosis, especially those with extrapulmonary manifestations.