A “Hole” New World: Empyema Necessitans From Mycobacterium kansasii

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Abstract

Empyema necessitans (pleurocutaneous fistula) is a rarely seen late complication of empyema thoracis. It is typically associated with Mycobacterium tuberculosis and Actinomyces spp., aggressive pathogens capable of dissecting through tissue planes. However, this entity may occasionally occur late in the course of infection with more indolent organisms. Cases due to coccidioidomycosis, mucormycosis, and aspergillosis have all been described. Only 3 cases of empyema necessitans due to nontuberculous mycobacteria have been reported in the literature and no cases have been reported in association with Mycobacterium kansasii. In addition to appropriate antimicrobial therapy, more definitive treatment is considered on a case-by-case basis and may consist of either tube thoracostomy and drainage or open thoracotomy, depending on the specific clinical circumstances. Although it must be recognized that a pleurocutaneous fistula could rapidly lead to the development of a tension pneumothorax, in all reported cases due to nontuberculous mycobacteria, patients were suitably treated with conservative medical management alone. This case demonstrates that less pathogenic organisms, such as M. kansasii, are indeed capable of causing empyema necessitans if not treated effectively. Physicians should be aware of this rare complication of mycobacterial infection, especially in difficult-to-treat patient populations.

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