SUBMITTED 21 DEC 21 1 REVISION REQ. 2 FEB 22; REVISION RECD. 6 MAR 22 2 ACCEPTED 22 MAR 22 3 ONLINE-FIRST: MAY 2022 4 DOI: https://doi.org/10.18295/squmj.5.2022.041 5 6 Haemophilus influenzae empyema in a 2-month-old-infant 7 Saif Al-Yazeedi,1 Rima Al-Farsi,2 Hatem Al-Rawahi,3,4 *Laila S. Al 8 Yazidi3,4 9 10 1Medical Laboratory Department, Yanqal Hospital, Al Dahira region, Oman; 2Radiology 11 Department, Ibri Hospital, Al Dahira region, Oman; 3Child Health Department, Sultan 12 Qaboos University Hospital, Muscat, Oman; 4Oman Medical specialty Board, Muscat, 13 Oman. 14 *Corresponding Author’s e-mail: lailay@squ.edu.om 15 16 Abstract 17 Empyema can rarely complicate pneumonia in neonates. It carries high morbidity and 18 mortality in this population. We report the case of a 2-month-old healthy term neonate who 19 presented with fever, mild shortness of breath and reduced feeding. Investigations revealed 20 the presence of Haemophilus influenzae empyema. He was managed with video- assisted 21 thoracoscopic surgery (VATS) and prolonged course of antibiotics. A clinic follow-up at the 22 end of the antibiotic course revealed complete symptoms resolution with a repeated CXR 23 showed significant right chest opacity improvement. A baseline immune work-up was done 24 and was reported to be within normal ranges. 25 Keywords: Empyema, neonate, Haemophilus influenzae 26 27 Introduction 28 Empyema can rarely complicate pneumonia in neonates.1 It carries high morbidity and 29 mortality in this population.1,4,5 It is defined as a progressive pleural pus build up, which is 30 mainly seen as a complication in patients with pneumonia.1-5 Empyema can be fatal if sub-31 optimally treated.1 Barbosa M et al reported 3 (0.04%) cases of empyema diagnosed out of 32 7,200 NICU admissions over 18 years.2 Risk factors of developing empyema in neonates 33 mailto:lailay@squ.edu.om include premature rupture of the membranes, maternal fever during labour, prematurity, 34 extremely low weight birth, viral infection and immunosuppression.1 35 Case Report 36 A 2-month-old healthy term infant presented to Sultan Qaboos University Hospital 37 emergency department with a 10-day history of fever and runny nose, associated with mild 38 shortness of breath and feeding difficulty on the day of presentation. He received his birth 39 and 2-month vaccinations as per Omani immunization schedule. On presentation, his 40 temperature was 37.7C, pulse rate was150 b/min, respiratory rate was 30 breaths /min, with 41 saturation of 94% in room air. His chest examination showed reduced air entry on 42 auscultation with a stony dullness percussion over the right chest. Other systemic 43 examinations were unremarkable. Laboratory investigations showed leukocytosis of 37.1 x 44 109/L with neutrophilia of 24.7x109/L. The initial chest x-ray showed air space opacities in 45 the right lung with silhouetting of the cardiac border and the right hemidiaphragm. The right 46 costophrenic angle was obliterated, suggestive of right pleural effusion (Figure 1). He was 47 started on IV ceftriaxone and clindamycin for a complicated community-acquired 48 pneumonia. CT chest was done and showed a large right-sided pleural effusion which 49 appears to be encysted in apical region, causing compressive atelectasis of right lung and 50 shift of the cardiomediastinal structures to contralateral left side. The right lung appeared to 51 collapse with minimal aeration of the anterior segment of the right upper lobe (Figure 2). A 52 video-assisted thoracotomy done and drained a significant amount of pus, with both bacterial 53 culture and viral studies were reported to be negative. A 16S rDNA PCR testing from the 54 pleural fluid was processed and reported positive for Haemophilus influenzae. He was 55 managed with IV ceftriaxone and clindamycin and then oral co-amoxyclav for a total of 3-4 56 weeks. A clinic follow-up at the end of the antibiotic course revealed complete symptoms 57 resolution with a repeated CXR showed significant right chest opacity improvement. A 58 baseline immune work-up was done and was reported to be within normal ranges. Consent 59 for publication has been obtained. Here we discuss the causes and management of empyema 60 in infants. 61 62 Discussion 63 Medical literature on the clinical and laboratory features, and management of neonatal 64 empyema is very limited.1 Neonates with empyema have a wide range of symptoms, being 65 asymptomatic to having significant respiratory distress requiring respiratory support.1,4 These 66 patients can present with pallor, jaundice, or poor feeding.1 The mean age of presentation of 67 empyema in one study was 13.5 days (6–38 day).1 68 69 Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus are the most 70 common causative organisms of empyema in children. Drained pus should be sent for 71 biochemistry, microscopy, Gram stain, culture, and molecular testing to optimize the 72 identification of the causative organism and guide targeted therapy.4,5 Friesen et al reported 2 73 cases and reviewed another 86 cases of neonatal H. influenzae from the literature. They found 74 that 79.6% of these cases were due to non-typeable H. influenzae strains. Most of these 75 infections were associated with maternal complications, prematurity, low birthweight, and 76 early onset sepsis.6 Sarah Collins and her colleagues reported 115 neonates with HI empyema 77 from England and Wales over a 5-year period. 96% had non-typable HI and 30 (26%) of 78 these neonates had pneumonia.7 No reported cases of neonatal HI empyema from Oman that 79 we can identify. 80 81 Managing empyema starts with accurate diagnosis through plain x ray followed by lung 82 ultrasound (US) to obtain further details and characterize the fluid.3 Although Kurian et al 83 showed that CT chest did not provide additional useful information compared to chest US in 84 their study,8 chest CT has a role in complicated cases and particularly in 85 immunocompromised children where it can reveal other serious clinical problems.9 Bacterial 86 culture enables the detection of living bacteria only.10 Giving empiric antibiotics can cause 87 sterilization of pleural culture which makes it difficult to identify the offending organism. 88 Molecular testing like targeted polymerase chain reaction or broad range 16S rDNA PCR 89 have the advantage of detecting viable and nonviable organisms in such cases.10 90 91 The therapeutic course depends on the severity of the empyema and the type of the causative 92 micro-organism. Antibiotics and pus drainage, using intercostal chest tube (ICD) or video-93 assisted thoracic surgery (VATS), are the mainstay of treatment.3 A combination therapy of 94 third generation cephalosporin and vancomycin in areas with high rates of MRSA 95 colonization is the recommended empiric therapy.1 Giving antibiotics for 3-4 weeks after 96 adequate drainage of the pus is reasonable and has shown to be effective.1,4 VATS is more 97 effective for multiloculated empyema.5,4 Follow up with a repeat chest-x-ray after 4-6 weeks 98 is highly recommended.1,5 The prognosis is excellent after proper treatment with no long-99 term complications in the majority of neonates reported in the literature.1 100 101 Conclusion 102 In conclusion, early identification of effusion, immediate initiation of antibiotics, and prompt 103 chest tube insertion are the key for successful treatment of this condition. Molecular testing 104 of the pus is highly recommended in children with culture negative empyema to optimize the 105 identification of the causative organism and guide targeted therapy. 106 107 Conflict of Interest 108 The authors declare no conflicts of interest. 109 110 Funding 111 No funding was received for this study. 112 113 Author Contribution: 114 HR and LY conceptualized the idea. SY and RF drafted the manuscript while HR and LY 115 revised the manuscript. All authors approved the final version of the manuscript. 116 117 References 118 1- Diez JRV, Perez MLM, Malayan GV, Cenabre MVL. Loculated empyema in a neonate 119 successfully treated with chest tube thoracostomy and antibiotics. Respir Med Case Rep. 120 2020;31:101274. doi:10.1016/j.rmcr.2020.101274 121 2- Barbosa M., Rocha G., Flôr-de-Lima F., Guimarães H. Neonatal pleural effusions in a 122 level III neonatal intensive care unit. J Pediatr Neonat Individual Med. 2015;4(1):1. 123 doi: 10.7363/040123 124 3- Mandal KC, Mandal G, Halder P, Mitra D, Debnath B, Bhattacharya M. Empyema 125 Thoracis in Children: A 5-Year Experience in a Tertiary Care Institute. J Indian Assoc 126 Pediatr Surg. 2019;24(3):197-202. doi:10.4103/jiaps.JIAPS_112_18 127 4- S Sharma S, Sharma A, Sharma M, Ghosh S. NEONATAL EMPYEMA THORACIS. 128 Pediatr Oncall J. 2018;15: 19-21. doi: 10.7199/ped.oncall.2018.2 129 5- Kotrashetti V, Sonawane VB, Bainade K, Nair S, Bunde S. Empyema thoracis in an 130 infant: A case report. Indian J Child Health. 2020; 7(10):427-429 131 6- Friesen CA, Cho CT. Characteristic features of neonatal sepsis due to Haemophilus 132 influenzae. Rev Infect Dis. 1986 Sep-Oct;8(5):777-80. doi: 10.1093/clinids/8.5.777. 133 PMID: 3538317. 134 7- Sarah Collins, David J. Litt, Sally Flynn, Mary E. Ramsay, Mary P. E. Slack, Shamez N. 135 Ladhani, Neonatal Invasive Haemophilus influenzae Disease in England and Wales: 136 Epidemiology, Clinical Characteristics, and Outcome, Clinical Infectious Diseases, 137 Volume 60, Issue 12, 15 June 2015, Pages 1786–1792, https://doi.org/10.1093/cid/civ194 138 8- Kurian J, Levin TL, Han BK, Taragin BH, Weinstein S. Comparison of ultrasound and 139 CT in the evaluation of pneumonia complicated by parapneumonic effusion in children. 140 AJR Am J Roentgenol. 2009 Dec;193(6):1648-54. doi: 10.2214/AJR.09.2791. PMID: 141 19933660. 142 9- Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of 143 pleural infection in children. Thorax. 2005;60 Suppl 1(Suppl 1):i1-i21. 144 doi:10.1136/thx.2004.030676. 145 10- Patel A, Harris KA, Fitzgerald F. What is broad-range 16S rDNA PCR? Arch Dis Child 146 Educ Pract Ed 2017;102:261–264. doi:10.1136/archdischild-2016-312049 147 https://doi.org/10.1093/cid/civ194 https://doi.org/10.1093/cid/civ194 148 Figure 1: Initial chest x-ray which showed air space opacities in the right lung with 149 silhouetting the cardiac border and the right hemidiaphragm. The right costophrenic angle is 150 obliterated. 151 152 Figure 2: CT chest showing large right-sided pleural effusion which appear to be encysted in 153 apical region, causing compressive atelectasis of right lung and causing shift of 154 cardiomediastinal structures to contralateral left side. 155